Health: A Political Choice - Investing in Health For All

Health: A Political Choice

Edited by Ilona Kickbusch, Global Health Centre, and John Kirton, Global Governance Program

Investing in Health For All

Health: A Political Choice

A

A Global Governance Project

Publication

MAKING THE CHOICE FOR HEALTH

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Choosing health for everyone

Tedros

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One Health for one planet

Inger Andersen, executive director, UN Environment Programme

Published by: GT Media Group Ltd

Published by: Ltd

Adhanom Ghebreyesus, director-general, World Health Organization

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Co-Director: Tom Kennedy

Tom Kennedy

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Publisher & Co-Director: Khaled Algaay

Co-Director: K h a led A lgaay

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Co-Editor: Ilona Kickbusch

Co-Editor: I lona Kic kbusc h

Co-Editor: John Kirton

Co-Editor: Joh n Kirton

Editor: Madeline Koch

Managing Editor: Emily Eastman

Editor: Made l ine Koc h Emi ly

Contact:

In times of crisis

Axel Radlach Pries, president, World Health Summit

Open up science, foster Health For All

Audrey Azoulay, director-general, UNESCO

20-22 Wenlock Road

London N1 7GU, United Kingdom +44 207 6085137

20-22 Wen loc k Road London N1 7GU, United +44 207

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Connect@GlobalGovernanceProject.org

Connect@Globa lGovernanceProject.org

@GloGovProj

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www.GlobalGovernanceProject.org

www.Globa lGovernanceProject.org

Capture the moment

Karl Lauterbach, minister of health, Federal Republic of Germany

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Investments in our future

Petr Fiala, prime minister, Czech Republic

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Women’s health: a global issue

minister, Scotland

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A new precedent for tackling infectious diseases

Sir Jeremy Farrar, director, Wellcome Trust

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Rethinking our values

Mariana Mazzucato, chair, WHO Council on the Economics of Health For All

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The gateway to all vital health interventions

Seth Berkley, CEO, Gavi, the Vaccine Alliance

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EDITORS’ WELCOME

2.1

Advancing health by caring for nature

Ilona Kickbusch, founding director, Global Health Centre, Graduate Institute of International and Development Studies

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3.1

A people-led pandemic response

SOCIETIES BUILT ON HEALTH

The Honourable Andrew Little, minister of health, New Zealand

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3.2

Equal chances for health

Shula Rijxman, deputy mayor, Amsterdam

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3.3

A polio-free world

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Global health governance for the world’s well-being

John Kirton, director, Global Governance Program, University of Toronto

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Jennifer Jones, president, Rotary International p46

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Faults in our methods

Sabina Faiz Rashid, dean and professor, BRAC James P Grant School of Public Health, BRAC University

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The road to global health security

K Srinath Reddy, president, Public Health Foundation of India

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The value of universal health coverage investments

Peter Yeboah, executive director, Christian Health Association of Ghana

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4.1

The beating heart of health systems

RESILIENT HEALTH SYSTEMS

The Right Honourable Helen Clark, board chair, Partnership for Maternal, Newborn and Child Health, and former prime minister, New Zealand

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4.2

Curing vulnerabilities

Interview with Francesca

Colombo, head, OECD Health Division

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4.3

Actions speak louder than words

Ayoade Olatunbosun-Alakija, chair, African Union, African Vaccine Delivery Alliance and founder of the Emergency Coordination Centre, Nigeria

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For a safer future

Chikwe Ihekweazu, WHO Hub for Pandemic and Epidemic Intelligence

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Lessons from East Asia

Gabriel M Leung, executive director (charities and community), Hong Kong Jockey Club, and honorary professor, University of Hong Kong

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5 LONGTERM HEALTH FOR ALL

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Reshaping the global health architecture

Svenja Schulze, minister for economic cooperation and development, Federal Republic of Germany

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For the greater good

Tharman Shanmugaratnam, co-chair, G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response

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5.3 No smoke

Adriana Blanco Marquizo, head of the Secretariat, WHO Framework Convention on Tobacco Control

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Drivers of political choice

Aleksi Yrttiaho, director, Anu Niemi, specialist in public health and general practice, and Markku Tervahauta, director-general, Finnish Institute for Health and Welfare

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The face of health issues

Norio Ohmagari, director, Disease Control and Prevention Centre, National Centre for Global Health and Medicine, and Norihiro Kokudo, president, National Centre for Global Health and Medicine

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Brain health: the paramount investment

Vladimir Hachinski, professor of neurology and epidemiology, Western University, and Detlev Ganten, founding president, World Health Summit

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PEOPLE & PLANET: A BETTER WORLD

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Strengthening health and climate

John H Amuasi and Andrea S Winkler, co-chairs, The Lancet One Health Commission

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Healthy people, healthy planet

João Campari, global leader, Food Practice, WWF International

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At the intersection of gender, health and climate change

Soon-Young Yoon, chair of the board, Women’s Environment and Development Organization

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Climate-smart health systems

C James Hospedales, founder, EarthMedic and EarthNurse, and Dana Van Alphen, senior adviser, Pan American Health Organization

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Systems for planetary health

Antonio M Saraiva, Aline Martins de Carvalho, Dirce Maria Lobo Marchioni, Raquel Santiago, Tatiana Camargo and Carlos Nobre, Planetary Health Brazil

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First Nations–led health solutions

Chief Perry Bellegarde, former national chief, Assembly of First Nations, Canada

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Real, urgent and present

Fiona Armstrong, founder and strategic projects director, Climate and Health Alliance

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WELL-BEING OF THE FUTURE THE FALLOUT OF CONFLICT

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Plugging into digital health

Alain Labrique, Garrett Mehl, Derrick Muneene and Natschja Ratanaprayul, Department of Digital Health and Innovation, and Soumya Swaminathan, World Health Organization

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A new world order of global infections

Peter Hotez, dean, National School of Tropical Medicine at Baylor College of Medicine

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Health in the digital age

Nanjia Sambuli, co-chair, Transform Health p110

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Strengthening science and innovation

Daren Tang, director-general, World Intellectual Property Organization

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Why C-TAP?

Román Macaya, former executive president, Costa Rican Social Security Fund, and Daniel Salas, former minister of health, Costa Rica p116

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Conflict zones: a war on health

Ahmad Al-Mandhari, regional director, WHO Regional Office for the Eastern Mediterranean p118

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Hope for a healthy future

Inger Ashing, CEO, Save the Children International p120

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Seize the moment

Jagan Chapagain, secretarygeneral, International Federation of Red Cross and Red Crescent Societies p122

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Protect our health, our rights

Ma Thida, activist and physician p124

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Health equity for fragile contexts

David Miliband, president and CEO, International Rescue Committee p126

HOW TO GET GOVERNANCE RIGHT

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Returns on health investments

Hans Henri P Kluge, director, and Natasha Azzopardi Muscat, director, country health policies and systems, WHO Regional Office for Europe

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Time for reform: local and global health governance

Precious Matsoso, director, Health Regulatory Science Platform, University of the Witwatersrand, and Viroj Tangcharoensathien, co-founder, International Health Policy Program

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How to prepare for the next pandemic

Mamta Murthi, vice president, human development, World Bank p132

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Seven rules for getting the politics right

Ricardo Baptista Leite, president, UNITE Parliamentarians Network for Global Health p134

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Bridging people with their right to health

Martin Chungong, secretary-general, Inter-Parliamentary Union

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Choosing health for everyone

By Tedros Adhanom Ghebreyesus,

More than two and a half years since Covid-19 turned our world upside down, reported cases and deaths are near their lowest levels since the pandemic began, and in many countries, life looks much like it did before the virus struck.

But the pandemic is by no means over: at the time of writing, Covid-19 is still killing more than 13,000 people every week; more than three-quarters of the population of low-income countries remain unvaccinated against Covid-19, including two-thirds of health workers and older people; and a precipitous drop in testing and sequencing is blinding us to how the virus might be changing to become more transmissible or more deadly. These dynamics continue to pose a risk to all people, in all countries.

An even greater risk is that the world moves on to the next crisis – and there are plenty demanding its attention – and forgets the painful and costly lessons the pandemic has taught us.

At this year’s World Health Assembly, I outlined five priorities for countries and the World Health Organization as collectively we recover and rebuild.

TO RECOVER AND REBUILD

The first is promoting health, by making an urgent paradigm shift in all countries towards an approach to health centred on creating the conditions in which health can thrive and addressing the root causes of disease.

Making this shift begins with recognising that health starts not in the clinic or the hospital, but in schools, streets, supermarkets, households and cities. Much of the work that ministries of health do is dealing with the consequences of poor diets, polluted environments, unsafe roads and workplaces, inadequate health literacy, and the aggressive marketing of products that harm health.

This requires empowering and enabling individuals, families and communities to make healthy choices and it requires governments to create the legislative, regulatory and commercial environment in which people can make those choices. In particular, it requires radical action to safeguard the health of the planet on which all life depends, by addressing the existential threat of climate change.

Such a shift could cut the global disease burden in half, but it would also offer massive economic gains, by reducing the burden on health systems and increasing the productivity of populations.

The second priority is providing health, by reorienting health systems towards primary health care as the foundation of universal health coverage.

The pandemic has demonstrated that a resilient health system is not the same thing as an advanced medical care system. Some countries with the most sophisticated medical care were overwhelmed by Covid-19. By contrast, some middle-income countries with fewer resources fared much better, thanks to investments in public health after outbreaks of SARS, MERS, H1N1 and others.

The backbone of public health is robust primary health care, for detecting outbreaks at the earliest possible stage, as well as for preventing disease and promoting health at the community level.

The third priority is protecting health, by strengthening the global architecture for health emergency preparedness, response and resilience.

The Covid-19 pandemic is a stark reminder that health is the singular foundation of prosperous, peaceful and secure societies – and we must not forget the lessons it has taught us

The pandemic has exposed serious vulnerabilities in the world’s defences against epidemics and pandemics, and the global monkeypox outbreak is yet more evidence – if any were needed – that the world’s collective failure to address neglected diseases in neglected communities puts us all at risk.

Building on several reviews of the global response to the pandemic, in May the WHO published a white paper with 10 key proposals for making the world safer, in the areas of governance, financing and systems and tools, under the umbrella of a new legally binding international instrument on pandemic preparedness and response, which the WHO’s member states are now negotiating.

Several of those proposals are already being acted on, including the recent establishment at the World Bank of the new Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response, to provide catalytic and gap-filling funding to strengthen global, regional and national capacities. The WHO is grateful for Indonesia’s leadership in prioritising the establishment of the FIF as part of its G20 presidency.

The fourth priority is powering health through science, research, innovation, data and digital technologies.

Advances in science and research are constantly pushing back the boundaries of the unknown and the impossible, increasing our understanding and opening new possibilities. Innovations in health products and service delivery are helping to provide care in new ways. Developments in big data and machine learning are helping us to see who is being left behind and where the biggest gaps are, and to track progress against our targets. And digital technologies offer huge potential for delivering health services in new ways, to more people, especially in hard-to-reach areas.

The fifth priority is performing and partnering for health, by building a stronger, empowered and sustainably financed WHO.

A HISTORIC COMMITMENT

At this year’s World Health Assembly, the WHO’s

TEDROS ADHANOM GHEBREYESUS

Tedros Adhanom Ghebreyesus was elected director-general of the World Health Organization in 2017 and re-elected for a second term in May 2022. He was the first person from the WHO African Region to serve as WHO’s chief technical and administrative officer. He served as Ethiopia’s minister of foreign affairs from 2012 to 2016 and minister of health from 2005 to 2012. He was elected chair of the Global Fund to Fight AIDS, Tuberculosis and Malaria Board in 2009, and previously chaired the Roll Back Malaria Partnership Board, and co-chaired the Partnership for Maternal, Newborn and Child Health Board.

@DrTedros who.int

member states made a historic commitment to gradually increase assessed contributions to 50% of the base budget over the next decade, from just 16% currently.

This commitment will transform the WHO’s ability to deliver results where it matters most – in the lives of the people we serve.

Of course, it is incumbent on us to return the trust our member states have put in us by providing value for money, with enhanced governance, accountability, transparency and efficiency. Even before the pandemic, we had already made major progress in these areas, and we are committed to further improvements. In particular, our focus in the coming years is to significantly strengthen our country offices to support greater country capacity and greater country ownership.

More than 70 years ago, the WHO’s founders wrote in our constitution that “the health of all peoples is fundamental to the attainment of peace and security, and is dependent upon the fullest cooperation of individuals and States”.

The Covid-19 pandemic is a brutal reminder that health is not simply a by-product of development, but the foundation of prosperous and secure societies. ▪

“The pandemic has demonstrated that a resilient health system is not the same thing as an advanced medical care system”

In times of crisis

By Axel Radlach Pries, president, World Health Summit

As the organisers of one of the key global health gatherings – the World Health Summit that takes place every year in Berlin – we have the responsibility to address the key concepts and actions that are required to move global health forward. We are very aware that the field of global health is totally different today compared to when the WHS was initiated in 2009. Multiple crises are happening simultaneously and demand action: for example the world is dealing with several public health emergencies of international concern as declared by the World Health Organization: Covid-19, monkeypox and polio. Not only are the global health goals set out in the context of the Sustainable Development Goals increasingly more difficult to reach, but the world is also facing a climate crisis. The war in Ukraine has ramifications all over the world, including a global food and energy crisis. Poverty has increased significantly.

The origins of the pandemic and the increasing risk of similar events in the future are linked to the deterioration of natural habitats by human intervention and to human-made climate change, which is why some experts speak of a new age: the Anthropocene.

A NEW AGE

The present systems for dealing with global crises – including the United Nations – seem ill-equipped to deal with the complexity and impact of such a ‘polycrisis’. Multilateralism too is facing unprecedented challenges as the global power balance shifts and the present rules-based order is weakened. Global cooperation is also endangered by

increasing competition between authoritarian and democratic political systems that increasingly spills over into development aid. The national and global responses to the pandemic were strongly driven by political interests and by economic considerations, with countries choosing very divergent responses. At the WHS we aim to create awareness of the effects of all these challenges and interests on global health and provide a platform to reconsider well-established concepts and approaches. Health is related to nearly every aspect of human life and therefore also to many sectoral policies. It is also an important economic factor. The pandemic shut down social life, stopped travel, affected supply chains, hurt economies, separated families, and isolated high-risk individuals and social groups. It brought about incisive consequences in nearly every aspect of people’s lives all around the world, throwing a spotlight on inequalities within and between countries. In the face of crisis and uncertainty, trust in governments, established institutions and in one another turned out to be a determining factor of pandemic response. The polycrisis and the ensuing interface between health and politics, economy and the environment set new challenges for making health a political choice. It requires decisive synergistic measures that address climate, health, peace, security and trust. Global health can no longer be anthropocentric and focused on disease –it requires strategies for health and well-being that recognise planetary boundaries and are committed to reducing inequalities. This is why the WHS is committed to promoting the dialogue between science and policy and among the many stakeholders at national and global levels.

FUNCTIONING SYSTEMS

With respect to global health, a prerequisite for strengthening healthcare systems worldwide and corresponding investments is the existence of functioning national political systems and

The global challenges we face today are immense. To have a sustained impact, we must make the political choice for health in all policies, communities and countries – working through these uncertain times together to achieve a healthy future

their sustained international interaction in multilateral institutions. On the national and the international level, this requires transparency, trust and accountability. Trust is particularly key to allow governments representing a wide variety of national interests to work together in areas of global concern and to achieve changes that are accepted and supported by societies. It is here that the international community failed in the face of the Covid-19 pandemic.

It is certainly intimidating to realise the magnitude of the challenge. But at the WHS we are stimulated to contribute to practical improvements in the different settings. If countries and sectors work together, they can make a difference. Three action areas emerge.

First, the Covid-19 pandemic made it absolutely clear that neglecting health provisions and preventive measures can come at an extremely high economic and societal cost. To counteract this in the future, it is prudent to strengthen health-related structures at all levels, and specifically the WHO as the key international body. Strengthening in this context requires respecting the WHO’s advice and authority as well as ensuring adequate financing.

Second, we must move beyond the understanding that global health can be delivered by ministries of health or multinational health institutions alone. Instead, we need a health-in-allpolicies approach to address the broad range of determinants of health that exist in the economic, environmental, social and other realms.

Third, similarly, we cannot achieve Sustainable Development Goal 3 on ‘Good Health and Well-being for All’ if we try to control one disease at a time, in one country separate from the others. Health as a political choice needs to be a global and a sustainable decision, not just in times of crisis. Political action focused on health aspects has been called for repeatedly during the Covid-19 pandemic. Promises were made to finance targeted programmes for pandemic preparedness and relief. Such efforts are important and needed to tackle the very dynamic development of a global infection, but health measures alone often fail to have a lasting impact unless countries establish universal health coverage.

The global challenges we face today are immense. We not only need to start taking strong, focused actions. We also need to act together to have sustained impact. We need to make the political choice for health in all policies, in all communities and in all countries so that we all can have a healthy future. The World Health Summit is a platform to engage policymakers to make the political choice for health based on science, evidence and political participation. ▪

AXEL RADLACH PRIES

Axel Radlach Pries became president of the World Health Summit in 2021. He was appointed dean of the Charité Institute in 2015, having been made head of the Charité Institute for Physiology in 2001. He has chaired the Council for Basic Cardiovascular Science and the Congress Programme Committee basic section in the European Society of Cardiology, was president of the Biomedical Alliance in Europe and CEO of the Berlin Institute of Health. He has received the Malpighi Award, the Poiseuille Gold Medal and the Silver Medal of the European Society of Cardiology.

@WorldHealthSmt / @ChariteBerlin worldhealthsummit.org / charite.de

“

We cannot achieve Sustainable Development Goal 3 on ‘Good Health and Well-being for All’ if we try to control one disease at a time, in one country separate from the others”

Germany has continued its commitment in taking up a leading role in global health during its German G7 presidency. When Germany welcomed the G7 health ministers to Berlin for their meeting in May 2022, the war of aggression by Russia against Ukraine had already lasted for more than three months, with millions of Ukrainian refugees fleeing the country due to the unlawful attacks by the Russian Federation. In light of the violence that Russia continues to inflict on Ukraine’s sovereignty, the security of Europe and the entire world, the G7 health ministers’ meeting in Berlin powerfully demonstrated the strength of multilateralism and particularly the G7’s work in times of crisis. I am very pleased that my G7 colleagues and I jointly agreed to continue our support for Ukraine with a view to strengthen the functioning and rebuilding of the Ukrainian health system, now and in the future.

Considering these severe changes to the international order and the insecurities that the world is currently facing, I am also delighted that my G7 colleagues and I were able to achieve progress in addressing pressing global health challenges of the 21st century – pandemic preparedness and response, combatting antimicrobial resistance, and climate change and health.

ENHANCED DISEASE SURVEILLANCE

The global rise in monkeypox cases and the resurgence of new Covid-19 waves once again demonstrate the need for strengthened global pandemic surveillance and response mechanisms and capacities to closely monitor the spread of new and existing

Capture the moment

By Karl Lauterbach, minister of health,

pathogens that have epidemic and pandemic potential. Even before Covid-19, but even more so during this pandemic, the G7 and the entire world witnessed the establishment of a variety of institutions that aim to enhance disease surveillance and response to detect potential outbreaks at an early stage. However, the Covid-19 pandemic also highlighted the necessity for greater alignment of these initiatives to foster a network of collaborative surveillance to effectively exchange data and rapidly respond to the dynamic development of pandemics. Only by synergising the collective knowledge of the different actors will we be able to effectively prevent and respond to current and future emerging health threats. In addition, the past has provided evidence that it is key to invest in the education, training and know-how of people who can analyse the data and detect, assess and raise the alarm if necessary. Investing in people is sometimes more sustainable than focusing only on certain infrastructure or product components. We need to improve building and investing in the workforce that is at the forefront of any detection of and rapid response to a health emergency.

FOCUS ON ACTIONS

Together with my G7 colleagues, we agreed on the necessity of a collaborative effort that will achieve this exact alignment by focusing on concrete actions, namely the G7 Pact for Pandemic Readiness. The pact is a strategic and conceptual exercise to decisively improve implementation, coordination and cooperation of our G7 actions in the area of collaborative surveillance and predictable and rapid response by

Federal Republic of Germany

Under its G7 presidency, Germany has forged ahead with a pact for pandemic readiness that enhances a global network approach to public health emergencies

advancing a global network approach and strengthening the Public Health Emergency Workforce of the future. To achieve its objective, the G7 Pact for Pandemic Readiness has two pillars: Under the pillar of collaborative surveillance, the goal of the pact is to strengthen interoperable and interdisciplinary cross-sector surveillance capabilities and capacities following a One Health approach, while reinforcing the global network approach by connecting regional and national nodes as well as centres of expertise. To enhance capacities, we also intend to mount structures for education and training.

KARL LAUTERBACH

Karl Lauterbach was appointed Germany’s federal minister of health in December 2021. He studied medicine in Aachen, Düsseldorf and San Antonio (Texas). He holds a PhD in medicine, and a master of public health, a master of science in health policy and management, and a doctor of science in health policy and management from Harvard University. His parliamentary career began in 2005 when he became a member of the German Bundestag. From 2013 to 2019 he served as deputy parliamentary party leader of the SPD.

Under the pillar of predictable rapid response, the G7 Pact for Pandemic Readiness will support the establishment and maintenance of professional, multi-sectoral and well-trained readiness groups, which must be embedded in the national and regional levels, while being connected globally. To invest in and strengthen the Public Health Emergency Workforce, the pact supports existing education and training networks with up-to-date curricula and by bolstering global peer and alumni networks.

@Karl_Lauterbach bundesgesundheitsministerium.de

The G7 Leaders’ Communiqué this year endorsed the G7 Pact for Pandemic Readiness in order to accelerate the momentum and reiterated the joint commitment of all G7 partners to further align and prepare for future potential outbreaks. In the second half of the German G7 presidency, we as G7 partners are developing a roadmap for practical cooperation that will build upon the above-mentioned pillars by convening technical meetings with relevant stakeholders and the G7.

THE SILENT PANDEMIC

Additionally, we as G7 health ministers jointly addressed the so-called silent pandemic of antimicrobial resistance. In 2019, 1.27 million deaths were attributed to antibiotic resistance. An estimated 11 million people worldwide die of sepsis each year, with AMR playing an important role in this regard. These deaths must be prevented. We therefore committed to strengthening the data basis by establishing and improving integrated surveillance systems on AMR and antibiotic use following the One Health approach, strengthening the prudent use of antimicrobials, defining

1.27m 11m

deaths attributed to antibiotic resistance in 2019 people worldwide die of sepsis each year

national targets and strengthening early detection, diagnosis and therapy of sepsis. Under the German presidency’s lead, we were able to build upon previous G7 commitments by actively supporting the development of new antimicrobials and alternative treatments through institutions such as the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) and the Global Antibiotic Research and Development Partnership.

The third priority subject of this year’s G7 health ministers’ meeting focused on the increasingly crucial topic of climate change and health. We witness extreme weather events each year, which demonstrate the urgency to combat climate change in all areas of life, including in the health system. We need to prepare our health systems to cope with new disease patterns and demands such as an increase in the burden of disease from infectious and non-communicable diseases. As G7 health ministers, we agreed to build climate-informed health and surveillance systems that integrate socio-demographic, climate, environmental, and animal and human health data as well as early warning systems. To reduce the burden of our health systems on climate change, all G7 partners committed to the common aim of building environmentally sustainable and climate-neutral health systems at the latest by 2050.

In the collective spirit of multilateralism, the G7 health ministers were able to achieve sustainable progress in these pressing areas of global health. I look forward to following up with these commitments in the second half of the German G7 presidency, in order to progress towards a more equitable and healthier world. ▪

By Petr Fiala,

Investments in our future

THE MOST IMPORTANT FACTOR

It is obvious that the ongoing Czech presidency of the Council of the European Union cannot sideline endeavours accomplished in this domain. Under the motto ‘Rethink, Rebuild, Repower’, our main task is to help construct resilient systems across Europe. The healthcare sector cannot be omitted because health is the most important factor in our lives.

The time to perceive health as an investment rather than an expenditure is now. The international environment offers us unprecedented tools to help us achieve this common goal as we enter a new era of big opportunities and possibilities.

The Covid-19 pandemic took the international community by surprise. We have been reminded that there is no wealth without health. The pandemic is far from over and our economies are still trying to build back better after lockdowns and shocks caused by the unexpected development of new virus variants. To avoid these surprises as much as possible in the future, we must build on multilateralism, an international rules-based order, and shared good practices and information. Keeping in mind the principles of solidarity and the Sustainable Development Goals, we must reiterate our strong commitment to achieve a higher overall quality of life.

The Czech Republic is firmly anchored in the structures of the European Union, after 18 years of membership. Thanks to ongoing respect for solidarity and multilateralism, which are the basic values of the Czech Republic, we have been able to endure the hardest times of the Covid-19 pandemic. The common values we share in the EU have allowed us not to leave anybody behind. Based on lessons learnt from the pandemic, the EU established a strong European Health Union with a clear goal – to improve EU-level protection and prevention and to tackle health hazards.

The Czech presidency is prepared to provide further support to Ukraine. In the context of a rapidly evolving situation, it is appropriate to consider now the tools to be implemented in the short term and also in the medium and long term, to ensure the best possible coordination of solidarity actions that will be necessary to enable fast access to healthcare for all refugees and to strengthen our healthcare systems at the same time. It is our moral duty to help war refugees and to work together on a strategic plan to ensure that Ukrainians get appropriate medical treatment once they return to home. This is an opportunity to foster the Ukrainian health system so that it emerges from the crisis stronger than before. Another lesson of the Covid-19 pandemic and a real challenge is that we must make sure that future pandemics do not paralyse the rest of healthcare services. Finding the right balance between responding efficiently to the pandemic and providing essential healthcare services is one of the most serious obstacles we have faced. The Covid-19 pandemic has caused delays and disruptions across the entire sector with a dramatic impact, especially on the availability of cancer care. Thus, the Czech presidency ranks oncology very high on its agenda: we know that high-quality cancer treatment is essential not only on an individual scale but also on the global level due to its considerable social and economic consequences.

REMARKABLE SCIENTIFIC PROGRESS

The scientific progress made during the Covid-19 pandemic is remarkable. Thanks to broad international cooperation, humankind was able to produce safe and effective Covid-19 vaccines in an unusually short time, as the roll-out started only one year after the Covid-19 disease started to spread worldwide. Unfortunately, vaccination in general – one of the greatest success stories in public health history, saving millions of lives every year – has become partially a victim of its success. According to the World Health Organization,

We are entering a new era of health opportunities and possibilities that requires shared thinking: that health is an investment, not an expenditure

PETR FIALA

Petr Fiala was elected prime minister of the Czech Republic in 2021. He has a degree in the Czech language and history, and served two terms as the rector of the Masaryk University (2004–2011) during which it became the most popular Czech university and one of Central Europe’s leading educational and research institutions. In his scientific work, he specialised in comparative political science, European politics and conservative political thinking. From 2012 to 2013, he was the minister of education. In autumn 2020 he became the nationwide leader of the newly formed electoral coalition SPOLU (together), which won the parliamentary elections in October 2021. The Czech Republic holds the presidency of the Council of the European Union from 1 July to 31 December 2022.

@P_Fiala / @EU2022_CZ eu2022.cz

vaccination coverage has plateaued in recent years and even dropped for the first time in a decade in 2020. The Czech presidency stands ready to focus on the fight against misinformation and vaccine hesitancy. Moreover, as the Covid-19 pandemic continues, we must supply every country in the world with adequate support, particularly with Covid-19 vaccine delivery. International organisations should serve as a platform for this kind of collaboration. Hopefully the motto ‘No one is safe until everyone is safe’ will not remain just an empty phrase.

Profound changes in the global health landscape go well beyond the concept of a global health architecture – a system of fixed international institutions with pre-established rules. Indeed, we are witnessing today the emergence of a new kind of global health cooperation, an ever-evolving, dynamic system with multiple actors and initiatives that together redefine global health relations against the backdrop of a complex geopolitical context – and the risk of waning political attention that is crucial to face global health challenges. This is another reason why the Czech presidency will pay close attention to global health. We note the negotiation of the Pandemic Convention and amendments to the International Health Regulations (2005) in the context of strengthening the EU’s role in health at the international level. We would also like to propose and discuss setting up coordination mechanisms between the groups of health diplomats working at the WHO in Geneva and at the EU in Brussels to ensure an effective real-time exchange. And, last but not least, the preparation of the revised EU Strategy for Global Health will also take place during the Czech presidency. All these initiatives clearly show that a strong political commitment at the highest possible level can bring tangible results leading to better health for all. ▪

We must make sure that future pandemics do not paralyse the rest of healthcare services”

Interview with Zhi Yang, chairman, BVCF Management

What are the origins of BVCF Management?

I founded BVCF Management in 2005. At the time, it was one of the first venture capital/private equity firms in China focused on the healthcare sector. Dr Robert Li, who joined BVCF in 2007, and I envisaged bringing the VC-driven innovation model to China healthcare sector, drawing on our experience in the United States where we studied and became familiar with American academia, biotech companies and the VC industry.

BVCF was founded on the belief that effective R&D is the cornerstone of better treatment and health options for China’s vast population. The team at BVCF comprised staff with PhDs and other professionals with meaningful scientific, operational and clinical expertise – not a common practice then when China’s healthcare sector was mostly dominated by low-end generics, and capital market activities mostly involved pharma distributors and generics manufacturers.

BVCF’s evolution runs parallel to the development of China’s healthcare sector. How are the two connected?

Back in the 1980s, I was in the first class of the China–United States Biochemistry Examination and Application Program, a China government sponsored programme that from 1982 to 1989 selected and placed 422 top Chinese students into top universities in the US to study for advanced degrees. I studied at Harvard University and Dr Li, in the fourth class of the CUSBEA Program, joined later.

In 2005, with backing from the World Bank’s International Finance Corporation, we raised the first BVCF fund. Since then, BVCF has raised four more funds with total assets under management of more than $700 million and additional investors from the US, Europe and Asia. To date, BVCF has invested in 43 companies across different healthcare subsectors, which created more than 4,200 job opportunities. Ten of the portfolio companies have gone public and five have executed trade sales. BVCF was the lead investor in 90% of the investments

Championing R&D for public health

and spent a substantial amount of time working with entrepreneurs to help them build a lasting organisation.

BVCF’s work coincided with the push by the China government to create a public health system that delivers broader and more comprehensive coverage to the whole population. From the start, from the government’s goals to increase basic medical coverage to all and ensure equal access of health services across the

country, to the push for development of a local R&D ecosystem and the creation of capital market rules that allow the public listing of pre-revenue biotech companies, my team and I have observed and understood the role that R&D can play and how the private sector can be an active contributor to public health. Without the development of effective and applicable products and services, many of which have come from private sector

BVCF Management has a long history of funding and championing China healthcare sector pioneers, and today its work is having a positive impact on global health equity and improving access to sustainable health technologies

enterprises, it is impossible to deliver health care to a population of 1.4 billion. China’s healthcare sector has evolved from me-better products and in-licensing technologies from other countries to now vigorously developing proprietary technologies.

What does the future look like for BVCF?

BVCF’s global investors have supported our work with portfolio companies that created meaningful impacts for China as well as for the global healthcare sector. This strengthened the case that many have made before: that R&D investments can be globally beneficial and there are incredibly valuable possibilities of partnerships

ZHI YANG

Dr Zhi Yang is founder and chairman of BVCF Management. He launched the firm in 2005 when he returned to China after two decades studying and working in the United States with the vision to bring the VC-driven innovation model to China. He launched BVCF as one of China’s first venture capital/private equity firms focused on the healthcare sector. bvcf.com

among scientists and investors across different countries and backgrounds. The BVCF team observes many parallels in the development paths, needs and supply gaps of healthcare sectors in other countries and that of China’s own healthcare sector. We seek to actively share our learning and network with other countries and companies, in addition to our portfolio companies in China. However, while global R&D investments have led to many new technological breakthroughs, most of the benefits are being enjoyed in a limited number of countries. We hope to facilitate and enable the growth of companies with technologies that are globally applicable, rather than just in high-income countries.

How is BVCF aligned with the work of the World Health Organization?

Our general partner, Vanessa Huang, is a member of the WHO Council on the Economics of Health For All, which aims to reframe Health For All as a public policy objective. Through her work, she advocates for the creation of a globally recognised health taxonomy. A health taxonomy can serve as a common language to define a set of common health goals. It can ensure that stakeholders have a more holistic appreciation of health-positive as well as -negative economic activities, and ultimately prevent ‘healthwashing’. A health taxonomy will help to intensify awareness for positive health investments, start adding better health metrics into sustainability frameworks and allow all stakeholders to proactively contribute to global health.

As the BVCF team looks forward under the current global environment that seems to be heading towards more divisiveness, we aim to be a positive contributing stakeholder to global public health. We hope that through our work, we can have a positive impact on global health equity and further improve global access to sustainable health technologies. ▪

My team and I have observed and understood the role that R&D can play and how the private sector can be an active contributor to public health”

By Nicola Sturgeon,

Women’s health: a global issue

free of harassment or intimidation, which is why we are supporting the development of national legislation to protect that right, and we are progressing these plans as quickly as possible. This is not a problem unique to Scotland, but it is one that we must act on. Hostile gatherings outside clinics create additional stress for anyone using these facilities, for any purpose, and for those who work in them. But for women accessing abortion services, the upset, distress and fear they cause can be profound.

AN UNACCEPTABLE SITUATION

In my view, the current situation is unacceptable, and it is one we must address as a matter of urgency. I am determined that we do so.

That we need to take this action highlights the way in which women’s health care has been politicised in a way that men’s health care has not. It also highlights the inequalities between men’s and women’s health care that we must resolve.

Healthcare systems and healthcare research have developed using the male body and men’s needs as the de facto patient. That must be challenged.

The United States Supreme Court’s decision to overturn the landmark Roe v Wade ruling, thereby ending the established right to abortion in all parts of the US, was one of the darkest days for women’s rights in my lifetime and will have a catastrophic impact on American women.

Experience tells us that countries that seek to ban abortion only ever succeed in banning safe abortion – we should be in no doubt that abortions will continue, but in a way that means women’s lives will be harmed and lost.

While the current focus is very much on the US, those who value women’s rights across the world should also be concerned. There is little doubt that this will embolden anti-abortion forces in other countries.

A woman’s right to choose – in other words, to decide what happens to her own body – is a fundamental human right and that must be protected.

In Scotland we are considering what needs to be done to improve safe access to abortion services, including how we can improve access to mid-trimester abortions for those who need or want them. Our key focus is to establish safe access zones. Women must be able to access health care,

Scotland was the first country in the United Kingdom to have a Women’s Health Plan, which aims to address women’s health inequalities and raise awareness in areas of health that need more focus and support, and to be spoken about more openly, including menopause, women’s heart health, menstrual health including endometriosis, sexual health and contraception.

It sets out several actions to be taken across sectors, including our health and public health systems, to ensure all women and girls enjoy the best possible health and health care throughout their lives. Crucially, it takes on board the real-life experiences of women who have given their feedback on what is important to them –something that has often been lacking when it comes to health care.

In Scotland, we recently passed groundbreaking legislation to become the first country in the world to make period products free for anyone who needs them. There is now a menopause specialist service in each mainland health board. And we are committed to improving access for women to appropriate support, diagnosis and the best treatment for endometriosis.

Our vision for women’s health is an ambitious one – and wider change must happen to ensure all

Women’s health is not just a women’s issue. When women and girls are supported to lead healthy lives, society benefits –and the Scottish Government is leading by example

NICOLA STURGEON

Nicola Sturgeon was sworn in as Scotland’s first minister in November 2014. She is the first woman to lead any of the devolved United Kingdom administrations. Before entering the Scottish Parliament to represent Glasgow in 1999 she was a solicitor in Glasgow. She served as cabinet secretary for health and well-being between 2007 and 2012 and then cabinet secretary for infrastructure, investment and cities with responsibility for government strategy and the constitution until 2014. Throughout this period she also served as Deputy First Minister of Scotland.

@scotgovfm gov.scot

Just as we act to protect and enhance services for women in Scotland, we must also support those working to improve access to women’s health care around the world, including supporting access to education for women and girls”

our health and social care services meet the needs of all women, everywhere.

In taking action in Scotland, we are starting from a position where women’s rights and women’s equality are established in law even when they are not always delivered in practice. In other parts of the world, the politics of improving women’s health care is part of a wider campaign to improve women’s lives. Just as we act to protect and enhance services for women in Scotland, we must also support those working to improve access to women’s health care around the world, including supporting access to education for women and girls, a key step in improving access to health care.

INVESTING IN WOMEN’S HEALTH

Through our international development work to date, we have invested in women’s health initiatives in our partner countries. In Malawi, through Edinburgh University, a collaborative project is developing and delivering sustainable cervical cancer screening with a focus on strengthening services for women in rural areas. And in Rwanda, we are funding, through Oxfam, a project that aims to benefit the victims of sexual and gender-based violence.

In our future international development work, we are committed to a feminist approach. We know that Covid-19 has deepened pre-existing inequalities, exposing vulnerabilities in social, political and economic systems. We have committed to prioritise the rights of women and girls, their advancement and equality. We are establishing a new Equalities Programme with a focus on the empowerment of women and girls, as well as targeting other specific areas of inequality that intersect with gender. And we will mainstream gender equality throughout the rest of our international development programmes, including in the key area of health in Malawi, Rwanda and Zambia.

Women’s health is not just a women’s issue. It is a global issue, it is a political issue and it is an economic issue. When women and girls around the world are supported to lead healthy lives and fulfil their potential, the whole of society benefits. ▪

One Health for one planet

The high-carbon, throwaway economic models that built our societies have also caused great harm to the environment and the biodiversity it hosts – the very basics we rely upon to live. Our economic system has made the planet sick. Now it is making us and other species sick.

However, if governments make the political choice to follow a One Health approach as part of broader systemic transformations to end the triple planetary crisis of climate change, nature and biodiversity loss, and pollution and waste, we can heal the planet and ourselves.

The health benefits of the natural world are incalculable. Nature gives us breathable air, drinkable water and productive soils. Nature gives us medicines, traditional and new. Nature provides a buffer against emerging zoonotic diseases. Time spent in nature improves health outcomes across the board, from stress to hyperactivity.

HEALTH IN CRISIS

Every one of these benefits is under threat. I could spend a day listing every threat we are seeing today: growing floods and wildfires; dirty air that clogs the lungs of most people on the planet; emerging diseases, such as Covid-19; plastic and other waste that pollute our rivers, lakes and ocean; people dying prematurely in their millions every year from environmental degradation.

I could spend another day listing what is to come: an extra 9 million premature deaths per year from hunger, 1.5 million from diarrhoea and more than 6 million from air pollution; more diseases jumping from animals to humans; growing antimicrobial resistance that could render large chunks of

modern medicine useless; and so much more.

In the face of such a heavy burden, is it any wonder that healthcare systems are on their knees in many countries, with a disproportionate impact on the poorest and most vulnerable? The World Bank estimates that air pollution alone costs the welfare system more than $5 trillion every year. We will probably never know the true economic damage of the Covid-19 pandemic, but some conservative estimates peg it at well over $10 trillion. Set against these costs, we would be foolish not to invest in a healthy planet and in strong health systems.

ONE HEALTH

We did see a major landmark in July, when the United Nations General Assembly adopted a resolution recognising the right to a clean, healthy and sustainable environment. Now we must build on this victory by investing, hard and fast, in One Health.

One Health is an effort to integrate human, animal, agricultural and ecosystem health to improve outcomes and address the triple planetary crisis. A One Health approach would help prevent disease, reduce costs, improve food safety and security, and save lives. Many potential disease outbreaks would be identified early in animals before spreading into human populations. And spillover risks from zoonotic disease could be reduced by halting habitat conversion and maintaining healthy, functioning ecosystems.

The expected benefit of One Health to the global community was estimated in 2022 to be at least $37 billion per year, according to the Food and Agriculture Organization. The estimated annual

By Inger Andersen, executive director, UN Environment Programme

$5trn

Our way of living is making the planet – and us – sick, but by taking a One Health approach to systemic transformations, we have a chance to heal and thrive

Health to the global community per year

need for expenditure on prevention is less than 10% of these benefits. However, funding for One Health remains weak.

We have seen growing recognition of the One Health approach. New bodies are forming, such as the One Health High Level Expert Panel and the Global Leaders Group on Antimicrobial Resistance. The G7 and G20 have issued declarations backing One Health. The UN Environment Assembly passed a resolution on biodiversity and health, led by African member states. The four organisations of the Quadripartite on One Health – FAO, UNEP, the World Health Organization and the World Organization for Animal Health – are working together to mainstream One Health. The Quadripartite has developed a One Health Joint Plan of Action to address many of the challenges I have described.

USE THE MOMENTUM

Now is the time to use growing political momentum on One Health to promote integrated, multisector and multi-stakeholder initiatives that are backed by adequate structures, governance mechanisms and funding.

Under such initiatives, we can implement actions that ensure strong global stewardship of nature and biodiversity to reduce health risks, coupled with coordinated surveillance and early warning systems on zoonotic diseases, antimicrobial resistance and other emerging health threats. Actions that create incentives to improve sustainable farming practices and sustainable, legal and safe trade in domestic and wild animals. Actions that strengthen tenure and management rights of local communities and Indigenous peoples – because they are the best guardians of nature and hold deep knowledge and skills on health risks.

We are a species in peril, living on a planet in peril. But if we act urgently on the triple planetary crisis, we can save lives and reduce the burden on our healthcare systems. This means decarbonisation. This means backing solutions that work with nature. This means financing adaptation in developing countries. This means a shift to sustainable consumption and production. And this means a rapid shift to One Health. ▪

INGER ANDERSEN

Inger Andersen is an under-secretary-general of the United Nations and the executive director of the UN Environment Programme. From 2015 to 2019, she was the directorgeneral of the International Union for the Conservation of Nature. Ms Andersen has more than 30 years of experience in international development economics, environmental sustainability and policymaking and has held various leadership roles at the World Bank and United Nations.

@unenvironment @andersen_inger unenvironment.org

“

One Health is an effort to integrate human, animal, agricultural and ecosystem health to improve outcomes and address the triple planetary crisis. A One Health approach would help prevent disease, reduce costs, improve food safety and security, and save lives”

Investing in women is an investment for alll

The decision of when – and whether – to start a family is one of the most important decisions a woman can make with critical consequences for her life and that of her family, community and economy. But for millions of women and girls worldwide – especially women from poor economic backgrounds and women of colour – this life-altering decision is at times no choice at all.

The predictable result is that nearly half of all pregnancies worldwide today are unintended – a major global health crisis. The reasons are complex and varied, but one of the most critical aspects is the need to increase access to contraceptive options. An estimated 162.9 million women worldwide still have an unmet need for contraception.

This issue came into even sharper focus during the pandemic when family planning services were disrupted for 12 million women around the world, leading to an estimated 1.4 million unintended pregnancies.

For many women and girls, their UIP create extraordinary challenges and hardships. Girls and women aged 15 to

By Geralyn Ritter, executive vice president of external affairs and ESG, Organon

24 years have the highest unmet need for contraception. UIP can undermine educational opportunities, diminish employment prospects and present life-threatening health complications.

The situation calls for urgent action in terms of expanding access to family planning information and options. Women’s health and gender equity are critical global priorities, as set forth in the United Nations Sustainable Development Goals. By investing in the health of women and helping them take control over their reproductive choices, there is an opportunity to advance the health of all of society.

HER PROMISE IS OUR PURPOSE

GERALYN RITTER

Geralyn Ritter is executive vice president of external affairs and ESG for Organon, leading the global communications, public policy and government affairs, and ESG sustainability functions of the company. She is focused on advancing Organon’s vision by developing the company’s strategy in each of these areas, leading its implementation and engaging with the company’s many stakeholders.

organon.com

Organon is a global healthcare company established just over one year ago with a clear purpose: to enable the almost 4 billion women and girls in this world to achieve their promise. We are seeking to be the world’s leading women’s health company and are working to find new solutions to address the significant unmet medical needs women face through a variety of programmes and initiatives.

One of our key initiatives is to prevent

Half of all pregnancies worldwide are unintended – and it’s time for action

The mural depicted on this page is part of a global activation initiated by Organon, which works with artists to visualise women’s promise and potential through better health. More than 20 murals around the world have been created as part of this effort.

120 million UIP by 2030 in the least developed countries – an ambitious goal that we are undertaking alongside public and private collaborators. These partnerships are critical because no one company can tackle UIP alone.

Below are some of the actions that we believe deserve priority attention, where Organon is playing a role, and where partnerships can accelerate progress towards reducing the rate of UIP. All are focused on creating a journey that is not only for her, but with her – and ensuring girls and women have a voice in their reproductive journey.

Reimagine reproductive health education. Education plays an integral role in reproductive health. An estimated 33 million UIP are a result of contraceptive failure or incorrect use. Changing this outcome requires a sea change in how we help people to understand not only their contraceptive options, but also the proper use of their chosen method. At Organon, we are especially committed to advancing understanding of modern contraception, including long-acting reversible methods, that have the highest rate of success in preventing unplanned pregnancies. We believe over time we can help with the education process and be a resource for women and healthcare professionals looking for science-based information.

Meet youth where they are. Globally, girls and adolescents are the most seriously impacted when it comes to UIP. Young people are our future leaders, and we are leaving too many behind. Reducing UIP among youth requires meeting them where they are with the people, organisations and channels that resonate most. Women’s health – in particular reproductive health –is still full of stigma, too often in the shadows and often deprioritised. We must tackle this head on as part of our

work by normalising conversations about women’s health topics and battling a tangle of taboos and stigma around gynaecological and sexual health.

Focus on the most vulnerable. UIP rates are highest among low-income women, young women and women of colour. Expanding access to family planning among such groups is critical to reaching the SDGs. A variety of cross-sector initiatives are needed to move the needle on access. For its role, Organon operates the Her Promise Access Initiative, part of a multi-agency global effort to expand information and contraception availability to the world’s lowest-income countries. Significant progress has already been achieved since the programme’s inception and we are committed to helping millions more women take control of their own fertility and have children only if and when they feel ready to do so.

Raising her voice. Finally, we need more advocates for women and their health care, including those who are involved in decision-making and policy design. Women hold around 70% of jobs in the health sector but only 25% of senior and decision-making roles. This means, in the near term, we need to listen far more intently for her voice – because we can only address women’s unmet health needs when we hear her. Simultaneously, we can all work to advance women to leadership positions, so that they can advocate for other women and their reproductive health needs.

PARTNER ON A PROMISE FOR HER

The impact of UIP ripples through society and calls for urgent action. Especially when we know that the future of women and girls could be so much brighter.

It’s critical that public officials recognise the severity of the crisis of UIP – and the cost-effective solutions available. Globally, it is estimated that every $1 spent on family planning yields an estimated $120 in health and economic benefits.

The investment in women benefits all society and has a multiplier effect. When women have access to contraceptives and control over the timing of their pregnancy, they are more likely to achieve higher levels of education, seek more employment opportunities, and have children that are healthier and more educated.

The bottom line is that healthy women are the backbone of a thriving, stable and resilient society. And when we invest in her health, her equity and, especially, access to her options, we all benefit from the power of her promise. Join us on the journey at organon.com.

“ Globally, it is estimated that every $1 spent on family planning yields an estimated $120 in health

Open up science, foster Health For All

director-general, UNESCO

Health will not be accessible to all without open science.

If scientists have been able to work quickly and efficiently to develop safe Covid-19 vaccines in record time, it is because the barriers that often hinder science have been lowered – even if temporarily.

Scientific publications are a case in point. While 70% are normally locked behind paywalls – often prohibitively expensive for researchers from low-income countries – only 30% of publications specifically on the pandemic were subject to restrictions on access.

Health For All will also be impossible without more egalitarian and geographically diverse science.

Although the number of researchers and public and private funding increased by 14% and 19% respectively between 2014 and 2018, this growth

The Covid-19 pandemic has shown the incredible potential of open science. Now is the time to deploy it and remove existing barriers

has been mainly attributed to just two countries, the United States and China. Four in five countries spend less than 1% of their gross domestic product on public and private research.

Indeed, the scientific landscape remains one of extremes.

This unbalanced process of scientific development has tangible impacts, such as unequal access to vaccines against Covid-19. This is not only unethical and unacceptable, but also creates bottlenecks in health systems. It is high time that we made science more egalitarian and more open.

A SOURCE OF INNOVATION

It must be more open to interdisciplinary exchanges, which throughout history have been a source of innovation. As the UNESCO Science Report recalls, the rapid development of messenger RNA vaccines was made possible by research in the 1990s that targeted cancer immunotherapy, a discipline far removed from epidemiology. It must be more open to scientists from diverse backgrounds. As such, it will be important to tackle the concerning trend cited by the UNESCO Science Report of a disaffection towards scientific careers. For some, it is the low salaries, outdated equipment and inadequate budgets that holds them back. For others, it is the precarity of their employment, the heavy teaching workload or the relentless paper-pushing to obtain project funding. These institutional obstacles should not be overlooked.

It must be more open to women, who at present represent only one-third of the world’s researchers. That number only drops when we include fields such as engineering or artificial intelligence – fields that will be increasingly important in the future. It must be more open to society, because opening science also means taking it beyond the scientific community. By developing free educational resources and scientific culture, we can democratise science and bring it closer to the needs of contemporary societies. As the pandemic has taught us, we cannot have a healthy public without confidence in science.

“

By developing free educational resources

science and bring it closer to the needs of contemporary societies. As the pandemic has taught us, we cannot have a healthy

In October 2020, UNESCO, the World Health Organization and the Office of the United Nations High Commissioner for Human Rights called for a more open science and the construction of a fairer, more equitable and ultimately more effective scientific community.

To guide states towards this goal, UNESCO developed a Recommendation on Open Science, adopted in November 2021 by its 193 member states. This recommendation complements UNESCO’s actions in the field of international cooperation, notably with its network of independent centres of excellence, and chairs at universities and research institutions.

The time to act is now. The frameworks are already there. The only thing left to do is to make a decision: to open up science and make health accessible to all. This is a political choice that we must have the courage to make, and that UNESCO is advocating for.

AUDREY AZOULAY

70%

publications are normally locked behind paywalls, but just 30% of pandemicwere subject to restrictions on access

4 ⁄5

countries spend less than 1% of their GDP on public and private research

Just of the world’s researchers are such as engineering intelligence

1⁄3

Audrey Azoulay has been director-general of UNESCO since 2017. She led a vast Strategic Transformation programme to position the organisation at the heart of emerging challenges in the 21st century, including major projects on protecting cultural heritage, through the initiative ‘Revive the Spirit of Mosul’ in Iraq, on the achievement of universal quality education, in particular for girls and women, as well as on UNESCO’s role as a global laboratory of ideas on issues such as sustainable development and the ethics of artificial intelligence.

@AAzoulay unesco.org

A new precedent for tackling infectious diseases

Just this year, we have seen an astonishing number of infectious diseases resurfacing and spreading at concerning rates in a way that we have not seen before. The continuing Covid-19 pandemic, the global spread of monkeypox, the first reported outbreak of Marburg in Ghana, and now the sustained detection of vaccine-derived polio viruses in New York and London are all indicators of the world’s growing vulnerability to infectious diseases.

We could attribute this to an inevitable consequence of 21st-century life. The link between climate and health is increasingly evident, and human interactions with disease vectors, often within animal populations, continue to rise. These are further amplified as cities continue to expand rapidly, and populations are more interconnected than ever, with international trade and travel rebounding. These factors are putting us all at further

By Sir Jeremy Farrar,

risk of exposure to infectious diseases. This threat will only truly be addressed through global cooperation and concerted political will and action.

The Covid-19 pandemic has demonstrated that we can achieve much more by working together. Uncommon levels of global scientific collaboration and the sharing of data and research across borders enabled the world to develop tests, treatments and vaccines in record time. Yet we must acknowledge that more could have been done and faster, if governments had collaborated earlier and the right tools and equitable distribution systems been in place –an opportunity that we must act on now.

DISEASES ARE BORDERLESS

Infectious diseases do not respect borders. To prevent and control outbreaks, we need to have the sustained teams and tools in place to monitor diseases locally, while ensuring this information is shared rapidly and

A failure to prepare costs us far more in the long run. Now is the time to set a new precedent for global collaboration in the fight against infectious diseases

director, Wellcome Trust

transparently nationally and globally and the benefits that arise – access to tests, treatments, vaccines and public health interventions – are also equitably shared. In recognition of the need for a better detection of future threats, last year the G7 launched plans for an International Pathogen Surveillance Network, so that we can spot new variants and emerging pathogens and get ahead of them. This laid the groundwork, but through the G7 Pact for Pandemic Readiness, the World Health Organization Hub in Berlin and other initiatives – we can go a lot further. This work is just beginning and undoubtedly considerable effort is needed, but we are by no means starting from scratch. Covid-19 has shone a light on how valuable high-quality, real-time data is for an effective response for clinicians, researchers, policymakers and the public alike. In the United Kingdom recently, it was astute clinicians in sexual health clinics – trusted by the communities they were designed to support –that provided the first evidence of the new monkeypox outbreak in non-endemic countries, highlighting the difference that investments in this infrastructure, but also trust, can make.

SIR JEREMY FARRAR

Sir Jeremy Farrar is the director of Wellcome, a global charitable foundation that supports science to solve urgent health challenges. He is a member of the UK Vaccine Taskforce and the Principles Group of the Access to COVID-19 Tools Accelerator, and chairs the World Health Organization’s R&D Blueprint Advisory Group. In 2018, he received the President Jimmy and Rosalynn Carter Humanitarian of the Year Award and in 2019 was knighted for services to global health.

@JeremyFarrar wellcome.org

Now is the time to build on this, improving local resources and expertise as well as testing and sequencing capacity, linking this up globally and ensuring that insights lead to rapid intervention. To work, this must become part of the sustained local infrastructure, not just set up in times of crisis, and able to monitor and respond to all day-to-day health issues as well as monitor for outbreaks of diseases. The persistent rise of drug-resistant infections – a slow-styled pandemic – kills hundreds of thousands of people every year, in all parts of the world. With this infrastructure we could begin to combat it.

MAINTAINING FOCUS

However, this vital work must continue even as other important matters vie for our attention. Whether at the national level across ministries or at the global level across continents and multilateral organisations, our leaders cannot put this on the backburner. As with any generation-defining event, we owe it to ourselves and future generations to act now, so that a pandemic never disrupts on this scale again. Collaboration will be key to preventing and combatting current and future outbreaks.

As parts of the world strive towards their new ‘normal’, it remains vital that we maintain momentum so that we can enhance health systems and better detect any infectious disease outbreak before it is too late. An easy win is for global leaders to step up support for the World Health Organization and join the International Pathogen Surveillance Network.

Governments must take responsibility and be committed to transparency, and be willing to share information collected nationally with the global communities. But they also have a responsibility to create the right incentives for sharing data and ensure that those who share data do not suffer negative consequences for doing so. Enhancing skills, disseminating knowledge, and integrating local and

international teams are critical in addressing inequity and inefficiency in global surveillance. Now is the time for world leaders to provide and sustain not only the political will but also the sustainable financing required to enable better preparedness. This includes adequately resourcing the newly established Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response, which has broad support from the G20. This new fund will focus on supporting country and regional capabilities, addressing gaps in the world’s infectious disease prevention and preparedness system by working through our communities and established structures, so not adding to an already fragmented system. The importance of this cannot be underestimated, which is why earlier this year Wellcome contributed £10 million as a founding partner to help launch the fund. The saying ‘unprecedented times’ can lose meaning in overuse, and the urgency behind ‘never again’ often fades as crises recede. We must not let this happen. Recent events have taught us that a failure to prepare costs far more in the longer run. The world is more vulnerable to infectious diseases than perhaps ever before – it is not ‘if’ but ‘when’ there will be a new threat. World leaders must move from warm words to action, and they must do so sooner rather than later. ▪

Impact on health

How does Sanofi’s corporate mission reflect a commitment to global health and equity?

Our commitment to global health and equity is a long-term effort with a legacy that spans decades. We are at a point in time where our world is changing at an unprecedented rate; the global population is expected to increase to 8.5 billion in 2030 and currently 2.5 billion people have limited access to quality health care, a staggering figure not limited to low- and middle-income countries. It is time to rethink how we approach shared global responsibility.

Given the increasing health access challenges for so many populations, we are at a turning point in our company’s history. Sanofi has revamped its social impact strategy and is approaching our core initiatives with a renewed purpose that underscores our corporate mission: we chase the miracles of science to improve people’s lives. This reflects our goal to make life better for patients, partners, communities and our own people.

Through the Global Health Unit, one of Sanofi’s three social impact pillars, we’re doubling down on our efforts to support better health and better access to quality medicines and vaccines, particularly the underserved population and vulnerable communities across all geographies, to foster economic growth.

In short, access to health care is at the core of our corporate mission: research, development, and the manufacture and supply of medicines and vaccines to people who need them.

What factors led to Sanofi’s Global Health Unit formation, to take on such tasks as making quality medicines accessible and helping ministries of health and non-governmental organisations build universal health coverage for non-communicable diseases?

According to the World Health Organization, “17 million people die from a non-communicable disease before the age of 70 and 86% of those premature deaths occur in low- and middle-income countries”.

In 2015, the United Nations adopted its 2030 Agenda for

Sustainable Development where it recognised health as both a precondition for and an outcome of the agenda, and non-communicable diseases were included as a sustainable development priority for all countries for the first time.

As part of the global effort to tackle the scourge of NCDs, Sanofi, which leveraged the UN SDGs as the foundation for its social commitment strategy, established a new global non-profit, the Sanofi Global Health Unit, in 2021.

Why is it so important for the private sector to help increase access to health care and how does it do that best?

As we are coming out of the Covid-19 pandemic, there are several lessons that have been learned that should be prompting us to rethink how we can expand global access to essential medicines. The pandemic showed us that we need to take a more holistic approach to public health challenges and that industry, healthcare systems, governments, NGOs and local engagement all play a role.

The private sector has a strong infrastructure, logistics experience and resources to move the needle forward and to help increase access to health care.

We know that there is a growing burden of NCDs, especially in low-income countries. Considering all these factors, the GHU is designed with this three-pillar approach to make it successful by delivering the right medicine to the right person at the right time and not only doing it once but ensuring that when we do, we leave a sustainable legacy that improves the overall health of our population.

To do all this effectively, we will have an operating model that allows us to be incredibly efficient and

Interview with Jon Fairest, head of Global

Driving measurable and meaningful change in health care demands broad support and investment. Enter Sanofi, whose ambition is to build sustainable, cost-effective health systems that manage themselves

cost effective. We'll also be testing new technology. We are planning to have QR codes in the future so that patients can access in many languages their medical information without us having to have expensive repackaging. We also will be able to use this brand to ensure that patients know every time they buy a box of this product, they get consistent quality medicine from Sanofi.

What makes the Sanofi GHU model unique? What medicines does the Impact Brand include and what therapeutic areas do they cover? What resources is it devoting to the task, including through its Impact Brand and Impact Fund?

Our portfolio of 30 essential medicines includes first-line treatments for diabetes, hypertension, thrombosis, stroke/prevention, malaria, tuberculosis, and breast, lung and prostate cancer. We already reach patients in 22 countries. We work with global and local regulatory bodies to ensure systematic availability and with international distributors to reduce mark ups and optimise prices.

As mentioned above, our holistic three-pillar approach on providing affordable treatments, strengthening health systems through public and non-governmental organisations, and supporting inclusive businesses in the private sector in those 40 underserved countries is unique.

Our approach to sustainability is also unique with our non-profit self-sustained model, our philosophy of engagement from selling medicines at access prices and efforts at shaping healthy markets versus donations. Additionally, engaging in projects with local partners having the ownership and with a clear path to sustainability, and support from the private sector, are critical factors in building financially viable care-delivery ventures.

The Impact Fund will focus on improving access to health – with a specific focus on NCDs – in Sanofi global health countries, supporting the scale-up of a portfolio of healthcare delivery ventures through financing and technical support.

JON FAIREST

Jon Fairest is head of the Global Health Unit at Sanofi where he leads strategy and implementation of the newly launched non-profit, sustainable business that will operate in the 40 poorest countries in the world to expand access to 30 essential Sanofi medicines. Jon joined Sanofi in 2002. He held general manager roles in Bulgaria, Finland, Portugal and Canada before taking the position of head of the Africa region. In 2019, Jon became head of external affairs for Eurasia, Middle East and Africa and served as head of trade and revenue management, a transversal organisation across Sanofi Global Business Units. Jon began his career with Bayer in the United Kingdom where he held positions in sales and marketing. He is a member of the Chartered Institute of Management Accountants.

@sanofi sanofi.com

This initiative is firmly in line with the GHU strategy, creating impact in GHU focus countries through a business approach. The fund will complement current GHU work with public actors through the private-sector scale-up. In addition, the development and scale-up of new ventures will generate additional demand for GHU activities: better healthcare systems will enable GHU to sell affordable medicines in the targeted countries in areas where a poor supply chain or lack of healthcare services are currently preventing it. Sanofi is contributing through an initial commitment of €25 million to be invested over several years.

What advances has Sanofi’s GHU made thus far? How many lives have been saved or improved as a result? What challenges and tasks lie ahead?

We announced a year ago that we were going to make 30 medicines available in 40 countries and we’ve been serving some 145,000 people since.

Now we’re focused on how to do this best, with an ambition to ramp up this care to 2 million NCD patients by 2030 and doing it effectively by establishing and bolstering healthcare systems. For example, by developing our own GHU brand with dedicated cost-of-goods access prices, by supporting ministries of health and NGOs to advance universal health coverage, and by investing in local entrepreneurs’ social businesses with the Impact Fund.

How is the GHU building authentic sustainable partnerships to deliver end-to-end access programmes? Has the GHU’s unique, self-sustained model led other firms in the health sector to follow, to help with this global cause?

We understand that this issue is too large a challenge to be tackled single-handedly, so the GHU is focused on creating partnerships and empowering start-ups. The goal is to create a legacy that can assist LMICs at a strategic level.

We want to build partnerships, not just with governments but also with NGOs and communities: partnerships that will become entrenched and programmes that are sustainable, that communities can own. It’s also about partnering with organisations that are already working in communities and providing them with the support they need to access patients with chronic diseases. Local education on diagnosis and care is also extremely important.

In the face of such a multifaceted problem, trying to ensure that the GHU delivers measurable and meaningful change is a challenge. It’s critical that we change mindsets and increase patient reach. We believe we can do that by supporting local entrepreneurs and building sustainable private initiatives with equity investments through the Impact Fund. That’s why we’re working with ministries of health, local start-ups, and NGOs and faith-based organisations involved in local delivery of health care to work out where funding is coming from, which patients we are going after and how we are going to collect data that will enable us to measure outcomes. The end result is that in five years’ time, we can have health systems that manage themselves. ▪

Rethinking our values

The Covid-19 pandemic and ensuing global economic crisis helped lay bare what we truly value as a society – health and well-being for all – and our collective failure to build an economy on those values. It showed us that if we fail to design our economic systems to tackle humanity’s greatest challenges in ‘normal’ times, no amount of money and last-minute firefighting will fix them in a crisis.

We need to start with the core goal of Health For All to decide what we should value moving forward, and then work backwards to reorient our economic and financial policy levers and metrics according to those goals. This has been the work of the World Health Organization

Council on the Economics of Health For All. It proposes three key values as the foundations of a well-being society and values-based economy. These are:

▪valuing planetary health, including essential common goods such as clean water, clean air and a stable climate;

▪valuing diverse social foundations and activities that promote equity, including social cohesion, supporting people in need and enabling communities to thrive; and

▪valuing human health and well-being, with every person able to prosper physically, mentally and emotionally, and provided with the capabilities and freedom to live lives of dignity, opportunity and community.

BEYOND ECONOMIC GROWTH

Such a reimagining of values means moving away from fetishising economic growth as the North Star and guiding light of all economic policies, institutions and governance systems. It means taking a ‘dashboard’ approach to assessing economic performance, where gross domestic product growth is just one of many metrics that help us assess how we are advancing the health of people and the planet and promoting equity in our societies. For example, by introducing time-use data into its national household

Beginning with the ambitious goal of Health For All, we should work backwards to reorient our policies in the direction of well-being societies and values-based economies, and advance a healthy planet

By Mar M r arianianaaM M a Mazz zz z a ucaatto, to, cha c ir ir, WHHOC O C Coun o cil il on o the h he Econo n no i mic mi so s of f Hea Health lt l ForA r A r ll l

surveys, Uruguay identified a 20% gender gap in labour force participation, and ultimately introduced a national care plan that in 2017 reallocated $67 million for early childhood services and people with disabilities, among other things. By collecting data on the things we value, we can then identify new gaps and redirect budgets towards Health For All in powerful ways.

Achieving a values-based economy also means taking a much more proactive, market-shaping approach to the governance of innovation, where governments are an active driver and partner in stimulating innovation, rather than seeing their role as a ‘market fixer’ when the private sector fails to deliver on Health For All. A great example of this is intellectual property rights – we need to rethink how we govern patents in such a way that we can truly foster collective intelligence and equitable access to innovation, rather than transferring billions in public resources to pharmaceutical companies for research and development, and then allowing them to reap all the upside at the public’s expense. We need to reimagine public-private partnerships in ways that enable society to capture and benefit from more of the value being created by governments when they partner with the private sector in areas such as health and climate.

MAJOR GOVERNMENT INVESTMENT

Reimagining economic systems to achieve a well-being society also means major government investment in the values that underpin Health For All, as well as the capacity to deliver on them. For many low- and middle-income countries, the current economic landscape of enormous debt, high inflation, climate disaster and a global food crisis have created overwhelming fiscal challenges and thrown the Sustainable Development Goals years off track. These countries require radical new forms of support from the global community, from massive debt relief and cancellation, to access to more substantial, longer term, deeply concessional finance from development banks, to the issuance of new special drawing rights, to the end to the decades-long theology of austerity, which even according to the International Monetary Fund has only exacerbated inequality and gutted public sector capacity in the process. Alongside external support for increasing fiscal space to advance Health For All, countries can also pursue more equitable domestic tax systems that ask those with the most to pay the most, rather than relying on regressive value-added and sales taxes that disproportionately burden the poor to finance government services. Countries at all income levels can also introduce outcomes-based budgeting, where values-based metrics such as ‘reducing maternal and child mortality’ or ‘reducing the carbon footprint of the industrial sector’ are the basis for allocating and assessing government expenditure.

Achieving a well-being society that functions within planetary boundaries will not happen by accident. Indeed, deferring to the invisible hand of unfettered capitalism in pursuit of constant economic growth is what helped generate the unprecedented levels of economic inequality and planetary crises we now confront. We need a clear, massively ambitious goal such as Health For All to reorient our economies around and guide us out of this mess. The well-being of our societies and our planet itself hang in the balance. ▪

Mariana Mazzucato chairs the World Health Organization’s Council on the Economics of Health For All, established in May 2021. She is a professor on the economics of innovation and public value at University College London, where she is the founding director of the UCL Institute for Innovation and Public Purpose. She is also a member of the OECD secretarygeneral’s Advisory Group on a New Growth Narrative and of the United Nations High Level Advisory Board for Economic and Social Affairs, among other roles. Her most recent book is Mission Economy: A Moonshot Guide to Changing Capitalism.

@MazzucatoM marianamazzucato.com

“ A reimagining of values means moving away from fetishising economic growth as the North Star and guiding light of all economic policies, institutions and governance systems”

MARIANA MAZZUCATO

The gateway to all vital health interventions

A progressive universalism approach to health care would prioritise immunisations for children, offering the fastest and most effective way to cover lost ground in global public health – and helping to bring universal health coverage within reach

It is now well established that Covid-19 has widened the global health equity gaps that existed even before the pandemic, pushing the Sustainable Development Goals wildly off track. But although Covid-19 remains an ongoing concern, we were already off track before the pandemic. In terms of challenges to the SDGs, Covid-19 is more a taste of things to come, and just one of many global trends that now threaten to make it increasingly difficult to achieve global goals – including Health For All – by 2030. In the face of what will likely be an increasingly uphill struggle, it will now take unprecedented financing, political support and prioritisation to get back on track.

Consider the context. Even as Covid-19 continues to spread, research suggests that the probability of us experiencing another pandemic with the same kind of impact is increasing by 2% each year. Similarly, every year now climate change, migration, conflict and food insecurity continue to leave hundreds of millions more people displaced, vulnerable and at risk. The implications of all this for public health are dire, which is why it is so important now not only to reverse the backslides we have seen, but to also gain ground as quickly as possible. And one way, and perhaps the best way, to do this is to prioritise vaccine equity.

By Seth Berkley, CEO, Gavi, the Vaccine Alliance

THOSE LEFT BEHIND

The ultimate vision of Health For All means reaching a point where every country is able to provide access to affordable, quality health care to every person, everywhere, regardless of their social and financial status. In practice, the biggest barrier to achieving universal health coverage by 2030 will be reaching those people who have been left behind, the vast majority of whom live in the most marginalised communities in middle- and low-income countries where resources are often already limited, even more so thanks to Covid-19. That will take domestic and international investment in public health across the board to ensure that everyone, everywhere has – at the very least –access to stronger and more resilient primary health care. And routine immunisation has by far the greatest potential to make sure this occurs where the impact is the greatest, namely among missed communities.

That’s because the challenge, as we have seen with Covid-19, is that the last to be reached are often the hardest to reach. These are also the communities with the most to gain, and routine immunisation can help because it is an enabler. As the most efficient and cost-effective healthcare intervention, with the greatest reach and secure health outcomes, immunisation is

often a gateway to other vital health interventions, helping to strengthen primary health care and bring us closer to universal health coverage in the process.

If a child misses out on routine vaccines, then the chances are that that child, their family and community are also not getting access to other forms of primary health care. But once a community gets access to vaccinations, it brings with it an entire service delivery infrastructure, including supply chains, cold storage, trained healthcare workers, data systems and surveillance, all of which help to improve access to other critical health interventions, from nutritional supplements and deworming to malaria prevention and maternal care.

REACHING ZERODOSE CHILDREN

That is why Gavi’s mission to halve the number of zero-dose children –those who do not receive even a single dose of a basic vaccine – by 2030 is so critical to the success of the SDGs. These children are the face of extreme poverty and missed communities, too often with limited access to both health and non-health services such as education, water and sanitation.

By redoubling our efforts to reach more zero-dose children, we help protect the most vulnerable children in the world from infectious disease. Plus it serves as an opportunity to build stronger and more resilient primary health care, arguably where it counts the

most. And in the process, it also helps to improve pandemic preparedness. Local communities often have a better understanding of what they need the most, and when empowered with better health, knowledge and support, they are best positioned to design and implement preparedness interventions that address their specific health needs and challenges.

However, given the enormous toll that Covid-19 has placed on immunisation services in low-income countries, increasing immunisation coverage will not be easy. In 2021, the percentage of children receiving routine immunisation in the 57 low-income countries that Gavi supports had fallen to 77%, a drop of five percentage points since before the pandemic. Similarly, the number of zero-dose children in these countries rose for the second consecutive year to 12.5 million. That is a lot of ground to make up, let alone improve upon.

For low-income countries, many of which have even more limited resources than before the pandemic and many competing priorities, the goal of attempting to provide all health services to everyone may simply be too much. However, by focusing resources and efforts on those solutions that are most cost-effective and most beneficial to the poorest and most vulnerable communities, even the most cash-strapped government can start to build on this to make other health services available too.

Routine immunisation is just such a solution. It is already the most widely available health intervention in the world, but through this approach, known as progressive universalism, it can help to improve and accelerate access to stronger, more resilient primary health services to the communities most in need, bringing

SETH BERKLEY

Seth Berkley joined Gavi, the Vaccine Alliance as CEO in 2011. A medical doctor and infectious disease epidemiologist, in 2020 he co-created COVAX, the only global multilateral solution aimed at ensuring equitable access to Covid-19 vaccines for people in all countries, regardless of their ability to pay. He founded the International AIDS Vaccine Initiative in 1996 and served as president and CEO for 15 years. Previously, he worked for The Rockefeller Foundation, U.S. Centers for Disease Control, Massachusetts Department of Public Health and the Carter Center.

@GaviSeth gavi.org

us closer to universal health coverage and Health For All. And in the process, everyone benefits, because it also helps to build resilient societies.

So, while it remains imperative that we continue to work towards achieving equity with Covid-19 vaccines, we also urgently need to restore and expand routine immunisation. That does not mean it should be our only focus. There is also an urgent need for investment in the healthcare workforce in many of the worst affected countries, without which immunisation programmes cannot operate, not to mention disease surveillance and many other areas that need political support and funding. But with an increasingly challenging global health landscape, taking a progressive universalism approach, by prioritising zero-dose children, offers the fastest and most effective way to simultaneously make up lost ground and have the biggest impact, by making sure that no one is left behind. ▪

“

By focusing resources and efforts on solutions that are most cost-effective and beneficial to the poorest and most vulnerable communities, even the most cash-strapped government can start to build on this to make other health services available too”

Better health care, universally

What is Bayer doing to respond to planetary crises and improve access to health care globally?

Guided by our vision of “Health for All, Hunger for None”, we at Bayer are making incredible leaps in advancing health and agriculture to address the major challenges facing humanity today. Historic droughts and floods, rising temperatures, and water and food scarcity put acute pressure on our global health and food systems. Lowand middle-income countries feel the brunt of this pressure the most.

Innovation and collaboration will be key to combating these challenges. We’re using innovative breakthrough technologies to create a more sustainable, resilient food system while helping farmers create better harvests with less land, water and energy. We have established ambitious and auditable targets aligned to the United Nations Sustainable Development Goals to keep us on track. We’re supporting, for instance, 100 million smallholder farmers in LMICs to feed themselves and others by 2030, by improving access to knowledge, products and services.

To provide greater access to health care, we’ve stepped up our access to medicine activities with new tiered pricing models, patient affordability programmes and focused partnerships with supranational organisations, to name a few. One of our goals is to help provide 100 million women in LMICs with modern contraception by 2030 –an ambitious endeavour that can only be realised through partnerships. As planetary crises increase, girls and

Interview with Stefan Oelrich, member of the board of management, Bayer AG and president, pharmaceuticals division women will be faced with further gender inequalities and sexual and reproductive health rights issues, so we must work together to tackle this.

How can collaboration and innovation solve the world’s most pressing health challenges?

At Bayer we believe we can best identify concrete ways to reach those left furthest behind in some of the most challenging, crisis-ridden parts

of the world by partnering with local and global stakeholders. Collaboration and innovation are key to protecting our climate and to improving access to health care globally.

We have partnered with the World Health Organization, for instance, to eradicate or control several neglected tropical diseases. In collaboration with the Drugs for Neglected Diseases initiative, we have a new compound in clinical development for the treatment of river blindness. And with our implementing partner GIZ/International Services we have launched the Ghana Heart Initiative, a multi-stakeholder project aiming to increase the effectiveness of cardiovascular treatment in Ghana.

As we are a leader in women’s health, gender equality is a topic close to our hearts. We provide a broad range of contraceptives at preferential prices to the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA) and non-governmental organisations to help provide women with more family planning options. We use revenues from such sales to fund capacity-building, such as The Challenge Initiative, hosted by the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg

Collaboration and innovation together provide the key for unlocking Health For

All – and Bayer is one organisation that is leading the charge

School of Public Health. Additionally, a collaborative pilot between Bayer and the German Red Cross explores how to address sexual rights and reproductive health issues in humanitarian response.

How will technological advancements improve access to health care?

STEFAN OELRICH

Stefan Oelrich is a member of the board of management of Bayer AG and president of its Pharmaceuticals Division. Over his 30-year career in the pharmaceutical industry, he has spearheaded healthcare innovation transformations to improve the lives of patients. Stefan is a supervisory board member of the university hospital Charité.

@Bayer bayer.com

Digital tools and data are changing how we discover and develop medicines, the kinds of therapies we offer and how they are delivered to patients. Technological advancements are making health care more patient-centric and participatory. We can see this clearly in the example of clinical trials. There has been an accelerated uptake of virtual, or decentralised, trials that use software and sensors to monitor patients in the comfort of their own homes, rather than requiring them to travel to trial centres.

Telemedicine has a profound effect on improved access to health care. In rural communities in some developing countries, smartphone cameras are being used these days to remotely screen patients for eye conditions and other illnesses. We know that even simply sharing healthcare information and advice via SMS can help prevent or minimise the need for intervention.

Yet, technical advancements are not enough – we need a faster transition from ideas to products and go-to-market to really make an impact. Ideally, there needs to be platforms or forums where non-profit and profit sectors can come together to help accelerate and incubate technological offerings, which could include technical and digital assets, business coaching and mentoring, and networks to accelerate growth and access to investors. At Bayer, our G4A and Bayer Foundation support us in this mission.

How is Germany’s G7 presidency in 2022 putting health innovation and sustainable health firmly on the agenda?

I think it is making good inroads. For example, Germany’s G7 Leaders’ Communiqué recognised the rapid rise in antimicrobial resistance, a looming crisis that has the potential to dwarf Covid-19 in terms of deaths and economic costs. The communiqué also reiterated that no

efforts will be spared to continue addressing this silent pandemic. It understands that we must act now to safeguard our future from this global threat. Bayer is part of the recently launched AMR Action Fund, a groundbreaking partnership that aims to bring two to four new antibiotics to patients by 2030. With this fund, we aim to overcome key technical and funding barriers of late-stage antibiotic development. But more needs to be done. In the most recent Berlin Declaration –which Bayer fully supports – the innovative biopharmaceutical industry proposes to create a collaborative solution for more equitable rollout of vaccines, treatments and diagnostics for future pandemics. Industry is willing to do its part, but it calls on the G7, the G20 and all stakeholders in the global health community to play their part too. Open boundaries and no trade restrictions are requisites for success. Here, too, sustained political support is essential. ▪

Telemedicine has a profound effect on improved access to healthcare … We know that even simply sharing healthcare information and advice via SMS can help prevent or minimise the need for intervention”

Advancing health by caring for nature

By Ilona Kickbusch, founding director, Global Health Centre, Graduate Institute of International and Development Studies

The world must commit to a transformative approach that promotes health and well-being. Living in the Anthropocene – an epoch defined by the human impact on our ecosystems – moves us into unknown territory. The challenge is to find a way of living that aims to meet the needs of all people within the means of the living planet. Policymakers require foresight, determination, courage and agility to shape the future.

In 2015 the world adopted a blueprint – the 2030 Agenda for Sustainable Development – and its 17 Sustainable Development Goals have been important in setting global priorities and highlighting the interrelationships among humanity’s big challenges. Today, as the world drifts apart geopolitically and multilateralism weakens, progress towards most of the SDGs is moving backwards. According to the World Bank, poorer countries are now contending with a deep, long-lasting crisis, reinforced by the pandemic and the war in Ukraine, that has increased global poverty and is reversing recent trends in reducing inequalities within and between countries. Human development,

especially women’s rights, has also been set back by a full generation. Millions of people have fallen back into poverty because of out-of-pocket healthcare costs. We are clearly on the wrong track.

IN SHORT SUPPLY

Public policy for the common good is in short supply. This is a legacy of the neoliberal decades. We do have models, knowledge and technologies at our disposal that could significantly improve health and well-being and create fairer, more sustainable societies. Yet they are not used widely to serve public purposes or the global good. The Covid-19 pandemic demanded a united response based on solidarity between developed and developing countries –but that did not arise.

Instead, vaccine nationalism and geopolitical vaccine diplomacy took centre stage. Fighting a global pandemic became an ideological issue of system competition. This does not bode well for addressing other global challenges together. It has further destroyed trust in a global governance system seen to favour the richest and punish the poorest. This makes global cooperation increasingly difficult.

The SDGs embrace complexity – what seemed initially to be a ‘nice to have’ approach has now become an existential necessity for our future. The post–World War Two organisations and governance modalities – based on silos and distinct technocratic solutions – have great difficulty in responding to simultaneous and cascading systemic crises that are triggered by inequality, climate change, pandemics, food insecurity, war, digitalisation and a weakening democracy.

Meeting the needs of all people within the means of our living planet is rooted in policy choices that take a broad view –capturing what affects our happiness, the new types of inequalities arising from technology and climate change, and how to restore the bonds within and between societies

The leadership challenge ahead is:

▪how to engage in policymaking in such an extremely complex and dynamic environment,

▪ how to deal with uncertainty,

▪ how to deal with highly non-linear cause-and-effect relationships and the spillovers between policy sectors, and

▪how to convey this new way of policymaking to the public.

▪This will challenge decision makers in new ways. In the face of multiple crises they need to build forward rather than react to risks, and reach out to other sectors and communities to engage them in co-designing the future.

NEW SOCIAL CONTRACTS

A priority for co-design is to consider generating new social contracts that reflect the world as it is and will be – not how it was – and to define jointly what binds us in this much more dangerous world of power shifts and social unrest. Many of the premises on which the post-war social contracts – national and global – were drawn up no longer hold, ranging from the power relationships between men and women to the power relationships between countries.

Our very understanding of what we consider successful policies must be questioned at its core. All major international organisations agree that macroeconomic data alone,

Human development, especially women’s rights, has been set back by a full generation. Millions of people have fallen back into poverty because of out-of-pocket healthcare costs”

ILONA KICKBUSCH

Ilona Kickbusch is the founding director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva, Switzerland. She served on a panel of independent experts to assess the World Health Organization’s response to the Ebola outbreak and is a member of the Global Preparedness Monitoring Board. She previously had a distinguished career with the WHO and Yale University, and has published widely on global health governance and global health diplomacy. She is a member of the WHO Council on the Economics of Health For All.

@IlonaKickbusch ilonakickbusch.com

such as gross domestic product, do not provide a sufficiently detailed picture of the living conditions and the health and well-being that ordinary people experience and want. The measure we seek must be the health and well-being that people experience in the context of everyday life. These measures must also include environmental sustainability. Policies to promote well-being must address the structures that shape people’s aspirations and impact on their experienced well-being through social relationships over time.

The World Happiness Report 2020 for the first time ranked cities by their subjective well-being and analysed how the social, urban and natural environments combine to affect our happiness.

The metrics proposed by the Organisation for Economic Co-operation and Development measure individual well-being through a combination of quality-of-life and material conditions and relate it to sustainability of well-being over time. But even the most progressive measures do not yet capture dimensions of well-being that we have only recently begun to acknowledge – such as the impact of structural racism or the level of violence against women.

New types of inequalities are opening in technology and climate change, which in turn show significant effects on health and well-being.

The Covid-19 lockdowns have made clear how dependent we are for our well-being on supportive social and physical environments and social interaction with others as well as with nature. Feeling valued and feeling safe, and having dignity and opportunity are key components of perceived well-being. Having access to green spaces

improves our well-being. Just as we begin to design the physical environment to fulfil ecological requirements, we can co-design our social environments to promote health and well-being. We need, says Minouche Safik, to “restore the ties that bind”. We can no longer only consider our individual well-being and that of our closest family and friends but must also take the broader view and “recognise our global interdependence while also reknotting the ties of mutuality that hold our societies together”. This, she says, requires significant investments in people’s security and capabilities. But above all we must learn to manage risk collectively, in solidarity.

REFOCUSING ON A COMMON PURPOSE

The SDGs aimed to set a common purpose for all peoples. But more than two years into the Covid-19 pandemic it has become clear how far removed we are from those goals, not only in terms of achievement but especially in terms of aspiration. Politicians need to counteract this trend. One approach could be to base their policies on the ‘doughnut’ model developed by economist Kate Raworth. It considers an economy as prosperous when 12 social foundations are met without overshooting any of the 9 ecological ceilings that need to be considered (see figure). Based on this, it is possible to identify the safe and just space for humanity supported by a regenerative and distributive economy.

No approach is perfect. But this is a sufficiently concrete start to co-design policies and address systemic risks and their combined impacts. We have no choice but to act now. ▪

Global health governance for the world’s well-being

By John Kirton, director, Global Governance Program

healthcare workers. The growing prevalence of long Covid and its physiological and neurological harms will burden health and social security systems, patients and their families for many years.

Global health challenges are growing, as policymakers still struggle to mount an effective response. Almost three years after it erupted, the Covid-19 pandemic continues, having taken many millions of lives and now spreading in countries that had largely escaped its initial waves. Joining it is a monkeypox pandemic. Even polio has reappeared in New York, London and Jerusalem.

Also more abundant and apparent are the many impacts of Covid-19 on chronic and non-communicable diseases and of other illnesses fuelled by the broader economic, social and ecological determinants of health. The compelling claims of Covid-19 on always limited and often inadequate healthcare resources have led to delayed treatments, surveillance, appointments, and research and development for many other illnesses. Covid-19 has infected and exhausted skilled and dedicated

Policymakers struggle to cope with these challenges, amid the many interconnected, inherently global, economic, ecological and geopolitical crises they now face. These include soaring inflation, slowing economic growth, the increasing ecological assaults of climate change and biodiversity loss, and military conflict in poor countries and now in Europe too. They place new demands on global governance and on the intergovernmental institutions of global relevance and reach at the core.

The central pillar is the World Health Organization, created in 1948 with a mission that recognised that “health is a state of complete physical, mental and social well-being … The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. The health of all peoples is fundamental to the attainment of peace and security and is dependent on the fullest cooperation of individuals and States.”

INNOVATIVE PROGRESS IN HEALTH

The Covid-19 pandemic has spurred much innovative progress in investing in health at the WHO. Its members’ World Health Assembly agreed to increase the portion of the WHO budget coming from their assessed contributions rather than voluntary donations. The WHO has played a key role in launching many new partnerships, notably the Access to COVID-19 Tools Accelerator, COVAX and the COVID-19 Technology Access Pool. WHO director general Tedros

Innovatively investing in Health For All is the key to a future unblighted by debilitating illnesses, diseases and pandemics, but it places new demands on governance around the world

JOHN KIRTON

John Kirton is the director of the Global Governance Program, which includes the Global Health Diplomacy Program, the G20 Research Group, the G7 Research Group and the BRICS Research Group, all based at Trinity College in the University of Toronto, where he is a professor emeritus of political science. He is coauthor, most recently, of Reconfiguring the Global Governance of Climate Change, and is co-editor of a series of G7 and G20 summit publications including G7 Germany: The 2022 Elmau Summit and G20 Indonesia: The 2022 Bali Summit

@jjkirton

www.ghdp.utoronto.ca www.g7g20.utoronto.ca www.brics.utoronto.ca

Adhanom Ghebreysus swiftly declared monkeypox to be a public health emergency of international concern. WHO members have agreed to negotiate a new pandemic treaty, to prepare for and help prevent the next pandemics sure to come. Yet the WHO, with a biennial budget of only $6.12 billion for 2022–23, rising only 5% from the previous period, still has fewer resources than hospitals in a single major city have to meet the global need.

The World Bank, founded in 1944 with an exclusively economic mandate, is increasingly investing in health. It has offered developing countries much financial support to counter Covid-19. Its governing board has agreed to host the new Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response, to be managed in partnership with the WHO.

The International Monetary Fund, also founded in 1944, shares the World Bank’s exclusively economic mandate, but has also responded to the Covid-19 crisis with financial support. It recently issued $650 billion in new special drawing rights and encouraged its rich country members to channel some of theirs to poor countries through its new Resilience and Sustainability Trust designed to

address health and climate change. Yet it and the World Bank both face the crises of proliferating poverty among many of their members, caused by the food and energy crises and the resulting diversionary demands on their own resources.

SUPPORTING VACCINE EQUITY

The G7 major developed democratic powers have also acted. On 19 May 2022, G7 health and development ministers met jointly for the first time to support vaccine equity and pandemic preparedness in developing countries. On 22 May, health ministers met to create the G7 Pact for Pandemic Readiness, to strengthen surveillance and response through a global network approach and the public health emergency workforce. They also addressed antimicrobial resistance and the connection between climate change and heath.

G7 leaders at their Elmau Summit in June made 41 commitments on health, led by those on pandemic preparedness, One Health, Covid-19, antimicrobial resistance, universal health coverage and the United Nations 2030 Agenda on Sustainable Development. Their commitments also covered local vaccine manufacturing, vaccine access, new variants, R&D,

sepsis, AIDS, tuberculosis and malaria, primary health care, non-communicable diseases and mental health, neglected tropical diseases, sexual and reproductive health and rights, polio, and women, children and adolescents’ health.

G7 leaders also launched the Partnership for Global Infrastructure and Investment to mobilise $600 billion for developing and emerging countries to build modern health infrastructure, including hospitals, primary healthcare centres, cold storage and transportation facilities for Covid-19 vaccines to reach those who need them most, and, potentially, to allow poor countries to produce and invent safe, effective, affordable vaccines of their own. Still, the summit did nothing on long Covid, little on mental health and brain health, and little linking health to climate change.

The broader, more diverse G20 systemically significant states acted too. They held a special health summit in May 2021. The G20’s regular Rome Summit in October 2021 made 35 health commitments. It has pioneered and continually pushed for the new Financial Intermediary Fund. But it neglected mental health and many other illnesses beyond Covid-19. It has held no special summit on health in 2022. And although its priorities for its Bali Summit on 15–16 November put health first, they focused on the global health architecture and were soon competing with, and potentially crowded out by, Russia’s invasion of Ukraine.

This leaves much need and space for the many contributions to global health governance of other actors, notably non-governmental organisations, scientists, business, philanthropies, sub-federal governments, parliamentarians and Indigenous peoples.

COMBING ALL ACTORS

Multi-stakeholder forums that combine all actors are key. One is the annual H20 summit, organised by the G20 Health and Development Partnership and co-hosted by the Think 20 this year. It assembles G20 policymakers and those from international organisations, the broad global health community, the private sector, civil society and academia to consider and craft specific recommendations for the G20.

Most broadly, at the established centre stands the World Health Summit, held each autumn in Berlin. As one of the key multi-stakeholder policy forums on global health, it brings together stakeholders from relevant communities and sectors across the world. We are proud to produce this book in the context of the WHS and that many of this year’s speakers, among others, have agreed to share their thinking with us.

THE CHAPTERS AHEAD

Indeed, this book focuses on innovatively investing in Health For All. It begins with “Making the choice for health”, which explores how key leaders have paved the way on key components. After the editors’ introductions, the next section, “Societies built on health”, examines how to go beyond narrowly conceived economic growth to generate people’s well-being as a whole. “Resilient health systems” covers making societies and their health systems better able to withstand the many shocks of today and the future. “Long-term health for all” addresses where the needed financing and in-kind resources can and should be found. “People and planet: a better world” focuses on the major ecological determinants of health, from climate change, biodiversity loss, chemical and other pollution, and their significant impact on women, small island developing states and Indigenous people – as well as the contributions from those communities. “Well-being of the future” analyses the promising developments and how to turn them into solutions for all. “The fallout of conflict” examines how deadly militarised conflict within and between countries directly kills and hurts combatants, healthcare workers and civilians, destroys and damages the healthcare facilities that treat them, and constrains NGOs in delivering the desperately needed humanitarian relief – and also highlights the dedication of healthcare workers who rush in to help, and the innovative adaptations amid the violence raging. The final section, “How to get governance right”, returns to the key questions of how those with public authority and influence can and should make the right choice to innovatively invest in Health For All. ▪

The WHO, with a biennial budget of only $6.12 billion for 2022–23, rising only 5% from the previous period, still has fewer resources than hospitals in a single major city have to meet the global need”

The future, now

The mental well-being of the world’s youth is an increasingly recognised challenge, but by investing in evidence-based approaches we can unlock better outcomes

Physical, emotional and social changes, including exposure to adversity, poverty, stress or violence, can make young people vulnerable to poor mental well-being. Millions of young people around the world experienced such changes during Covid-19. But poor mental well-being already constituted a major challenge for young people before the pandemic: around one in five of the world’s children and adolescents have a mental health issue.

However, mental well-being is still neglected: worldwide, less than 2% of national health budgets in low- and middle-income countries is spent on mental health. Equally, only 0.15% of official development assistance is dedicated to child- and adolescent-specific mental health. Investing in evidence-based, effective approaches informed by the experiences and ideas of young people is critical to giving the mental well-being of young people the attention it deserves.

Interview with Manvi Tiwari, country executive of India, Global Mental Health Peer Network

WHAT ACTION IS NEEDED

The perspective of a young mental health advocate with lived experience

Manvi Tiwari, a 19-year-old woman from India, is no stranger to speaking out about the challenges to mental well-being. At 12 years old, Manvi had to care for her mother who was diagnosed with obsessive-compulsive disorder and depression. Five years later in 2020 and prompted by the mobility restrictions imposed in response to the Covid-19 pandemic, Manvi had to confront her own struggles with depression and OCD. Shaped by these challenges, Manvi has become a strong advocate for intersectionality in global approaches to youth mental health and well-being.

What are the main challenges to mental well-being you have experienced?

At the time my mother was formally diagnosed, mental health awareness was limited in India.

It took three years to learn that mum should receive care from a psychotherapist, rather than a general practitioner. In terms of my mental well-being, self-stigma and stigma outside the family were major challenges. We didn’t want friends, neighbours or teachers to know about my struggles. I thought I was open-minded as I knew mental health conditions were normal, but I later realised I had self-stigmatised it and had attached some shame to it.

How do you deal with challenges to your mental well-being? What kind of support did you receive?

Due to my mother’s experiences, my family was aware of the issues I was facing and emotionally very supportive. Unfortunately, many young people don’t receive the same kind of support and parents can dismiss their children’s experiences. Weekly therapy, which I still attend, along with my family’s support was critical. Reassurance that there are others with similar experiences was also important. The Global Mental Health Peer Network has given me this shared sense of understanding – we get to talk and share stories. Sharing my own story was also cathartic for me and could hopefully empower others.

What are the challenges for young people more broadly in terms of mental well-being?

Young people who identify as LGBTQIA+, are disabled or have a refugee background experience different challenges. Therefore, a one-size-fits-all approach to mental well-being won’t work. Moreover, mental health services are not always accessible to young people – there are long waiting lists, sometimes high costs, and they may not be youth-friendly. Parents can also be a barrier to their children seeking care as they do not understand what poor mental health is or the purpose of specific therapies. More investment is needed to ensure that mental health support is available to everyone.

What more must be done to ensure adequate support for young people with mental health issues?

If someone is having an anxiety attack, what do you do? Sometimes we can be insensitive and make it worse despite our best intentions. Mental health first aid taught in schools is one way to address this. If awareness is created at a young age, people may be more sensitive and able to better care for someone close to them suffering from poor mental well-being. We also need an intersectional approach to mental well-being, based on evidence. For example, we lack data especially in India and LMICs on the intersection of mental well-being

MANVI TIWARI

Manvi Tiwari is a mental health activist and lived experience expert. She serves as country executive of India at the Global Mental Health Peer Network and forms part of Generation Unlimited India’s Young People’s Action Team at UNICEF. Manvi is an undergraduate student of media and communication at the University of Mumbai.

A NEW MENTAL HEALTH INITIATIVE FOR YOUNG PEOPLE

and young people who are refugees or who identify as transgender or queer.

You are engaged in the Global Mental Health Peer Network. What is it about?

We participate in international fora and events to raise awareness and advocate for mental well-being. Young people with lived experiences are getting space to speak. I remember the 12-year-old girl who was crying herself to sleep at night, and now she is at the World Health Summit talking about why and how the mental health of young people must be improved. That girl is so proud right now. So that is the beauty of the network, that is what it does. ▪

A new mental health initiative for young people by Grand Challenges Canada in collaboration with United for Global Mental Health, Fondation Botnar and other partners strives to contribute to the continuous improvement of youth mental well-being in low- and middle-income countries. The initiative applies a systemic approach combining research, innovation, policy and advocacy measures that address social, economic and other drivers to create an enabling environment for mental well-being. Young people will be an integral part of developing locally driven approaches that have the potential for transformative change, helping alleviate the mental health burden seen in all ages. @FondationBotnar

Mental health services are not always accessible to young people – there are long waiting lists, sometimes high costs, and they may not be youth-friendly”

A people-led pandemic response

By the Honourable Andrew Little, minister of health, New Zealand

New Zealand’s policy responses to Covid-19 have given our small country an uncharacteristically high profile on the world stage.

In part this is because the actions we took at the start of the pandemic were particularly strong, including stringent lockdowns, border closures, managed isolation requirements, mandates around testing and widespread contact tracing.

These ‘go hard, go early’ measures have been credited with saving thousands of lives by limiting the transmission of the virus until widespread population vaccination could be achieved, particularly among our most vulnerable groups. They also meant New Zealanders were fortunate to enjoy around a year of relative normality and freedoms without Covid-19 in our communities.

Our response has continued to evolve as safe vaccines have become available and had strong uptake by most of our population, as less lethal variants of the virus supplanted

earlier strains, and as we have reconnected to the world.

ENSURING EQUITY

What has received less attention has been the intense focus New Zealand has placed on equity in our pandemic response. We have a unique history underpinned by a constitutional partnership between our Indigenous Māori people and those who settled later. We knew from honest self-reflection about that history that the effects of Covid-19 would be disproportionately experienced by some of our communities, including Māori, Pacific peoples, the wider ethnic communities and disabled people.

Equity does not mean just tailoring government approaches to the needs of communities, but also empowering and supporting those communities to lead their own responses. After the mainstream public health system proved slow to facilitate vaccination uptake by some Māori groups, it was Māori themselves who were supported to take charge of the vaccination campaign through kaupapa Māori (culturally relevant) and iwi-led (tribe-led) health services.

Actually, the equity challenges we experienced reinforced how the fundamental structures of our overall health system needed to change. So,

The challenges posed by Covid-19 have driven significant changes in New Zealand’s healthcare system, with the country rebuilding the way it delivers public health care

at the same time as responding to the pandemic, we have rebuilt the way our state delivers public health care.

Previously New Zealand’s population of only 5 million received public health services from one of 20 different local systems that struggled to share best practice and work together. The services and care that individuals had access to depended more on where they lived than on what they needed. The result was sometimes significant differences of access within a town, or even a suburb or street.

On 1 July 2022 new legislation came into effect to replace the old disjointed system with a unitary nationwide delivery agency, working in partnership with a new Te Aka Whai Ora/Māori Health Authority that has policy and commissioning powers to address equity issues in the delivery of good health services for Māori. The vision for the new system is to achieve Pae Ora or Healthy Futures for all New Zealanders.

LONG-TERM PLANNING

This year we have also transformed our fiscal management of health, with Parliament for the first time appropriating money for health on a multi-year basis to provide more certainty and greater opportunities for long-term planning by hospitals and providers. Our companion economic response to the pandemic has enabled us to fund the highest combined health and disability budget we have ever had.

It is, of course, early days in a period of profound change. We are fortunate that our location in the South Pacific has already seen us through this year’s winter respiratory illness spike, and now we look forward to warmer months in which to roll out changes.

But we have no illusions about the scale of the challenges ahead. Although New Zealand’s health workforce has been growing – underpinned by rising wages, more training opportunities and streamlined immigration settings –we face the same competitive pressures as others in the globally mobile health labour market. There is a legacy of deferred maintenance for our hospital buildings that must be remediated. Provision of mental health services are being built up from a low base. Despite having among the highest rates of internet penetration, we have lagged in ensuring equitable access to the revolution in digital health.

And through it all the world economy in which we trade remains fragile, Covid-19 persists with its ever-present threat of new strains evolving, and we must seek to be prepared for the next pandemic whenever it may come.

While government and its policies have played an unusually significant role in New Zealanders’ lives since the start of the pandemic, ultimately the policy decisions we have been able to take have been the decisions of our people. Fortunately there remains a broad political consensus about the need for our country to have a high-quality publicly funded health system, and a special commitment to protect the most vulnerable among us. How we deliver on that consensus remains a topic of lively democratic debate, as it should be.

ANDREW LITTLE

The Honourable Andrew Little was appointed New Zealand’s health minister in November 2020, as well as minister for Treaty of Waitangi negotiations and Pike River Re-entry, and the minister responsible for the New Zealand Security Intelligence Service and the Government Communications Security Bureau. He served as minister of justice from 2017 to 2020 and was minister for workplace relations and safety in 2020. A member of parliament for the New Zealand Labour Party since 2011, he was leader of the opposition from 2014 to 2017.

Twitter @AndrewLittleMP

 beehive.govt.nz/minister/hon-andrew-little

Much of what has worked in New Zealand throughout the pandemic might not have worked in other places. As we gain a better understanding of the successes of others, we continue to reflect on how we might have or could still apply those ourselves. What is most important now is redoubling efforts to share more knowledge and best practice, and to help each and every one of us to live healthier lives.

There is a whakatauki (proverb) in our Indigenous Māori language: “Ehara taku toa i te toa takitahi engari he toa takitini” – our success is not mine alone, it is the strength of many. For New Zealanders to pick up that wero (challenge) would be a fitting legacy from a period that has so challenged us all. ▪

Equal chances for health

By Shula Rijxman, deputy mayor, Amsterdam

The chances for a healthy life are not equally distributed in the Netherlands, and therefore not in Amsterdam. Health inequalities are often related to social problems that last for long periods, such as low education levels, low income, stress, an unhealthy living environment and inadequate access to health care. It is unacceptable that our city has a health gap between people with more and less education. Not only has the pandemic highlighted this inequality, but it has also exacerbated it. And it will also be affected by the fast-approaching energy crisis.

These are reasons enough to embrace Kate Raworth’s ‘doughnut economy’ concept and be the first major city in the world to put that theory into action on a local level. In 2020, Amsterdam City Council boldly stated that the City of Amsterdam aims to thrive

rather than to grow – to ensure that every resident has access to a good quality of life, without putting more pressure on the planet than is sustainable. This perspective gives us a much wider context of the common underlying societal and political drivers for poor health of both people and the planet. The holistic framework thus helps us with some of our most important and urgent challenges: achieving better human and planetary health.

THE RAINBOW MODEL

To apply this thinking to our health policy, we used the rainbow model developed by Göran Dahlgren and Margaret Whitehead. It shows that working on health equity takes a combination of political, professional, community and personal efforts. An individual cannot correct all the factors that affect their health. To promote health equity, we need

To ensure health equity in Amsterdam, the city has become the first to adopt the ‘doughnut economy’ model, where every resident has the opportunity to thrive in a way that doesn’t put more pressure on the planet than it can handle

to acknowledge the impact of the environment on individual choices and behaviour. We need to remove these social barriers that people encounter.

In Amsterdam, we actively apply this thinking to healthy lifestyle promotion for all generations –from the first 1,000 days until the end of life. The investment in prevention at the beginning of life pays off in long-term health benefits. Growing up as a child in a protective and loving environment and learning a healthy lifestyle mean better chances for good health later in life. Therefore, we increased our efforts to support future and young parents to create a (more) stable environment. We do this before their child is born and then after the child’s birth. Later on, our Healthy School Programme helps schools, including preschools, in fragile neighbourhoods to become healthy preschools and schools on a wide range of health topics such as socio-emotional development, food, physical exercise, screen time and sleep, addictions and sexuality.

In doing so, we make bold choices in order to achieve health equity. For us at the City, this means we do not deliver or support the same activities in every part of town in the same way or with the same intensity. We focus. For instance, we help to establish networks of (mental) health professionals and informal organisations mainly in those neighbourhoods where we know professional help is not easily found and reached out to by families. During the pandemic our Covid-19 prevention team was most active in communities and parts of the city where the number of tests and vaccinations lagged and infection rates were high.

Another type of bold choice is implementing policies that might rouse public debate or lead to resistance from certain political or societal groups. Research showed us that in Amsterdam, where one in five children is overweight or obese, 84% of the food providers in Amsterdam sell unhealthy food and drinks, and 94% of the advertising is for unhealthy food and drinks. So we joined the ‘Alliance to Stop Children’s Marketing for Unhealthy Food’, a broad collaboration of scientists and social, consumer and health organisations. Together we try to change the current national system of self-regulation that is not designed in the best interests of the child. As a municipality, we can regulate the advertising space that we tender ourselves. As a result, no children’s marketing for unhealthy food can be found in Amsterdam’s public transport, its stations and stops. We are working hard to make the existing and newly built environment more inviting to use active transport and playing outside, meaning less space for cars. We are also researching what kind of national or local laws or regulations are necessary to be able to regulate the food supply, such as refusing permits

for new fast food outlets around schools. All these measures benefit both people and planet.

AN ADAPTIVE APPROACH

While we are doing this, we take an adaptive approach. We use data and evidence-informed information as our foundation, but we refrain from too much policymaking and even more in-depth research. We are building a network in the city: formal care organisations, welfare initiatives, place- and topic-based communities, research and private partners, and, of course, all connected divisions of the municipal organisation. When the whole system is in the room, we listen to the stories of the parents, children and elderly and ask ourselves ‘what can I do’ and ‘how do we best work together as a system’. Monitoring and evaluating our efforts helps us to learn while we are doing and to constantly adjust and improve. We believe cities can play a unique role to help people thrive, in a flourishing environment, while respecting the well-being of all and the health of the whole planet. Investing unequally for equal opportunities and for a sustainable future for all of us is key. In this moment, when major challenges test our mutual solidarity, I hope more cities join us in this way of thinking and doing. Together we can be the voices of millions of citizens all around the world that want their children and grandchildren to thrive as they do and also want them to be able to live on a healthy and thriving planet. ▪

SHULA RIJXMAN

Shula Rijxman is responsible for the portfolios of public health and prevention, care and social development, information and communications technologies and the digital city, among others, for the City of Amsterdam. She served on the board of the Dutch Public Broadcasting service from 2011 to 2016, and as chair from 2016 until 2021. She was previously CEO of IDTV Amsterdam and ran Martsell Productpresentaties.

@GGDAmsterdam ggd.amsterdam.nl/english

“ The investment in prevention at the beginning of life pays off in long-term health benefits. Growing up as a child in a protective and loving environment and learning a healthy lifestyle mean better chances for good health later in life”

A polio-free world

president, Rotary International

More than three decades ago, Rotary envisioned a world without polio, setting an ambitious goal to immunise all the world’s children against polio – coining an inclusive ‘health for all’ appeal before it became a global health concept.

Rotary brought that vision to life by catalysing the Global Polio Eradication Initiative, a public-private partnership formed in 1988 following a World Health Assembly resolution to pursue the goal of a polio-free world. Ever since, Rotary has remained steadfastly committed to eradicating polio globally as its top priority in myriad ways, from fundraising to on-the-ground support.

In global public health, commitments like this help sustain a long-term focus. In that vein, I was honoured recently to join dedicated female health workers –whose safety is paramount – in Pakistan. More than 70% of mothers in this country prefer to have women vaccinate their children. By working together with our GPEI partners and front-line health workers with a common purpose, we are expanding healthcare access and opportunities so that everyone can grow and thrive, which helps drive change on an epic and global scale.

By way of example, the GPEI has achieved remarkable success to date:

▪ Three billion children are protected against polio in 122 countries

▪ Polio cases have been reduced by 99.9%

▪ 20 million people have been spared from disability

▪ 1.5 million childhood deaths have been averted

▪ Five regions of the world are certified free from wild polio

▪ Only two polio-endemic countries remain.

These achievements have resulted from the conscious, deliberate commitment of political, financial and human capital over a sustained period. Rotary is proud to play a vital leading role.

Rotary International’s laser focus on eradicating polio globally has helped to create a unique window of opportunity to stop poliovirus transmission for good

ENDING POLIO FOREVER

Specifically, we are uniquely positioned as an organisation with civically active citizens in hundreds of countries and regions worldwide. In polio-affected countries, Rotary club members not only participate in immunisation activities but also work with governments and stakeholders to ensure that polio remains a priority for those in authority, regardless of political affiliation. And every year, through our funding partnership with the Bill & Melinda Gates Foundation, Rotary commits $150 million to the global effort to eradicate polio. To date, we have contributed more than $2.6 billion and countless volunteer hours to end polio forever.

Despite challenges over the years –from targeted attacks on health workers in Pakistan and Afghanistan to vaccine resistance spurred on by myths and misinformation about the safety of polio vaccines – Rotary and its partners have worked to overcome roadblocks by building trust, engaging with a wide range of community leaders from all segments of society.

Now, the lessons and strategies learned from our efforts to eradicate polio are being applied to address other health issues. Notably, the infrastructure Rotary and our GPEI partners helped create to end polio is now being used to protect millions of people from other diseases –including Ebola, malaria and Covid-19. Even as the polio infrastructure is being used to address other diseases, Rotary believes we have a shared responsibility to keep the spotlight on polio eradication and raise awareness just as we did in 2002 when we – along with our GPEI partners and the Canadian government – placed polio on the G7 agenda. The G7 has upheld its commitment to polio eradication nearly annually since then. Rotary has also worked with the G20, the Commonwealth, the African Union, the Organization of the Islamic Conference (now the Organisation of Islamic Cooperation) and others to raise awareness and secure political and financial commitment towards the goal of a polio-free world.

FALLING IMMUNISATION RATES

This advocacy work has never been more critical, given that routine immunisation

rates have fallen during the Covid-19 pandemic, national budgets and health systems are facing unprecedented demands, and polio detections have surfaced around the world, from Malawi to Mozambique to New York and London. These detections are stark reminders that as long as polio exists anywhere, it is a threat everywhere. They also highlight the importance of immunisation as the only form of protection against polio and other vaccine-preventable diseases, and the work that needs to be done in our communities to encourage the uptake of vaccines.

The world currently has a unique opportunity to stop poliovirus transmission for good. This is why all parties, including donors and country governments, must re-commit to polio eradication by ensuring the Global Polio Eradication Initiative 2022–2026 strategy is fully resourced and implemented.

We look forward to applying all we have learned about using our collective voice to continue positively influencing political choices to deliver better health for all. Ultimately, Rotary and its partners look forward to fulfilling our promise of a polio-free world.

JENNIFER JONES

Jennifer Jones is the president of Rotary International for 2022/23, the first woman to hold the position. She is founder and president of Media Street Productions, an awardwinning media company in Windsor, Ontario, Canada. She is a member of the Rotary Club of Windsor-Roseland. Jennifer’s talents have strengthened Rotary’s reach and impact as she has served in roles including vice president, director, Rotary Foundation trustee and co-chair of the End Polio Now: Make History Today fundraising campaign.

@rotary rotary.org

“

The infrastructure Rotary and our Global Polio Eradication Initiative partners helped create to end polio is now being used to protect millions of people from other diseases –including Ebola, malaria and Covid-19”

What comes next?

We have a once-in-a-lifetime opportunity to redefine how we value health

The Covid-19 pandemic has been the most significant health event most of us can remember – with its impact felt in every corner of society. It has tested the way we think about protecting and enhancing health, and highlighted the fragility of the systems connecting people, countries and economies. Yet it has also triggered some of the greatest forward strides in how we view and value health that I can remember.

The past three years have exposed three fundamental truths. The first is that economic stability depends on public health.

While that inextricable link might have been evident already to some working in health care, seeing it acknowledged widely by politicians and the public was a new thing. For a brief time there was a broad consensus that the health of the community was the single greatest driver for productivity and social stability, and that it warranted every effort to protect it. This came through in force with numerous policy changes.

It’s a lesson we must remember, especially as the world’s population grows older and disease continues to place a disproportionate burden on the poorest in society. More of us

By Bill Anderson, CEO, Roche Pharmaceuticals

have now learned just how dependent our economic well-being is on our health. As we move on from pandemic conditions, back to the chronic challenges of ill health, we need to remember that relationship and get better at safeguarding health for all.

The second thing we learned is that innovation is our path to health solutions.

Innovation in all areas has had a huge impact on our ability to ‘live’ with Covid-19. But it has been the innovations in medicine that have allowed us to resume a degree of normality – both the vaccines that have mitigated the risk of the virus and the therapies that are lessening the consequences of infection for those most vulnerable.

But the research that paved the way for those treatments didn’t happen overnight. The development of mRNA vaccines in particular began in the 1970s, and took immense investment

– both financial and scientific –to enable them to be ready for the once-in-a-century emergence of a highly contagious and deadly virus.

So it’s vital that innovation is valued beyond the moment of crisis, because as Covid-19 has shown, we cannot leave it until the potential threat becomes a reality.

This is where our industry has a crucial role to play. The greatest contribution that companies like Roche make to global health is our ongoing investment in research and development, and that’s where the majority of our focus should be. As a company, our mission is to do now what patients need next – that’s why we’re investing in rare disease and antimicrobial resistance, advancing the science in neurological conditions and fighting to make cancer curable.

It’s also true that the world needs more from pharma. Because the third and most important reminder that Covid-19 brought is that medical innovation is only meaningful when it reaches the people who need it.

REACHING ALL PEOPLE

So this raises the question: how do we ensure scientific advances make their way to patients in a sustainable way for healthcare systems and economies worldwide?

The pandemic has reinforced the fact that the world needs innovation scaled up and served faster than ever before and we have a shared responsibility to make healthcare systems more resilient and sustainable in doing so.

It is my belief that 'big pharma' should be bringing more innovation at less cost to society, in partnership with governments, regulators and policymakers that commit to greater, sustainable access to that innovation.

Coming back to how we view and value health, and the economic imperative to sustain good health – we must consider more than specific clinical interventions and outcomes. We have the potential to reduce the overall cost of illness.

In partnership with healthcare providers and policymakers all around the world, life-science companies have a unique opportunity to deliver better medicines, diagnostics and devices that bring long-term efficiencies and cost savings to healthcare systems. We know treating cancer early prevents the later need for treatment and ongoing healthcare cost, yet early detection hasn’t received the public or private investment

BILL ANDERSON

Bill Anderson is the CEO of Roche Pharmaceuticals. He serves as a member of Roche’s Executive Committee, overseeing the pharmaceutical division. He is passionate about helping people make progress every day on the things that matter to patients. With a world-leading investment in research and development, his vision is to bring more medical advances to patients at less cost to society.

@Roche roche.com

it warrants. Reducing progression of a neurological disease, for example, increases time in employment and brings positive economic effects. Ongoing investments in scientific discovery here are vital to sustaining healthy societies for the long term.

Joining up the resources of industry with the improved approaches to healthcare delivery is a powerful way to build resilient healthcare systems that can stand up to future threats, and the toll that poor health takes on people and economies.

As we gain experience in cross-sector partnerships, and as platforms such as the World Health Summit bring the public and private sector closer together, we are building greater resilience in our healthcare systems. Innovation and equity haven't always worked hand in hand when it comes to healthcare. Together we can make it so. I’m optimistic about what comes next. ▪

“For a brief time there was a broad consensus that the health of the community was the single greatest driver for productivity and social stability, and that it warranted every effort to protect it”

professor, BRAC James P Grant School

On 25 March 2020, the Bangladesh government declared a rigid national lockdown to respond to the Covid-19 pandemic, like the strategy adopted worldwide by many countries. The army and police were deployed to force citizens to comply. The entire country came to a standstill. With the lockdown extended every few weeks for two months, people were in limbo, confused and petrified, scared of Covid-19, but mostly worried about starvation. The young women I was working with lived in slum settlements in Dhaka city, where most residents rely on an informal economy and daily

Faults in our methods

wages to survive. Here are some of the conversations I had, which reflected the panic:

There is no food in the house, we are down to our last sack of rice and our savings are dwindling … what will we do? Yes, we heard of Corona, but we fear because we have no income … what will we eat? (Female, 22 years old.)

The police caught my friend and I … we were selling fruit. I had tried pulling a rickshaw in April because we needed an income, but the police caught me and I was fined and abused. (Male, 26 years old.)

Everyone is talking about a virus, but my children are hungry. How will we

manage? Do you know when the lockdown will end? (Female adolescent.)

Dhaka city has a population of approximately 16 million, with an estimated 3,394 slums with about 7 million residents. It is an economic hub that has grown chaotically, with unplanned urbanisation, bursting to absorb the 20 million residents, with the largest number of slum

A biomedical approach to tackling Covid-19 has led to an unjust burden on the poor. To redress the balance, we must first dismantle the power imbalances and political obstacles that act as barriers to basic rights, health and well-being for all

settlements. During the first lockdown from March to May 2020, no one could leave their homes, whether one lived in a well-to-do suburb or a slum. The Covid-19 narrative focused on the clinical approach, with biomedical strategies dominating, with little regard to differing contexts and intersectional factors, which disproportionately affect vulnerable populations. Feelings of safety and security settled into many neighbourhoods. But for the poor, with no work available and the country completely shut down, most already living precarious lives, it meant food deprivation and a sudden loss of wages, among many other challenges.

A DIRE SITUATION

In Bangladesh, the clinical message focused on maintaining distance, wearing masks, washing hands frequently and remaining confined at home. Anyone who has visited a slum or shanty town, be it in Dhaka city, Nairobi or in other countries, will immediately observe crowded environments, often with five or more families squeezed into small, dilapidated, flimsy housing, with erratic water supply, unhygienic latrines and waste. These second-class citizens live in squalor, face insecure tenure, and can barely afford soap and masks. With income loss added because of the lockdowns, the situation was dire. Many residents are at the bottom of the social hierarchy, with little power and voice, yet they are responsible for keeping the city functioning and ensuring that the privileged live in comfort – by disposing of their waste, cleaning their houses and offices, supplying local transport and working in factories, retail and hospitality industries. These jobs are poorly paid and can be labour intensive. Practising social distancing, washing hands with soap and staying home are next to impossible for the vulnerable people living in slums. The complex factors that underlie and affect the lives and health of marginalised populations need to be recognised. Research has found evidence of adverse impacts of the lockdowns on the urban poor who basically were left without any income source and who could not follow the mandated guidelines because of their living conditions. Studies in rural and urban areas found high levels of mental distress, reduced food intake, and mounting loans and huge debts. One survey

of 4,872 households, with 54% from urban slums, 45% from rural areas and 1% from the Chittagong Hill Tracts region, found that households in slums experienced a more drastic ‘income shock’ due to both Covid-19 lockdowns. All this caused an ongoing negative domino effect, which continues well into 2022. Women have been even more unfairly burdened, having to do household chores and care for children, with a majority responsible for taking loans and ensuring repayment, often with interest to money lenders. This has resulted in heightened anxiety and stress. For many of the urban slum poorest, everyday life is already a battle and the pandemic was one addition to a long list of challenges for survival. The lockdown exacerbated their insecurities, as they already had erratic and meagre earnings and now had no work. Somehow these people still manage to demonstrate impressive resilience, but they are continually confronted with illnesses and deaths and living on the edge.

and the wider social, economic and political determinants of health are stacked heavily against these people. A strong political commitment, globally and nationally, with a responsive research agenda is the first step to developing and delivering policies and strategies that are supported by data. This agenda must be developed in partnership with affected communities, civil society organisations, practitioners and a team of multidisciplinary researchers, particularly social scientists, which should inform current and future policies.

REACHING

A SOCIALLY

JUST MODEL Bangladesh, like many other countries, rolled out an economic stimulus package to address the severe economic and business fallout from the pandemic. Numerous reports detail the mismanagement of relief, with weak governance a huge obstacle. The political and social actions taken at the global, national, sub-national and local levels need to respond to the context of the urban poor residing in slums in low- and middle-income countries, as Covid-19 has led to worsening poverty

We need to ensure a socially just model in public health, as an individual’s health and well-being are directly interconnected with their cash flow, housing and local environment. In any crisis, the state’s immediate response must have a long-term comprehensive approach with immediate cash and food relief, and subsidies in health care, for the most vulnerable, for longer periods. Structural and social inequalities and inequities persist in Bangladesh, particularly in urban slums – and in many other countries. The accountability of global actors is also key. With Covid-19 there was vaccine hoarding by some developed countries and rising border restrictions, with many migrant labourers forcibly sent back to their home countries. Unfair trade policies continue, which unfavourably affect lowand middle-income countries. Unless we also address some of these macro power imbalances and political obstacles, and an absence of global solidarity, we will be unable to ensure the basic rights, health and well-being of all human beings. ▪

SABINA FAIZ RASHID

Sabina Faiz Rashid is dean and professor at the BRAC School of Public Health at BRAC University. A medical anthropologist by training, she has more than 28 years of work experience in Bangladesh. Her areas of research and teaching interest and experience are ethnographic and qualitative research, with a focus on urban populations, adolescents and marginalised groups. She is particularly interested in examining the impact of structural inequalities and inequities and intersectional factors that affect the ability of these populations to realise their health and rights.

@bracjpgsph

bracjpgsph.org

The vulnerability of economies to public health emergencies has been painfully demonstrated by the prolonged Covid-19 pandemic, which is yet to end. The cumulative costs are still being estimated – of millions of lives lost or affected around the world, high public and private healthcare expenditures, enormous productivity losses, disrupted travel and trade, interrupted education, stalled social development programmes, triggered xenophobia and forced human migration. The losses are mind-boggling and remind us that the global economy will keep slipping on the banana skins of public health failures, unless health is earnestly envisioned as the best overall indicator of success in achieving the Sustainable Development Goals. For that to happen, the concept of health security must extend beyond the relatively narrow frame that currently restricts its application. Although the World Health Organization uses a broad definition of health, its description of global health security speaks of “activities required, both proactive and reactive, to minimise the danger and impact of acute public health events that endanger people’s health across geographical regions and international boundaries”. This definition restricts concern for health security to ‘acute’ events. But climate change, antimicrobial resistance and biodiversity loss, which gravely imperil human security, are not acute events. Even the ongoing Covid-19 pandemic is no longer acute. Nor can the high death and disease burden associated with coexisting chronic non-communicable diseases – Covid-19’s accomplices – be ignored.

THREATS TO HEALTH SECURITY

P andemic threats of zoonotic infections will not recede even when Covid-19 settles into endemic coexistence with a humbled humanity. Forest-dwelling microbes can speed across the world on conveyor belts created by wanton deforestation, escalating appetites for meat and the unbridled propensity of a growing global population to travel farther and faster. Climate change (with myriad effects on health and nutrition), pollution (of air, water and soil), loss of biodiversity, poor sanitation, antimicrobial resistance, social conflict and sectarian violence also threaten health security. Even weak health systems, unable to promote, protect, preserve and restore health through essential services, endanger the population.

K Sriina presideent ealth Fo He f I

ath R Redd t, Publ undati ndia

dy, ic on

By K Srinath Reddy, president, Public Health Foundation of India

The road to global health security

For personal health, threats to health security are evident as communicable, nutritional and non-communicable disorders, endangered maternal and child health, mental health disorders, physical disabilities, injuries, high-risk behaviours, addictions and financial barriers to accessing needed health services. These threats arise with differing levels of danger at different stages of life within a population, and with varying levels of risk across different populations. They too are influenced by social determinants that shape personal health, such as gender, education, income, occupation, social status and membership in social networks. Even gene expression is modified by social and environmental influences, through epigenetic pathways.

Learnings from the Covid-19 pandemic can pave the way towards secure health for everyone – but first, health security needs to be freed from its narrow definition

FROM POPULATIONS TO INDIVIDUALS

Too often, the population-level determinants of health and the bio-medical approaches to characterise individual threats to health security have remained disconnected. This undermines the political understanding of health among policymakers and the public, even as academic experts have pursued siloed efforts to elucidate the causes of ill health and evaluate potential solutions.

Nineteenth-century German pathologist Rudolf Virchow observed that: “If disease is an expression of individual life under unfavourable circumstances, then epidemics must be indicative of mass disturbances.” His words ring true, when we consider the determinants and dynamics of current threats to health such as zoonotic pandemics, climate change, tobacco addiction or the alarming rise in childhood obesity.

More recently, British epidemiologist Geoffrey Rose pithily summed this up: “Sick individuals arise from sick populations.” The determinants of health that operate at the population level, as well as the elements of the health system that must respond to individuals, are configured by the political choices societies make and the priorities they set as they pursue developmental goals. In an increasingly interconnected and interdependent world, many of these choices are shaped by a global consensus on priorities or driven by global power structures. Those choices then steer concerted action on an agreed agenda.

LESSONS FROM COVID19

The pandemic provides several valuable lessons, both on the imperative of addressing the socioenvironmental determinants of health and on the need to provide a robust health system response to threats that can harm millions of individuals. We have learnt that:

▪We need an efficient, equitable and empathetic health system existing in a steady state, to create a swift, strong and sustained surge response to counter public health emergencies effectively.

▪Primary

K SRINATH REDDY

K Srinath Reddy, a cardiologist and epidemiologist, is president of the Public Health Foundation of India. He has served as head of cardiology at the All India Institute of Medical Sciences and president of the World Heart Federation. He was the first Bernard Lown Visiting Professor of Global Cardiovascular Health at Harvard University and holds adjunct professorships at the universities of Harvard, Emory, Sydney and Pennsylvania. An International Member of the US National Academy of Medicine, he also co-chairs the Health Thematic Group of the United Nations Sustainable Solutions Network. The views expressed here are personal.

surveillance, timely detection and testing, triage for home or hospital care, and supported and supervised care during and after the acute phase of illness (including sequelae such as long Covid), and for administering vaccines efficiently, countering misinformation and fostering community engagement.

▪ Primary care must be comprehensive, respond to needs of chronic and acute care, provide continuity of care, and connect bidirectionally to secondary and tertiary care.

▪A multilayered, multiskilled and technology-enabled health workforce is essential to optimally utilise infrastructure, equipment and innovative technologies for delivering needed health care.

▪ Primary care–led universal health coverage creates the architecture for a well-functioning health system that provides needed services with minimal financial hardship to people, especially during public health emergencies.

▪Multi-sectoral coordination, often efficiently steered during an emergency, is essential even at other times to ensure that policies and programmes in other sectors enable and do not erode public health objectives.

▪One Health should be the platform for microbial surveillance across species and provide an ecologically responsible pathway for future developmental initiatives.

▪ Narrow nationalism compromises collective global responses to common challenges and ultimately recoils back on those who hoard resources, as demonstrated by Covid-19 variants that did not spare the vaccine-rich countries.

▪ Many calamitous challenges we currently confront are interconnected, both via common causes and confluent effects. They cannot be tackled in isolation, as the interplay of several complex adaptive systems creates dynamically changing situations. Our actions must involve multi-sectoral applications of multidisciplinary learning, with agile, adaptive responses that are contextually configured. This calls for visionary political leadership, nationally and globally. ▪

care is essential for effective disease

The global economy will keep slipping on the banana skins of public health failures, unless health is earnestly envisioned as the best overall indicator of success in achieving the Sustainable Development Goals”

Making More Health, together

It is not enough to supply medicine, if the patients don’t have access to it, or are unable to afford it. Nor is it enough, if awareness, education, culture, prevention, diagnosis, treatment and rehabilitation aspects and needs are not incorporated and addressed. For healthcare solutions to be sustainable, a holistic approach and better collective understanding are essential, to achieve more health for future generations.

By Maria Lucia Tereno, corporate vice president, sustainability and culture, Boehringer Ingelheim

Continuing a journey that began over 135 years ago, Boehringer Ingelheim is building on its track record in addressing unmet health needs and increasing ambitions to tackle global health and societal challenges. Our 2030 commitments include expanding access to health care for 50 million people, investing €35 billion in health innovation to tackle non-communicable diseases and €250 million in partnerships to combat emerging infectious diseases. While we believe in leading by example, our approach also focuses on the strength and value of collaboration, the integration of expertise through long-term partnerships and the development of innovative tools and technologies, to contribute towards achieving a healthier future for society.

In 2010, we teamed up with Ashoka, the largest global network of social entrepreneurs, to jointly create our flagship initiative “Making More Health”, a long-term partnership with the ambition to improve health care for both humans and animals in vulnerable communities around the globe. The initiative focuses on connecting innovative social entrepreneurial solutions with business expertise to address complex

healthcare challenges and aims to have a positive impact on another 50 million people by 2030, by empowering social entrepreneurs, communities, partners and our employees. The ambition is to facilitate collaboration to co-create healthy, inclusive and sustainable communities, by focusing on the “bigger picture” of health: addressing interdependent issues relating to economic development, infrastructure, education and culture, in order to help enable systemic change.

By engaging and collaborating with communities and other partners as equals, a better understanding, awareness and access to appropriate health care, as well as tangible, positive impacts on enabling factors (such as employment prospects and living conditions) has occurred. At the same time, we are fostering a “changemaker culture” within Boehringer Ingelheim through employee engagement to support these initiatives. To date we have achieved:

▪ Social Innovation: We support over 120 leading health innovators and social entrepreneurs worldwide from 42 countries working in the areas of human and animal health and the environment. They address much more than providing medicine.

▪ Community Activation: We have established three community centres in India and sub-Saharan Africa, which in partnership with local NGOs and social entrepreneurs drive programmes that support local communities. These include training for more awareness on NCD prevention or tackling issues related to nutrition, basic health care and mental health. We have learned that initiative-based approaches seldom create sustainable change, so we are also resolving access to clean water and hygiene issues, implementing innovative farming models,

(Clockwise from left) Making More Health in action: Providing training on soap making as a source of income generation in Coimbatore, India; raising awareness on albinism in Kenya to foster more inclusion; and providing animal health training in Kenya for smallholder farmers.

providing animal health and business skills training, and workshops on soap production. Inclusion and equity programs for marginalised community groups, such as people with albinism, have proven to be game changers.

▪ Cross-Sector Collaboration: We have supported 18 social enterprises through the “Business Accelerator” programme, which assists social start-ups in sub-Saharan Africa with financial means and management skills, to accelerate, scale up and sustain their business model. With an emphasis on ‘shared values’, the intention is to catalyse social innovation by leveraging the collective strengths of the social business through partnering for impact. The newly launched fund Boehringer Ingelheim Social Engagement aims to create a portfolio of complementary social businesses, enabling more sustainable and also scalable ecosystems to address healthcare challenges.

These endeavours are more than just providing medicine: Benacare, a Kenyan start-up, is striving to reduce the economic burden of long-term hospital stays for low-income families, by bringing affordable nursing services and medical equipment to their private homes. A second social enterprise, mDoc, is improving end-to-end selfcare by offering counselling, care and educating healthcare providers in Nigeria. Through MMH, mDoc is now partnering with the Chronic Drugs Medical Scheme (an e-commerce platform that aggregates demand from smaller hospitals and clinics to lower costs) and Jacaranda Maternity (which improves access and quality of maternal care) to create TeCLA (Tele-Education for Clinicians

MARIA LUCIA TERENO

Maria is a business executive with substantial pharmaceutical experience, including various roles within strategy and marketing, the implementation of the global diversity and inclusion programme and most currently, the sustainable development strategy. Born in Brazil, educated in Canada and fluent in five languages, Maria now lives in Germany with her family.

@Boehringer boehringer-ingelheim.com

“MMH goes so far beyond corporate social responsibility … Ashoka and [Boehringer Ingelheim] are working shoulder to shoulder, learning and building together … This is actually us thinking together, how to approach the world to ‘make more health’ and further spread this mindset shift. For over 10 years, this partnership has allowed us to learn how to build changemaker skills within both organisations and others across the globe.”

and Leaders in Africa), which upskills healthcare professionals in remote areas of Kenya and Nigeria. In 2021, they trained 1,100 healthcare professionals, positively impacting 600,000 patients. In animal health care, the social enterprise Cowtribe has implemented a ‘last mile’ veterinary vaccine and medicine distribution network in rural Ghana, which has enabled access to health care for the animals of more than 35,000 farmers, on whom their livelihood is dependent. FarmAlert in Nigeria aims to improve access to animal health support for smallholder farms, by increasing resource accessibility, building local support communities and educating farmers on key issues. In just two years, FarmAlert has increased the number of farmers it supports from 2,000 to 10,000 farmers annually.

What all these initiatives have in common is the clear focus on the bigger picture and helping to contribute to a much-needed paradigm shift, in how we as a society tackle the healthcare challenges of today. As a catalyst for change and by tapping into the expertise of more than 50,000 Boehringer Ingelheim employees, a network of over 4,000 innovative social entrepreneurs, as well as diverse partners and communities, MMH can help bring together critical puzzle pieces to create a sustainable social impact that lasts and multiplies. At Boehringer Ingelheim, we are aware that no one company or organisation can resolve today’s healthcare challenges on its own. We also understand that working together and forming strong collaborations with the right partners can create immense opportunities to better close the gap between business success and societal progress, to co-create healthier, brighter futures that can transform lives for generations. ▪

Diana Wells, president emerita, Leadership Team, Global Impact Team at Ashoka

By Peter Yeboah, executive director, Christian Health Association of Ghana

The value of universal health coverage investments

In September 2019, at the United Nations, world leaders endorsed the most ambitious and comprehensive political declaration on health in history. However, progress on universal health coverage is not on track, and the Covid-19, monkeypox and other pandemics are moving the world further away from the 2023 targets set by

the political declaration. Those targets include covering 1 billion additional people, with a view of covering all people by 2030, and reversing the trend of catastrophic out-of-pocket health expenditures and eliminating impoverishment due to health-related expenses by 2030. Gaps persist between policy, implementation and results.

Pursuing universal health coverage is an investment in a future built on responsive health services and defined by the well-being and safety of all

Nonetheless, both rights holders and duty bearers share the urgent need to accelerate investments to close those gaps. We need to highlight the imperative for intentional investments for universal health coverage with a view to identifying the barriers and enablers.

PROSPECTIVE INVESTMENTS

A review of Ghana’s flagship health financing interventions underscores the value of investing in universal health coverage to improve population health. Ghana has defined universal health coverage as: “All people in Ghana should have timely access to high-quality health services irrespective of the ability to pay at the point of use.” In 2003/2004, Ghana began implementing the National Health Insurance Scheme. Skilled care coverage increased from 44% to 57.6% in 2019, and maternal deaths declined from 199.7 per 100,000 to 139 per 100,000 livebirths in 2019. Life expectancy at birth also improved from 56.4 in 2005 to 64.74 in 2019. These statistics, while not sufficiently robust, show some association between the programmatic investment and key health outcome indicators.

The burden of non-communicable diseases is rising, in addition to our infectious disease burden, especially in low- and middle-income countries. Other health system challenges include inequitable training and deployment of essential health professionals to needy areas, low and erratic health sector funding, infrastructure deficits, suboptimal use of information and communications technologies for health, and low health literacy. Thankfully, the government recognises health as an instrument of wealth creation by human capital development, productivity and poverty eradication, which provides the impetus for scalable investments.

BARRIERS TO COVERAGE

The Covid-19 pandemic has exposed deficits in our fragile health system and affirmed the importance of investing in health. It amplified the connection between health and socio-economic security. It exposed the siloed thinking and years of disinvestments in the health sector. Evidence shows that countries that approached Covid-19 management from a systems perspective were better able to contain or mitigate the unintended consequences of the pandemic. Beyond the limited fiscal space is the issue of political leadership’s interest and appreciation of the health sector as a high priority input for socio-economic development. A study conducted from 2010 to 2018 assessed the performance of the 15 West African countries on universal health coverage, focusing on governments’ priority to spend domestic resources on health care. It found that no West African country beat the minimum 15% on a health

priority index. The top three countries were Ghana (8.4%), Cape Verde (8.3%) and Burkina Faso (7.5%). The study concluded that West African governments and relevant stakeholders must prioritise health in their political agenda, thus highlighting the essence of governments’ budgetary commitment to health and universal health coverage.

Furthermore, suboptimal investments are often undermined by two key factors. First, the health sector is often limited by inadequate technical skills (health economics, policy analysis), advocacy pitch (negotiation lexicons) and lobbying gravitas (networks, clout) to present the health sector as a vital socio-economic development instrument to the finance ministry. Second, because the concept of primary health care is overlooked, citizens remain passive in demanding accountable investments in providing equitable quality health services. Thus, limited household inclusion and community participation in health do not promote enhanced self-care and self-reliance as part of health promotion and disease prevention services.

These factors often culminate in suboptimal investments in core pillars of health systems strengthening: leadership and governance, health service delivery, health resources, health financing, medicines and technologies, health information and research, community participation and partnership development.

HEALTH ENABLERS

The paradox of the Covid-19 pandemic is that it presents rare opportunities for some catalytic investment in health. At the dawn of the pandemic, Ghana’s national response was anchored in a wholeof-government and all-of-society approach. Suddenly, this government-led and country-owned approach to pandemic containment proved critical in effectively managing the response. Political leaders, faith-based leaders, corporate entities, civil society organisations and the entire citizenry now realise that health is

Because the concept of primary health care is passive in demanding accountable investments in providing equitable quality health services”

everyone’s business. Perhaps there could be no more opportune moment to galvanise investments from all sectors (public and private) for health. Indeed, it would be a catastrophic missed opportunity not to consolidate the legacy of this state–society partnership as a platform for the mobilisation, optimisation and accountability of resources for health in a sustainable manner.

CALL TO ACTION

The lesson of the Covid-19 pandemic is clear: health is an investment in the future well-being and safety of all. There should be a renewed focus on the ‘Keys asks from the UHC movement’: ensure political leadership beyond health, leave no one behind, legislate and regulate, uphold the quality of care, invest more, invest better and move together. Translating political will into positive health impacts must be accelerated to achieve universal health coverage. In many ways, UHC2030 presents an optimistic outlook and performance framework for improved health outcomes. It validates the African Union members’ commitment to the 2001 Abuja declaration, which enjoins countries to allocate 15% of their government budget to health. External development assistance, although indispensable with its own trajectories and conditionalities, should complement intentional country efforts to attain universal health coverage, especially as donors transition from low- and middle-income countries such as Ghana. Given the value of investing in universal health coverage, the health sector requires a sustained push and pitch from all stakeholders and coordinated action from frontline actors – public, private, partners and top-level political leadership – to push health onto the high-level national investment radar. This shared responsibility must be anchored in the three key pillars of universal health coverage – inclusive population, responsive range of quality health services and financial protection – which require equitable financial contributions to national investment mechanisms. ▪

PETER YEBOAH

Peter Yeboah is the executive director of the Christian Health Association of Ghana, the oldest and largest non-state actor in the country’s health sector. He is the immediate past chair of the Africa Christian Health Associations Platform, a network of 41 health associations and networks in 32 countries of sub-Saharan Africa. With over 26 years’ experience in health policy development and practice, Peter has expertise in public-private partnerships, health systems strengthening, innovative solutions at community levels and primary healthcare, and has an evolving interest in global health diplomacy. @chag_official chag.org.gh

The beating heart of health systems

Health workers are what make a health system resilient – but we cannot test them again in the way they have been tested during the Covid-19 pandemic

The Covid-19 pandemic is severely testing the resilience of health systems the world over – from the first months of the initial onslaught, through the waves that continue to this day.

Health systems are as strong as their component parts, and health workers are the beating heart. Health system resilience is commonly defined as the ability to prepare for, manage and learn from shocks –this is the job of people.

Despite predictions of a new pandemic threat, it was nonetheless a shock when a new virus, reported and acted on too late, had the ability to overwhelm some of the best-equipped hospitals in the world. We watched in horror as nurses and doctors, some wearing garbage bags for lack of gowns, did their utmost to care for

By the Right Honourable Helen Clark, board chair, Partnership for Maternal, Newborn and Child Health, and former prime minister, New Zealand

increasing numbers of patients. They held dying patients with one hand and a tablet in the other to connect those people to say goodbye to their families. At the end of their shifts, those exhausted health workers pulled off their masks to reveal bruising around their eyes and welts across the backs of their ears. They went home to sleep separately from their families, if they went home at all.

As co-chair of the Independent Panel for Pandemic Preparedness and Response, I heard from front-line health workers from around the world. Many midwives, who provide essential, safe maternal and neonatal care, told us they received no personal protective equipment. They had to buy their own, reuse stock or otherwise improvise. Nurses, already facing a global shortage of more than six million personnel at the outset of the pandemic, told us about their resilience and ability to organise new ways of working almost overnight, and about their mental stress. “Nurses

were there and ready to work,” a nurse leader from Ghana told us. “But they also had a lot of fears as there was so little known about the virus.”

IMPACT ON MENTAL HEALTH

In one survey from the early phase of the pandemic, almost half of the health workers reported serious psychiatric symptoms, including thoughts of suicide. Health workers also reported an increase in their perception of incidents of violence against them at work, including physical aggression. The World Health Organization estimates up to 180,000 healthcare workers died due to Covid-19 in the first 18 months of the pandemic.

healthcare workers died due to Covid-19 of the pandemic, estimates the WHO

15m

predicted shortage of health workers by 2030

While prioritising Covid-19, health workers had no choice but to let other services take a back seat. Multiple WHO surveys showed disruptions to essential services in most country respondents throughout 2021. Data are beginning to show the longer-term impact: immunisation coverage globally dropped from 86% to 81%; tuberculosis deaths among people living with HIV increased for the first time in 13 years; closures of sexual and reproductive health services led to unplanned pregnancies, unsafe abortions, and preventable illness and deaths of women and children; cancers have been left undetected; and the pandemic has widened the mental health treatment gap. Behind these losses are health staff who were working overtime on Covid-19, and who now face a steep climb to reverse these setbacks.

180,000 ½

of health workers surveyed early in the pandemic reported serious psychiatric symptoms, including thoughts of suicide

Nurses warns that an additional 2.5 million nurses may leave due to the ‘Covid effect’.

A resilient health system begins with its people. One lesson of Covid-19 is that people will do their utmost to stand strong in the face of an immediate shock, but that people cannot be expected to withstand the effects of a pandemic for years. We must care for the carers. Countries must take stock of the impact of this pandemic on their health systems, and in particular on the people at the centre.

The solutions will take time – whether better working conditions, better pay, incentives to work in rural areas, greater and more strategic enrolment of students and their involvement in practice, a more rapid pathway to licensing for people trained abroad, investment in community health workers and mental health supports. Solutions must also focus on the fact that women make up 70% of the health workforce – and that now is the opportunity to provide better pay, better conditions, a harassment-free environment and a place at the decision-making table.

HEALTH SYSTEMS IN CRISIS

Today, many countries that were already experiencing health system challenges before the pandemic are in stages of health system crisis. Health workers are speaking out as they continue to battle waves of Covid-19, with decreasing political support and leadership. Too many are understandably burnt out, feel undervalued and are ready to leave professions in which they have invested their lives. We cannot afford to lose them – there is already a predicted shortage of 15 million health workers by 2030. The International Council of

HELEN CLARK

The Right Honourable Helen Clark chairs the boards of the Partnership for Maternal, Newborn and Child Health and the Extractive Industries Transparency Initiative. She also serves on other public-good advisory boards. In 2020–2021, she co-chaired the Independent Panel for Pandemic Preparedness and Response. She was prime minister of New Zealand from 1999 to 2008, and was the administrator of the United Nations Development Programme from 2009 to 2017, where she was the highestranking woman in the United Nations.

@HelenClarkNZ helenclarknz.com

Another solution is to dramatically reduce the risk of a new pandemic shock. A new health threat should not become a raging pandemic, and the Independent Panel found that Covid-19 could be the last pandemic of such devastation.

We recommended that a package of interlinked actionable reforms be implemented globally and nationally, to transform the system for pandemic preparedness and response. These include new finance; modern surveillance systems; a more independent, stronger WHO that has the authority to report global health threats rapidly; an equitable, end-to-end platform for pandemic countermeasures; all guided by a global high-level leadership council that would sustain momentum. Several reforms along these lines are under way – albeit slowly and in a piecemeal fashion.

We also recommended that countries invest in health and social protection to build resilient systems – and that these should be grounded in high-quality primary and community health services, universal health coverage, and a strong and well-supported health workforce, including community health workers.

People are what make a health system resilient. Health workers are some of the most resilient among us. But their resilience should never need to be tested again in the way it has been during this pandemic. ▪

Tackling the global challenge of women’s health disparities

The pandemic and other global events of the past few years have shined a light on the many gaps that exist when it comes to health care for all. Among the most striking disparities is the gender gap –but Organon, the largest global healthcare company dedicated to women’s health is facing this societal challenge head on, working to accelerate progress and make women’s health a priority

Interview with Kevin Ali, CEO, Organon

When it comes to women’s health, what are the greatest unmet needs?

People are waking up to the fact that there are deep disparities when it comes to almost every aspect of women’s health, and we have a responsibility to address them. The investment in women’s health has been too little for too long, despite the fact that women face significant unmet medical needs and represent half of the world’s population.

Today, only about 4% of all healthcare research and development is focused on women’s health. And women feel the impact of this lack of investment at every stage of their lives: approximately 10% of women have endometriosis, a chronic and painful reproductive health condition with no long-term treatment options; multiple barriers prevent women from accessing fertility treatment and care; maternal mortality and morbidity rates are shockingly high, including from complications such as postpartum haemorrhage; and menopause – which all women experience – has a number of challenging symptoms with few options for treatment. That’s not even touching cancers or chronic illnesses that disproportionately affect women.

The costs we pay for not addressing these unmet needs are huge – not just for individual women, but for society. By investing in women and addressing gender-related disparities in health, we can

create strong families, communities and economies, and help all women and girls achieve their potential.

The pandemic has had a disproportionate impact on women’s health. What area should be prioritised for investment?

One critical area that has been negatively impacted by the pandemic is access to comprehensive family planning services. The United Nations Population Fund called unintended pregnancies a global public health crisis, highlighting recent data that shows nearly half of all pregnancies worldwide are unintended.

The decision of when – and if – you are going to start a family is deeply important and personal. Every woman deserves to be in charge of their reproductive health and yet so much is dependent on access to family planning. Unfortunately, more than 160 million women around the world do not have access to contraception. Too often, access to contraceptive options depends on who you are and where you live: nearly 60% of all women and girls with unmet needs live in sub-Saharan Africa and South Asia, and girls and women aged 15 to 24 years have the highest unmet needs globally. Given that an unintended pregnancy can have a significant impact on a girl or a young woman’s life, her employment and – of course – her health, this is a massive gap that needs to be closed.

I should also note the importance of education in tackling unintended pregnancies. An estimated 33 million

unintended pregnancies are a result of contraceptive failure or incorrect use, so it’s important that everyone is informed about the different methods of contraception available and how to best use them.

And it’s hard to imagine a more valuable investment: every dollar spent on family planning globally is estimated to yield $120 in health and economic benefits.

How can we achieve measurable progress?

Women’s health and gender equity are critical global priorities, as set forth in the United Nations Sustainable Development Goals. Every investment in women and girls is an investment in the health of our society. But no one group can achieve these goals alone. It will take all sectors, working together, to accelerate progress and help create the change we want to see in the world.

At Organon, we’re playing our part. Earlier this year, we launched our Her Promise platform, steeped in our purpose to help the 4 billion women and girls in the world achieve their promise through better health. Included in that is the bold ambition we set for ourselves to prevent 120 million unintended pregnancies by 2030 in the least developed countries. We have a number of programmes and partnerships to help us achieve that goal. Our largest is the Her Promise Access Initiative, which is part of a multi-agency global effort to improve access to family planning information, training and

Kevin Ali is CEO and board member of Organon, with the vision of creating a better and healthier every day for every woman around the world. Kevin led the formation of Organon in 2021 to address the significant healthcare issues that women face and deliver impactful solutions all over the world. He has more than three decades of healthcare leadership experience.

 organon.com

“There is a strong societal and economic case for action to promote gender equity and women’s health. Investing in women’s equality could add between $12 trillion and $28 trillion to global growth by 2025”

4% unintended pregnancies are a result of contraceptive failure or incorrect use

of all healthcare research and development is focused on women’s health

≈33m contraceptive options, especially in low-income countries, where there is such a disproportionate need. We have a number of other goals and commitments to improve the health of women. Critically, we’re focused on accelerating innovation and introducing and expanding access to health options that help secure her promise and equitable place in the world. This is not only during her reproductive years, but at every stage of life. We are one of the few healthcare companies that is dedicated to pursuing scientific innovations for women’s health – we’re excited about our progress, and we are just getting started.

What’s your call to action?

There is a strong societal and economic case for action to promote gender equity and women’s health. Investing in women’s equality could add between $12 trillion and $28 trillion to global growth by 2025. Contraceptives and access to sexual and reproductive health care and information is a critical link to get there. We are calling on all stakeholders – governments, the private sector, civil society – for their commitment and to make the choice to invest in the health of women. ▪

KEVIN ALI

Curing vulnerabilities

Covid-19 has highlighted the need for more resilient health systems. What does ‘resilient health systems’ mean?

Health systems are vulnerable to a multitude of high-consequence shocks – not only pandemics, but also climate change, ageing, cyberattacks, war and many more. The notion of resilience refers to how complex systems, such as health systems, operate under stress and emphasises the need to prepare for and recover from shocks. It recognises the interdependencies within and beyond the health system – health supply chains, social care, the wider health innovation ecosystem – and promotes the design of systems capable of providing high-quality care under extreme stress.

Resilient health systems save lives and protect against disruptions that have major socio-economic consequences. Without resilience, health systems will fail under pressure, initially containable problems become larger, threatening the health of populations, economic security and societal well-being.

Resilient health systems are a buttress to disruption and recover more quickly. They have the workforce, the physical resources, the data and information technology systems, leadership and coordination mechanisms necessary to respond to new and changing circumstances.

The Covid-19 pandemic has dramatically shown how health systems are not as resilient as they ought to be. Most countries lacked spare capacity, especially in the workforce, with nearly four-fifths of the members of the Organisation for Economic Co-operation and Development reporting the number of hospital nurses to be an issue. Only one-fifth of OECD countries had real-time data about the health system at the start of the pandemic, which limited their responsiveness. Well-functioning health systems rely on other areas of society and economy. One salient example is supply chains. Two-thirds of OECD countries reported supply chain difficulties and almost all (92%) had difficulty obtaining personal protective equipment. A gold-plated

pandemic preparedness and response system will not be enough if the underpinning health systems are not fit for purpose. Improving the resilience of health systems involves addressing problems holistically.

How has Covid-19 affected vulnerable groups? What policy actions are needed to ensure equity in resilient health systems?

Vulnerable populations – poor and disadvantaged people – have borne a disproportionate burden from the pandemic. Several instances come to mind:

▪Socially disadvantaged groups and ethnic minorities have faced an elevated risk of infection, severe illness and death from the virus. Mortality data from 13 OECD countries show an 80% increase in the relative risk of dying for those living in the most deprived areas in the first year of the pandemic. Black and Hispanic ethnic minorities were also at least twice as likely as white

Interview with Francesca Colombo, head, Organisation for Economic Co-operation and Development Health Division

A multitude of high-consequence shocks threaten the world’s health systems, and time is running out to build in resilience that protects systems and the lives that rely on them

people to die from Covid-19 in the United Kingdom and the United States.

▪Socially disadvantaged groups have foregone care and experienced disruption in routine care and mental distress associated with the pandemic and lockdown measures.

▪The prevalence of depression was more than twice as high among people with lower incomes than people with higher incomes in Austria, Canada, the Czech Republic, France and the United States, to mention a few.

Achieving equity in the context of a highimpact shock such as a pandemic requires resilience, at least in three dimensions.

First, the resilience of populations needs to be improved through better investment in public health and prevention. The high prevalence of chronic diseases was a contributing factor to Covid-19 mortality rates. More than a third of the population in OECD countries had a long-standing illness before the pandemic, reaching 43% in the poorest income quintile of the population, compared to 24% for the richest income quintile. Yet still only less than 3% of total health spending went to prevention and public health in 2020 across OECD countries.

Second, primary healthcare services must be reinforced to reach the most disadvantaged populations and maintain care continuity during a crisis. Only 15 OECD countries were able to deploy mobile primary healthcare units to ease access to primary health care in underserved or deprived areas. In nearly half of OECD countries, community pharmacists took on roles traditionally reserved for doctors, maintaining access to care and reducing inequities.

Third, many interrelated causes of social gradient must be addressed: increased exposure through working and living conditions that are worse for vulnerable and poor populations, inequities in health conditions and risk factors, such as diabetes or obesity, linked to poor lifestyles and poverty, and wider socio-economic barriers to access and use of health care.

Can we achieve more resilient health systems without further investment?

The pandemic has demonstrated that when health systems are not strong enough to respond to major unexpected shocks, the cascading health and economic consequences are devastating. So yes, we do need to invest more to reinforce the ability and agility of health systems to respond to shocks.

FRANCESCA COLOMBO

Francesca Colombo oversees the Organisation for Economic Co-operation and Development’s work on health, which aims to provide internationally comparable data on health systems and apply economic analysis to health policies, advising policymakers, stakeholders and citizens on how to respond to demands for more and better health care and make health systems more resilient and people-centred.

@FranColombo2019 oecd.org/health

Targeted investments are crucial in at least three main areas:

First, as mentioned, we need to protect people’s underlying health, through better prevention and public health. This reinforces population defences in times of shock and stress and reduces pressures on health systems.

Second, we need to invest in the front lines of health systems, by building and maintaining sufficient numbers of doctors and nurses. Workforce deficiencies have been the most binding constraint during the pandemic.

Third, we need to build stronger foundations of health systems that are better able to exploit the potential of health data and information, as well as ensure adequate core equipment (for example, diagnostics, capacity of intensive care units).

Taken together, we have estimated that these targeted investments would amount to an additional 1.4% of gross domestic product on average across OECD countries, compared to pre-pandemic spending.

Such investments aim to protect society and stimulate the economy, but funding in a context where countries have both amassed huge levels of national debt that need to be paid off and are confronted with other crises will be challenging. Health systems will need to get better at getting buy-in from finance ministries, by showing how the returns from such targeted investments extend well beyond health benefits, and by continued efforts to tackle waste – from spending to correct preventable medical errors to poor flow of data to decision makers – that does not deliver improvement in health outcomes. ▪

Sources for the information in this article are available from Francesca Colombo at francesca. colombo@oecd.org.

A gold-plated pandemic preparedness and response system will not be enough if the underpinning health

ACTIONS ACTIONS AAAACTIONS ACTIONS ACTIONS speak louder than words

Ending the Covid-19 crisis for everyone everywhere and creating frameworks and mechanisms for equitable access to all medical countermeasures must be priorities for every person on the planet. Covid-19 demonstrated the stark reality of what ‘we are not safe until we are all safe’ really means in this interconnected world. The challenges brought by a lack of equity have been well articulated. It is now time to go beyond articulating challenges to designing and implementing solutions. I was on a panel at the 2021 World Health Summit that identified the need for Global South leadership and civil society voices to be heard. A solution to hold a dialogue was proposed. Ports to Arms – a Global South–led dialogue – was created and implemented within five months. It can be done. We must continue pushing for action.

Global health leaders, activists, heads of institutions, civil society and others have been articulating, debating and discussing the challenges to achieving equitable access to medical countermeasures since long before the Covid-19 outbreak. Yet most of these discussions have been located in and

By Ayoade OlatunbosunAlakija, chair, African Union, African Vaccine Delivery Alliance and founder of the Emergency Coordination Centre, Nigeria

led by the Global North. We have already identified the need for the following ingredients to achieve authentic health equity, such as genuine participation and engagement from the Global South, with equity in power dynamics; reformed global institutions with solidarity and outcomes for communities at their heart; alternative financial models and incentives for getting innovations for medical countermeasures from bench to bedside; and enlightened, collaborative – not competitive – leadership at sub-national, national and global levels.

THE WORK REQUIRED

Much work is needed to achieve equitable access to medical countermeasures for pandemics for all. We must work towards achieving a dynamic state of readiness for the next pandemic, wherever it might occur. While many populations are still dealing with the societal and economic impacts of Covid-19, some countries and populations are now also dealing with monkeypox. On top of global health threats, the effects of climate change and war all coalesce to affect equitable decisions on financing and resourcing. We cannot afford to continue to make

Achieving equitable access to medical countermeasures requires a transformation that can only be attained through clear, concerted action

siloed decisions. If we all agree that health is a global priority for our collective future, then collective commitments to support equitable access must be made now.

Health For All must truly deliver health for all – not health for some at the expense of the rest of us. We must overcome systemic and internal biases so that the value of a life in Tigray is considered the same as a life in Ukraine. In the news we see pets in high-income countries valued more in conflict situations than Black people. This is wrong and must be addressed – in action, not just words.

More than two years after the start of the Covid-19 pandemic, populations in low- and middle-income countries still cannot access the medical countermeasures afforded populations in high-income countries. A Nigerian friend of mine with Covid-19 was unable to access antivirals when she was very ill because she was told the drugs were not available in the country. Were she in a hospital in London or elsewhere in the Global North, the story would be different. We must address the bottlenecks in the system locally and globally.

I took up the call to action last year for a whole-of-society discussion hosted by the Global South. The Emergency Coordination Centre in Nigeria, with support from Wilton Park and UNICEF, designed and hosted Ports to Arms in Abuja in February this year. The dialogue focused on finding solutions and creative alternative approaches to achieve access to medical countermeasures where equity and solidarity are at the heart of all decision-making and where people do not feel disadvantaged either in the process of making decisions or implementing decisions, or in the impact and outcome.

JUST THE BEGINNING

The Ports to Arms Summit was just the start. We need enlightened leadership and commitment from leaders in the Global South and the Global North to invest funding, resources and time to achieve equitable access to medical countermeasures. It is not enough for

AYOADE OLATUNBOSUN-ALAKIJA

Ayoade Olatunbosun-Alakija is chair of the African Union, African Vaccine Delivery Alliance and founder of the Emergency Coordination Centre in Nigeria, as well as the former chief humanitarian coordinator for Nigeria. She currently serves as the World Health Organization’s Special Envoy for COVID-19, and cochair of the Access to the COVID-19 Tools Accelerator. She is also spearheading an initiative to create Safe Learning and Teaching Environments in Nigeria (The CASTLE Initiative).

@yodifiji

leaders of the Global North to acknowledge that equitable outcomes require changing power dynamics and moving away from traditional donor relationships. Leaders of the Global South must also step up, become masters of their own destiny, be proactive in their approaches and transform the ‘aid recipient’ mentality. Leaders must come together for global solidarity for equitable health outcomes.

To achieve equity, we must speak to the unconscious bias and the blindness of leadership that so many people have experienced when proposing alternatives to the status quo to achieve equitable access. I have personally experienced the unconscious bias of global health leaders who purport to stand for equity yet, behind closed doors, undermine and fail to support views that differ from their own, with little appreciation of the inequitable power dynamics at play. Peer-to-peer awareness raising is needed to address this unconscious bias, which continues to reinforce the status quo.

Leaders must be bold and courageous and take risks. They must move beyond pandering to financial markets and industry risks and dare to try other models to accelerate access to medical countermeasures to low- and middle-income countries. National leaders must go beyond nationalism and test collective, collaborative approaches. Global structures must be reformed to deliver because they are no longer global in reach or impact. Rather, they enhance the power of some and exclude those who are not part of the inner circle.

The Access to COVID-19 Tools Accelerator and COVAX as the vaccine pillar were originally conceived with the notion of equitable access and solidarity at their heart. National interests quickly undermined these principles. We still need a framework to address how we enable the development and delivery of all medical countermeasures for future outbreaks. But now is the time to agree on the reform and governance changes necessary to meet the originally intended impacts.

Our collective survival can no longer be based on the principle of competition and survival of the fittest or richest. This is an antiquated approach with no moral basis.

We must leave our egos behind if we are to collaboratively design and deliver global mechanisms for global public good. We know this can be done. We must continue our momentum with greater engagement with the Global South on global mechanisms that authentically listen to their challenges and potential solutions, and work collectively to design inclusive solutions. ▪

By Chikwe Ihekweazu, WHO Hub for Pandemic and Epidemic Intelligence

The year 2022 has proven to be another challenging year for global health. While the continuing fight against Covid-19 has taken its toll on health systems across the world, a monkeypox outbreak with more than 50,000 confirmed cases had spread to over 100 countries by 10 September 2022. The war in Ukraine and other conflicts have led to millions fleeing, thousands dead and hundreds of health facilities destroyed. The resurgence of polio and recent detection of Marburg in Ghana have reinforced the risk of emerging diseases.

However, this year also witnessed the development of three major global health security initiatives. The Intergovernmental Negotiating Body started its work on a pandemic accord in February, the newly created Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response was launched in September and Tedros Adhanom Ghebreysus, director-general of the World Health Organization, presented 10 proposals for a strong and inclusive health emergency preparedness, response and resilience architecture in May.

These are ambitious, far-reaching initiatives addressing the future on governance, financing and delivery of responses to health emergencies. They require hard work, collaboration and sometimes fierce diplomacy. Yet, together, they represent an unprecedented opportunity for global health leaders to make the world safer by laying out an ambitious path for national and global contexts.

STRONG HEALTH INSTITUTIONS

In the first edition of Health: A Political Choice in 2019, Dr Tedros highlighted that “universal health coverage is not just the best investment in healthier populations. It is also the

For a safer future

best investment in health security.”

The prescient nature of this statement has been evidenced by the Covid-19 pandemic. The resilience of health systems, as first responders, is a strong determinant of whether the world is prepared for the next health emergency. Therefore, our efforts to strengthen the global architecture must be underpinned with renewed interest and intentional focus on strengthening national health systems, thereby contributing to universal health coverage.

National Public Health Institutes play an important role in connecting the national and global public health system. As centres of expertise, NPHIs bridge the political decision makers and researchers by translating evidence into actionable insights while being firmly anchored in local contexts. Our best shot at dealing with any future health emergencies rests on having strong NPHIs everywhere. However, health institutions cannot be expected to transform overnight. I have learnt this over the course of my career while working in various NPHIs,

Figure 1: Monkeypox over two generations

most recently while leading the Nigeria Centre for Disease Control between 2016 and 2021. The progress in strengthening Nigeria’s health security capabilities illustrates how much is possible. Just a few years before the pandemic, NCDC did not have a national public health reference laboratory, and Nigeria’s outbreak surveillance system to protect more than 200 million people was based on paper and Excel spreadsheets. Over five years, we focused on gaining political commitment, getting a legal mandate, securing investments from government and other sources, building a strong workforce, establishing functional partnerships and other factors. Today, the strengthened capabilities that were implemented have enabled Nigeria to respond effectively to public health threats, mitigate their impact and contribute to global health security. Delivering meaningful change requires a long-term perspective. Investing in people and institutions can feel like a risk because the key performance indicators seem less quantifiable. But when a

As the world reels from Covid-19 and fights a spreading monkeypox outbreak, investing in National Public Health Institutes at a global and local level is a deliberate choice to build a safer future for everyone

CHIKWE IHEKWEAZU

Chikwe Ihekweazu is assistant director-general at the World Health Organization for surveillance and health emergency intelligence and leads the WHO Hub for Pandemic and Epidemic Intelligence. He was the first director-general of the Nigeria Centre for Disease Control, from 2016 to 2021. He was previously interim director of the West Africa Regional Centre for Surveillance and Disease Control, and has held senior public health and leadership positions, including in the South African National Institute for Communicable Diseases, the United Kingdom’s Health Protection Agency and Germany’s Robert Koch Institute.

Twitter @Chikwe_I

national public health institution is strong, supported and streamlined, then quantifiable outcomes follow.

BETTER UNDERSTANDING OF RISKS

Some public health challenges cannot be solved by one country alone. An effective system to avert and manage pandemic and epidemic risks needs global collaboration. Monkeypox is an unfortunate but timely example: discovered more than six decades ago, the disease has evolved from a local outbreak to a global threat (Figure 1). The first case of spillover to humans was recorded in 1970. A generation later, the virus led to the first outbreak outside of the African continent. In 2017, the outbreak in Nigeria changed our understanding of the disease and highlighted its potential to spread as a major concern.

Despite these warning signals, global interest was limited. The epidemiological and clinical aspects of monkeypox remained inadequately characterised. Up until the outbreak in the United States in 2003, global research on the risk from monkeypox had an average of five or six publications per year. Afterwards there were more than 30 articles published on average (Figure 2).

In an increasingly connected world, we cannot afford to allow such gaps in our understanding. More importantly, these gaps in epidemiology, vaccines and therapeutics are too large to be addressed by one country alone. The recent monkeypox outbreak is a stark reminder of the need for a strong global fabric for collaboration, based on solidarity and trust. This is crucial if we want to share data on surveillance and disease transmission, develop effective medical

* Note: Highlighted years on vertical axis correspond to years of major outbreaks/events in epidemiology of virus. Articles extracted from Pubmed using the search ‘monkeypox’ in abstract or title. No further limitations made.

and non-medical countermeasures, and ensure equitable participation in the benefits from research.

COLLABORATIVE APPROACHES

Developing new approaches to bring together diverse and interdisciplinary national public health actors at a global level is a cornerstone of the WHO Hub for Pandemic and Epidemic Intelligence, which I have been leading since November 2021. It supports countries and regional and global actors to avert and manage public health threats through collaborative problem solving informed by better data and robust analytics. Embedded in the WHO’s Health Emergencies Program, it leverages the WHO’s convening power to foster an architecture of global collaboration and trust.

These global efforts would not be possible without sustained political commitment. As countries increasingly seek to put Covid-19 behind them, there is a real concern that the damage inflicted by it will soon be forgotten. In a world perpetually plagued by the threats of climate change, we do well to remind ourselves that this is a privilege we cannot afford. Global leaders need to act unanimously to invest at national, regional and global levels in preparing for future health emergencies. Globally, the right step is to strengthen the WHO. As Ilona Kickbusch eloquently stated in her 2021 piece for this series, “It is simple. The greatest potential for global solidarity lies with the WHO – an organisation that builds on its ownership by 194 countries.” Nationally, we need strong National Public Health Institutes that are fit to collaborate at a regional and global level. ▪

Figure 2: Neglected topics illustrated: number of articles on monkeypox (1958–2022)*

Lessons from East Asia

Covid-19 has shone a spotlight on the current state of global health, revealed inadequacies, and taught lessons that need to be learnt and acted on to realise Health For All. I focus here on East Asia, where I live and work, and which has become the most important global economic engine in recent decades and has the potential, as well as the responsibility, to lead in strengthening global human security.

East Asia, generally comprising the 10 members of the Association of Southeast Asian Nations, China, Japan and the Korean peninsula, has achieved relatively good outcomes during the ongoing Covid-19 pandemic.

This can be explained, in part, by sociological imprinting of and learning from past outbreaks as well as competence in governance (see Figure).

Covid-19 revealed four main East Asian characteristics that may be relevant to improving global preparedness and responding to future outbreaks. Above all are the critical importance of maintaining high levels of preparedness, and the willingness and ability to respond swiftly and robustly to suppress an epidemic very early in its course. Contrast the

By Gabriel M Leung, executive director (charities and community), Hong Kong Jockey Club, and honorary professor, University of Hong Kong

East Asian response during the first quarter of 2020 with the European and American first waves.

A second lesson is the need to adapt strategies swiftly and innovate as more became known about the virus and its spread.

Third, East Asia demonstrated how the extensive application of technology, data fusion and analytics can contribute substantially to suppressing the spread of this highly infectious virus.

Fourth, Covid-19 has highlighted

The Covid-19 pandemic has highlighted inadequacies in the global health system, but harnessing the growing health diplomacy of East Asia could go some way towards realising Health For All

the importance of strong political leadership, coupled with a collective societal receptiveness to adhering to wide-ranging public health measures.

However, lessons from East Asia should be understood in context. In addition to valuing experiential learning through sociological imprinting by past outbreaks, East Asian societies tend to value collective well-being sometimes at the expense of individual liberties. Pre-existing social structures to enforce mass lockdowns are difficult to replicate elsewhere, as are the ubiquitous deployment of digital tracing tools. Of particular note, a ‘zero Covid’ approach might have saved hundreds of thousands or even millions of lives in 2020 or 2021, but this success has paradoxically delayed vaccine acceptance despite adequate access, and poses an ongoing conundrum of how best to safely exit towards endemicity.

LACKING SHARED STRATEGY

East Asian countries have also been expanding capacity in global health development and diplomatic outreach, although there is as yet no coherent regional vision, shared strategy or common set of operating principles, thus limiting synergistic impact.

Until the 1990s, Japan was the only major donor in East Asia, and the majority of East Asian economies were recipients of development assistance for health. This has changed substantially and rapidly since the mid-2000s, with China and Korea increasing the size and scope of development assistance for health (see Table). This trend is grounded in both an altruistic concern for the most vulnerable populations and an understanding among countries that in today’s interconnected, globalised world, a health crisis anywhere can affect one’s own population. Accordingly, national interests associated with global health have shifted from the development context to cover both economic and security perspectives. Likewise, the scope of global health has broadened from service delivery to include discovery and development of interventions. Therefore, the pivot of global health and development leadership from post–World War Two institutional arrangements towards Asia preceded

TABLE: DEVELOPMENT ASSISTANCE FOR HEALTH BY FUNDING SOURCE AMONG EAST ASIAN DONORS, 1990–2019

Donor 1990 1995 2000 2005 2010 2015 2019 China

Japan

Korea

Asian Development Bank

Note: All figures are in millions of 2019 US dollars. Source: Global Burden of Disease Collaborative Network. Global Health Spending 2018–2050. Seattle: Institute for Health Metrics and Evaluation, 2020.

much room for synergistic impacts through multilateralism, perhaps in ways different from today’s post-war institutions. A shared vision that can be operationalised through common principles and goals would be a prerequisite.

HOW TO BOOST COOPERATION

GABRIEL LEUNG

One of Asia’s most respected higher education, health and philanthropic leaders, Gabriel Leung is executive director (charities and community) of the Hong Kong Jockey Club overseeing its Charities Trust, while serving as a governor of The Wellcome Trust – both of which rank among the top 10 philanthropies globally. From 2013 to 2022, he was the longest-serving dean of medicine at the University of Hong Kong. Formerly, he was Hong Kong’s first under secretary for food and health and fifth director of the chief executive’s office in government.

@gmleunghku

the current pandemic but was also hastened by it.

However, thus far there has been little regional coherence, or tendency to foster this, among the bigger players in Northeast Asia (China, Japan and Korea) or within ASEAN, let alone across the region. Where bilateral actions currently predominate, there remains

Concrete steps to bolster cooperation and extend influence could include the establishment of an East Asian Centre for Disease Control, joint work in health and human security by the Asian Development Bank and Asian Infrastructure Investment Bank, and a region-wide research funding programme.

But much depends on evolving geopolitics writ large, notably the increasing bipolar reorientation of global alliances, which has the potential to split geographically neighbouring East Asian states. Rather than accentuating the contextual differences between East Asia and the rest, in attempting to explain and replicate recent Asian successes in human security, we should focus on embracing diversity in circumstances and histories by presuming commonalities. Health diplomacy for global human security can become a stabilising influence and be a topic around which all actors can more comfortably rally. This way we could better harness the burgeoning health diplomatic outreach of East Asia amid shifting geopolitics and chart a new course towards a common, secure and healthy future of globalism 2.0. ▪

Please refer to journals.plos.org/plosmedicine/ article?id=10.1371/journal.pmed.1003939 for a full exposition of the ideas in this article.

Reshaping the global health architecture

The German government is responding to the world’s health challenges with a new Global Health Strategy, which takes a human rights–based approach to providing barrier-free health structures and services to all

By Svenja minister for economic cooperation

and development, Federal Republic of Germany

In recent years, human health has been massively affected by global challenges, including the Covid-19 pandemic, antimicrobial resistance and climate change. This is a worrying trend, to which the international community must mount a joint response. And the only response can be the concept of global health. That concept centres on forward-looking, coordinated action across all sectors and disciplines to protect and promote the health of people worldwide. That is why Germany is channelling increased efforts into global health and championing more international cooperation, including through its current presidency of the G7. Half the world’s population, if not more, have no access to essential health services. Worst hit are women and children, poor people, marginalised groups and those living in conflict situations. The German government has responded by adopting a Global Health

Strategy, which draws on the 2030 Agenda and the 17 Sustainable Development Goals as the overarching framework. This is a human rights–based approach, aimed at non-discriminatory, gender-sensitive, inclusive and barrier-free health structures and services.

The Covid-19 pandemic highlighted what diverse and complex impacts health crises can have on politics, the economy and society across the entire world. Through lockdowns, many people had only limited access to health services, so health conditions were not spotted or properly treated. Millions of children did not receive routine vaccinations because the vaccine supply chains had broken down and because health professionals had to focus instead on treating people with Covid-19. In low-income economies, disruptions to basic health services led to spikes in maternal and child mortality. The pandemic also compromised people’s access to safe water, sanitation and hygiene (WASH), which opened the door to outbreaks of other infectious diseases such as cholera.

SUPPORT FOR HEALTH SYSTEMS

This goes to show that we need more decisive and preventive action against future pandemics and their possible consequences. That will only succeed if strong, robust health systems are in place. Germany’s goal in its development cooperation is therefore to create health systems that are resilient and accessible to all. We will be offering our partner countries even more support in establishing health insurance schemes, providing basic and advanced training to healthcare staff, and improving the quality of essential health services and access to those services. At the multilateral level,

Germany is making financial contributions to Gavi, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Global Polio Eradication Initiative, and is actively involved in their governing bodies.

SVENJA SCHULZE

Svenja Schulze has been Germany’s federal minister for economic cooperation and development since December 2021, having been Federal Minister for the Environment, Nature Conservation and Nuclear Safety from 2018 to 2021. She was a member of the North Rhine-Westphalia state parliament from 1997 to 2000 and 2004 to 2018, and served as Minister of Innovation, Science and Research of the State of North Rhine-Westphalia from 2010 to 2017. She has been a member of the Social Democratic Party since 1988.

Health feeds into and grows out of sustainable development. The only way to achieve lasting improvements in global health, then, is to approach health-related and development-related goals in combination. That is why Germany’s Development Ministry (BMZ) is strengthening its cooperation with its partner countries on health, WASH, social protection and rights-based family planning, promoting an intersectoral approach. Ultimately, it aims to recognise how health and other policy areas play into each other and to adopt policies in all areas that are conducive to health. So how does that look in practice? The World Health Organization has identified WASH deficits among the main global risk factors for disease. That is why reliable access to safe WASH provision in healthcare facilities is crucial to a functioning health system. And in daily life, it is one of the most powerful preventive measures, for example in maternal and child health.

RISK FACTORS AND FOCUS AREAS

Other factors posing a risk to global health are infectious diseases such as malaria and tuberculosis, neglected tropical diseases and AMR. To spot these risks early on and prevent them from becoming a reality, BMZ increasingly focuses on the One Health approach, a holistic view of human and animal health and environmental protection, including climate change. This means better reflecting the interdependency between humans, animals and the environment in health, agriculture, food, climate, biodiversity, the environment and water resource management so as to generate synergies. To ensure the One Health approach can take root, it is particularly important for international organisations to link up more with each other and for our partner countries to integrate it into their development strategies. The annual World Health Summit plays its part in this.

The international community can only achieve global health if we succeed in completely reshaping the entire global health architecture. When it comes to fighting pandemics, that means prevention, preparedness and response. My ministry is working through a wide spectrum of activities, including from disease surveillance to training for local professionals, from strengthening digital innovation to improving water and sanitation provision, including systematic wastewater monitoring. We will start supporting the Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response this year.

Another key focus is feminist development policy. Its aim is, not least, to enable women and girls to make informed decisions that enable them to take control of their own lives. Strengthening sexual and reproductive health and rights is one major aspect of Germany’s work. Through the bilateral Initiative on Rights-Based Family Planning and Maternal Health, BMZ is providing support in more than 20

bmz.de

partner countries for such issues as safe childbirth, rights-based family planning and maternal health. Sexual and reproductive health also includes the issue of menstrual health and hygiene. Worldwide, millions of women and girls experience exclusion and discrimination because they menstruate, holding them back from achieving their full potential. What a shocking violation of human rights! German development cooperation supports women and girls in the global South through education, improved access to gender-responsive water and sanitation infrastructure and affordable hygiene products and also through global partnerships. Only if women and girls participate equally in society – no matter where they are in the world – can the 17 SDGs be reached.

THE G7 PRESIDENCY

Many of these aspects have been integrated into the programme of Germany’s G7 presidency. I am very pleased that the G7 has committed to achieving universal health coverage as a priority, particularly regarding women and girls, sexual and reproductive health and rights, and improved water supply and sanitation. To achieve these aims, we in the G7 want to help strengthen health systems and assist the GPEI and Gavi in their efforts to fight polio.

We G7 health and development ministers also delivered strong evidence of our support for the continued fight against the Covid-19 pandemic with our G7 Pact for Pandemic Readiness. Through this pact we want to provide greater support to low-income and middle-income countries. We also aim to step up vaccine manufacture in Africa. Local manufacture of vaccines is also important for diseases other than Covid-19. An mRNA vaccine against malaria is currently being developed, for example, which could be manufactured right where it is needed most.

Ensuring healthy lives and promoting well-being for all at all ages – that is a priority of the German government and German development policy. Only when all people have access to quality essential healthcare services and affordable essential medicines and vaccines can we truly say that universal health coverage has been achieved. ▪

A view of the emerging markets healthcare sector

By Zhi Yang, chairman, and Vanessa Huang, general partner, BVCF Management

BVCF Management was founded in 2005 with a focus in Greater China healthcare sector. BVCF has raised five funds with total assets under management of more than $700 million and investors from the United States, Europe and Asia. To date, BVCF has invested in 43 companies across different healthcare subsectors, which created more than 4,200 job opportunities. The BVCF team spent a substantial amount of time working with entrepreneurs to help them build a lasting organisation. Our base view is that two macro financial forces – continuous new company creation and global asset allocation demand –

will continue to drive activities and interests in the emerging markets healthcare sector. However, we believe it is the social aspects that were accentuated by the Covid-19 pandemic that will change the dynamics of EM healthcare investments going forward (for good) – the urgency of global health infrastructure investments and the glaring gaps of global health access and equity. These are coupled with the increased awareness of better stakeholder accountability and the need to amplify R&D rewards beyond shareholders only. We remain positive on the private sector’s role in serving public health and appreciate the responsibility of private capital to be part of the solutions in building a resilient global health ecosystem.

A DEFENSIVE GROWTH PROFILE

Broadly speaking, the enterprise value of a company reflects its underlying sales/net income potential. For healthcare companies, that ultimately means the health needs of individuals. Most investors understand healthcare is defensive – in other words, human health is independent of the economic situation. However, the healthcare sector in EM has an additional growth dimension; as countries build and modernise their hospital and treatment infrastructure, it leads to increased consumption of health services and products across all ages. There is often a fundamental under diagnosis and treatment in many EM countries. The shortage in services

The right to health should not depend on the economic resources of a country. With products and services that are geared for emerging markets environments, China healthcare companies could help to bridge the gaps in health access and equity

and products will continuously drive company creation. The EM healthcare sector presents a unique and highly attractive investment profile of defensive growth that differentiates it from its developed market peers.

Furthermore, we are currently in a time of great scientific breakthroughs, research on mRNA, immunotherapy, and cell and gene therapy have all been validated with lifesaving products. The application of artificial intelligence and computing power to the process of drug development and disease management will continue to transform the way health and care are delivered to patients, as well as the healthy population. This excitement is global and especially meaningful to big population countries such as China and countries where basic health infrastructure is limited. Scientific breakthroughs always lead to active company creation, high capital demand and attractive investment opportunities.

Separately, there is a shortage of investible defensive growth market cap for global investors. For China healthcare companies, only those listed on non-China domestic exchanges such as the Hong Kong Stock Exchange are freely available to international investors. This translates to around $400 billion in investable market cap for China healthcare sector, which is approximately the market cap of Johnson & Johnson, the largest pharma company in the US. The rest of healthcare companies in emerging Asia, Latin America, Central and Eastern Europe, the Middle East and Africa have a combined market cap of around $600 billion, but many are listed on less liquid exchanges with currency risks. As a reference, the current total US healthcare market cap is around $6.5 trillion. While market cap is not the perfect reflection of sector value and part of the US healthcare market cap represents global

ZHI YANG

Dr Zhi Yang is founder and chairman of BVCF Management. He launched the firm in 2005 when he returned to China after two decades studying and working in the United States with the vision to bring the VC-driven innovation model to China. He launched BVCF as one of China’s first venture capital/private equity firms focused on the healthcare sector.

VANESSA HUANG

Vanessa Huang, general partner at BVCF Management, is a member of the WHO Council on the Economics of Health For All, which aims to reframe Health For All as a public policy objective.

bvcf.com

consumption, it is not hard to imagine we are still relatively early in the growth process given that EM has more than ten times the population of the US. Global asset allocation need has and will continue to drive strong investor demand for high-quality EM healthcare companies.

SOCIAL ASPECTS DRIVING INVESTMENTS

Like many, we believe healthcare R&D investments can be globally beneficial and we believe in the possibilities of partnership among scientists and investors across different countries and backgrounds. However, while global R&D investments have led to many new technological breakthroughs, most of the benefits are being enjoyed in a limited number of countries. With the urgency of global health access and equity, technologies that are applicable globally rather than just in high-income countries should be the core emphasis of future R&D investments. The pricing and distribution models of products should not remain status quo but should consider equity and R&D rewards sharing going forward, though best practices are yet to emerge.

The right to health is unfortunately economic resources–dependent in many countries. We believe (and hope) there will ultimately be discipline among global health ecosystem participants to share regional and country experience in building health access and health delivery systems without the lens of politics. We observe many parallels in the development paths, needs and supply gaps of the healthcare sector in other countries and that of China’s healthcare sector. Most China healthcare companies are still domestically oriented with limited overseas sales. We see the potential for China healthcare companies to be technology out-licensers with products and services that are geared for EM environments.

While we look forward to the exciting years ahead for EM healthcare, we should always remember the human aspects of healthcare investments. In the most fundamental sense, as healthcare companies transform from a few scientists to future giants, they will hire thousands of employees and the products they develop will save thousands of lives. We should also remember that if there is no capital available for these small healthcare companies, many drugs and technologies would never make it to market, many jobs would never be created and many lives would be left unsaved. ▪

While global R&D investments have led to many new technological breakthroughs, most of the benefits are being enjoyed in a limited number of countries”

By Tharman Shanmugaratnam, co-chair, G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response

For the greater good

It is in the interest of each nation that every other nation can halt a potential disease outbreak in its tracks, but without bold and practical steps to strengthen multilateralism in global health security, the world will remain at risk

As we make our way through a third year of the worst pandemic in living memory, our greatest challenge is complacency.

We are far from the finish line on Covid-19. New variants of the virus are a virtual certainty, with the chance that they will be more lethal than omicron and its recent sub-variants. Much of the developing world’s populations have not been vaccinated, let alone boosted. And evidence now suggests that herd immunity will be elusive, as new variants have been found to reinfect those infected with a previous variant.

Yet in too many countries, the politics of the day have moved on. Efforts to prepare for the next pandemic remain timid. And other ongoing global health challenges, particularly those that inflict continuing cost to lives in developing regions, still receive limited global attention.

While the war in Ukraine, crises in food and energy security, and inflation are understandably foremost in the public mind, it will be shortsighted to divert resources from global health security, and risk repeating the catastrophe experienced in the current pandemic.

There is no way to avoid such large-scale failure in public health without much stronger multilateral collaboration. It is in the interests of each nation

THARMAN SHANMUGARATNAM

Tharman Shanmugaratnam is senior minister in Singapore. He co-chaired the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response in 2021. He currently co-chairs the Global Commission on the Economics of Water, and is on the HighLevel Advisory Board on Effective Multilateralism established by the United Nations Secretary-General. He also chairs the Group of 30, and co-chairs the Global Education Forum, and the Advisory Board for the UN’s Human Development Report. He earlier chaired the G20 Eminent Persons Group on Global Financial Governance.

@tharman_s upandemic-financing.org

that every other nation is able to halt an infectious disease outbreak in its tracks and to respond forcefully to the next pandemic. Pandemic prevention, preparedness and response are a global public good.

It requires, first, a properly resourced World Health Organization, given the central role it plays in strengthening global surveillance and national health system preparedness. We must also invest at higher levels in prevention, preparedness and response, collectively and over a sustained period, to insure against future outbreaks. Further, we must adequately fund the international financial institutions such as the International Monetary Fund, World Bank and other multilateral development banks, and repurpose them to meet the new and interconnected challenges of the global commons. And we must repair a siloed global health security ecosystem, to ensure that multilateral, regional and national stakeholders work together in much tighter concert.

$1.3bn

committed by donors and NGOs to a fund for pandemic prevention, preparedness and response

TAKING STEPS FORWARD

There have been encouraging moves that we must build on. Credit must go to Indonesia and Italy, co-chairs of the G20 Joint Finance and Health Taskforce, for ably marshalling support for a new, overarching fund for pandemic prevention, preparedness and response (structured as a Financial Intermediary Fund hosted by the World Bank), following the recommendations of the G20 High Level Independent Panel on Pandemic Preparedness and Response. More than $1.3 billion had been committed by 15 sovereign donors and three non-governmental organisations by the end of August 2022.

This is a very good start, in a difficult year. But it is well short of the $10 billion that is the minimum additional sum that the world must invest through the FIF each year to strengthen our resilience against another Covid-19–scale pandemic. This sum is critically needed to enable early detection of new disease outbreaks anywhere and rapid development of vaccines, drugs and testing instruments. It will also help catalyse the public-private partnerships needed for investments in a globally distributed manufacturing network, so as to enable these key medical countermeasures to be produced at scale and reach low- and lower-middle income countries, much earlier in a pandemic.

investment each year is required to build resilience against another Covid-19–scale pandemic

Just

0.02%

But +$10bn of each nation’s GDP would cover this sum

This minimum funding size is beyond what we have been collectively willing to invest in the past. But with fair contributions by all, it is entirely affordable at about 0.02% of each nation’s gross domestic product – or several hundred times smaller than the costs to be avoided in another pandemic. To keep postponing such investments is financially reckless, besides being morally untenable.

We must take these bold and practical steps to strengthen multilateralism in global health security. We need to move with greater urgency, not wait for repeated reviews, and be willing to improve and innovate as we move forward. Waiting for the perfect has rarely been such a large enemy of the good. ▪

In too many countries, the politics of the day have moved on. Efforts to prepare for the next pandemic remain timid”

No smoke without fire

How significant is the burden of morbidity and mortality imposed by non-communicable diseases?

NCDs are among the leading causes of preventable disease, disability and premature death. They have been identified by United Nations members as a threat not only to health but also to development. Four major diseases account for the majority of the NCD burden, namely cancer, cardiovascular diseases, diabetes and chronic respiratory diseases. Tobacco use is a major risk factor in all four. The intimate connection between tobacco control and development is clearly acknowledged in Sustainable Development Goal 3, which specifically highlights strengthening implementation of the World Health Organization’s Framework Convention on Tobacco Control as a vital means to achieving the targeted one-third reduction in NCD premature deaths by 2030. And, of course, we are all very much aware that tobacco use itself is responsible for killing more than 8 million people a year, including 1.2 million non-smokers exposed to secondhand smoke.

Does tobacco use affect all countries and populations the same way?

No, it does not. Around 85% of the NCD premature deaths occur in low- and middle-income countries where health systems are typically less equipped to face the enormous burden that NCDs

Worldwide, tobacco use plays a major role in the escalating non-communicable disease burden. But with targeted measures and funding, tobacco controls could help prevent NCDs – and countries would see a significant return on their investment

present. Within countries across the income range, the poorest and most marginalised are more likely to consume tobacco and do so at a younger age, and are also more likely to be exposed to secondhand smoke.

And tobacco use is a significant driver of poverty, diverting expenditures away from essential commodities including food and education, while also exposing households to the risk of catastrophic healthcare expenditure in countries lacking universal health coverage. So we see that tobacco use deepens existing health, economic and social inequities.

What are the main economic impacts of tobacco use?

The provision of health care itself entails a significant cost, but the loss of human capital is the principal brake on economic growth. Most tobacco users who die from tobacco-related diseases do so in their most productive years. The total economic cost of smoking (from health expenditures and productivity losses together) was around $1.4 trillion in 2012, which represented around 1.8% of global gross domestic product. It is also worth noting the negative externalities of tobacco production. The soil that is used for and degraded by tobacco growing could be used to produce food, thus contributing – particularly in the current global situation – to food security while also providing a more sustainable livelihood to tobacco farmers and their families.

Secretariat, WHO Framework Convention on Tobacco Control

ADRIANA BLANCO MARQUIZO

Adriana Blanco Marquizo has led the Secretariat of the WHO Framework Convention on Tobacco Control since 2020. A medical doctor with a master’s degree in policies to prevent addictions in children and adolescents, she has worked in the Americas over the past two decades, including her home country of Uruguay. She previously worked at the Pan American Health Organization as a tobacco control regional advisor and later as chief of the Risk Factors and Nutrition Unit in the Department of Non-communicable Diseases and Mental Health.

@BlancoMarquizo who.int/fctc

Can a strong economic case be made for supporting tobacco control?

It can and has been made. In 2021, the WHO estimated that for each dollar invested in the five tobacco-control related ‘best buys’ to prevent and control NCDs, countries would receive a return on investment of $7.11 by 2030.

The Secretariat of the WHO Framework Convention on Tobacco Control jointly with the United Nations Development Programme and WHO has tailored tobacco-control investment cases for countries participating in the FCTC 2030 development assistance project, providing policymakers and other stakeholders with country-level evidence to inform tobacco control policy development.

How satisfied are you regarding the level of implementation of the WHO FCTC, and what are the main obstacles?

Despite the status of implementation having consistently improved since the convention’s entry into force in 2005, progress towards complete implementation of its various articles remains uneven. Measures concerning indoor smoke-free environments and warnings on tobacco packaging continue to be the most implemented, but the implementation of bans on tobacco advertising, promotion and sponsorship and increases of tobacco taxes continue to lag far behind. The most frequent challenges to implementation reported by parties to the convention are lack of financial resources and interference by the tobacco industry.

Is there an environmental impact from the use of tobacco?

Tobacco cultivation is a significant contributor to deforestation. Tobacco crops require large amounts of chemical fertilisers and pesticides that pollute the ground and water and endanger the health of farmers and their families. Cigarette butts are the most discarded waste item worldwide, accounting for approximately 767 million kilogrammes of toxic

8m

deaths a year are caused by tobacco use, including 1.2m non-smokers exposed to secondhand smoke

$1.4trn

The economic cost of smoking in 2012, representing around

767m kg

of toxic trash created by discarded cigarette butts every year

trash each year. The waste generated by new electronic products such as e-cigarettes and heated tobacco products is also a major and growing concern, as it contains not just toxic chemicals but also batteries, circuitry and the plastic in single-use cartridges. I can assure you that no amount of corporate greenwashing – and the tobacco industry does plenty of that – can wash away the environmental damage caused.

How does the Secretariat manage what is obviously a multi-sectoral challenge?

First, by being a role model at the international level, working with other multilateral organisations such as UNDP and the United Nations Environment Programme, as well as through mechanisms such as the United Nations Interagency Task Force on Prevention and Control of NCDs, to name just a few, and providing technical assistance to countries to connect with other sectors beyond health. The WHO FCTC, through the Global Strategy to Accelerate Tobacco Control 2019–2025, provides a roadmap for countries to build a cross-government response through the establishment of multi-sectoral coordination mechanisms to tackle the tobacco epidemic.

Are there any examples of initiatives introduced as part of tobacco control that might apply to other NCD risk factors?

Many examples exist, ranging from the use of warnings or cautionary images on tobacco products and advertising bans to the introduction of taxes that raise revenue while discouraging consumption. Such measures are already applied in some countries, examples including the provision of clear information about the nutritional profile of foods as a recognised way of encouraging consumers to healthier options and putting pressure on manufacturers to improve the nutritional profile of their products. Targeted taxation and pricing, so-called health taxes long used for tobacco and alcohol, are increasingly used to reduce the consumption of sugary beverages and foodstuffs. Less use has been made of advertising bans, but here too examples exist. With all these tools and mechanisms there is clearly scope for greater application. ▪

By Aleksi Yrttiaho, director, Anu Niemi, specialist in public health and general practice, and Markku Tervahauta, director-general, Finnish Institute for Health and Welfare

Drivers of political choice

It is becoming clearer that more data are required more frequently to address emerging health threats and provide services that are high quality and cost-effective – and Finland is leading by example

IMPACTFUL COMMON DATA AND KNOWLEDGE DRIVE POLITICAL CHOICE

Throughout the Covid-19 pandemic, we have seen increased demand for comprehensive and real-time data on the spread of the virus and the effectiveness of various countermeasures. The demand accelerated the adoption of digital services and intelligence gathering and sharing locally, nationally and globally, due to a common objective and sense of urgency. What if these data could be available to support all health policy?

SUPPORTING HEALTH POLICY

Finland has a long history of maintaining comprehensive social and health registers. Traditionally, they have been a source for statistics and analysis of long-term policy choices. It has become increasingly evident that more data are needed more frequently both to address emerging health threats and to provide high-quality and cost-effective services. Finland has moved from yearly statistics towards real-time data on primary and secondary health care as well as social care for the past 10 years. This transformation will continue by leveraging e-health and e-welfare solutions. Finland has also been a leader in adopting digital services in health and social care, and it is time for the full benefits of the available health data to be realised.

High-quality decisions are based on high-quality data. High-quality data are created through their use and clear feedback. The data should be generated as close to the actual services as possible. The primary use is to provide the best possible care for the patient. The same data are used for management, statistics and other secondary purposes leading up to local, regional and national policy and decisions for better public health. The Finnish model unites the data from primary use to policymaking to create a virtuous cycle to generate better data for better health policy. When possible, data created through health and social care services are complemented by longitudinal health interview studies and surveys to provide further insight on public health (see figure).

INGREDIENTS FOR LONGTERM SUCCESS

The recipe for long-term success needs three key ingredients.

First, trust is a prerequisite for e-welfare. In general, citizens have high levels of trust in health and social welfare professionals with whom they already have a personal relationship. Trust in the government and institutions has been exceptionally high in the Nordics, which has contributed to successfully adopting large-scale solutions for individual health and social care data in Finland. Trust can be cultivated through transparency on how data are used, who has accessed the data and clear value propositions on the benefits of sharing data. Citizens must always have control over how their data are used.

Second, process and data interoperability is vital to ensure the comparability and usefulness of data. The European Interoperability Framework models interoperability through legal, organisational, semantic and technical layers. Although data can be shared technically, it is of little use if common definitions and classifications are not used or if the differences in processes are not accounted for. Interoperability has been one of the leading principles for developing e-health and e-welfare in Finland since 1995 and is one of the key mandates for the Finnish Institute for Health and Welfare.

Third, governments should offer public and private health and social care providers incentives to accelerate

ALEKSI YRTTIAHO

Aleksi Yrttiaho is the director of technology, risk management and preparedness at the Finnish Institute for Health and Welfare. He led the implementation of national realtime health registers (2009–2021) and digital Covid-19 applications in Finland. He has played an active role in steering national e-health services and the secondary use of health and social data and currently focuses on leveraging technology and data to address emerging health threats.

ANU NIEMI

Anu Niemi is a specialist in public health and general practice and the head of the Knowledge Management and Co-Creation Unit at the Finnish Institute for Health and Welfare. She previously worked in management and development in social and health services at the regional level.

“ Development work will never end. New information management needs will always arise”

HEALTH AND SOCIAL DATA

PRIMARY USE SECONDARY USE

sharing data between organisations and with government institutions. A strong legislative basis for processing data and using it for policy support, budgeting and supervision provide positive incentives and also steer health and social care services towards common objectives.

MARKKU TERVAHAUTA

Markku Tervahauta has served as director-general of the Finnish Institute for Health and Welfare since January 2019. A doctor of medical science specialising in public health, he has held leadership positions in municipal and national public health organisations. He is a member of the executive board of the International Association of National Public Health Institutes and vice chair of the board of directors of Alko Inc. He is also chair of the National Nutrition Council.

In Finland, all these dimensions concern both social and healthcare data. Consequently, we have a unique knowledge base that can be used to manage health policy and political choices at local and national levels.

The journey towards comprehensive real-time data has taken time, but it has been worth it. But development work will never end. New information management needs will always arise.

FINNISH REFORM AND KNOWLEDGE MANAGEMENT

The organisation of public healthcare, social welfare and rescue services will be reformed in Finland in 2023. The responsibility for organising these services will be transferred from

municipalities to well-being services counties. The central government will mainly finance the costs incurred for organising the services. As a result, the importance of managing with comparable information is significant. Central government guidance and direction will be strategic in nature, focusing on the responsibility of the well-being services counties to organise services. They will have value-based information as their foundation. Strategic leaders of well-being services counties will also lean on the same data and knowledge when managing their own organisations.

The end result is that health policy will be backed by shared, real-time data at the local and national levels. This will bring the lessons learnt from the Covid-19 pandemic into use in health policy in general. Just as with the pandemic, it will take time to learn and improve the use of all the available data resources. Fortunately, the first leg of the journey has already been completed. ▪

We strongly believe that advances in medical science are meaningless when they do not reach those who need them.

This is why we are working in partnership across sectors to overcome barriers to care and improve health outcomes for all.

Health issues have a face. Context plays an important role in understanding health issues. Progressive and essence-capturing concepts lead to the formulation of health policies in many countries. It would be extremely effective if concepts could be considered in terms of practical issues and used to solve them. This is true for antimicrobial resistance.

Many people desire to live long, full and happy lives. However, by the time they reach the end of their healthy life expectancy, many will have some illness and require medical care. Older adults who require medical care are at a high risk of AMR problems. We have witnessed the Covid-19 pandemic, which puts these high-risk individuals at further risk. AMR in the older adult population is a significant problem, including in Japan, which is one of the most rapidly ageing countries in the

world. In the context of medical care for older adults at healthcare institutions, AMR control has taken the form of nosocomial infection control. To a certain extent, this has been effective.

RESOURCE ALLOCATION

However, the problem exists within the community. The challenge of AMR in community long-term care facilities and nursing homes has proven quite significant. It is a major problem in these facilities as well. However, as in many countries, the AMR issue in these facilities and communities is largely unrecognised by society, and, as a result, no resources are devoted to it. Therefore, it is extremely difficult to control AMR in such facilities and communities. This problem must be addressed: resources should be allocated to these facilities. The same challenge is occurring with regards to Covid-19. To return the functioning of society to where it was

The face of health issues

By Norio Ohmagari, director, Disease Control and Prevention Centre at the National Centre for Global Health and Medicine, and Norihiro Kokudo, president, National Centre for Global Health and Medicine

Finding progressive and practical solutions to health challenges – including antimicrobial resistance –starts with understanding the context in which those challenges exist

before the pandemic, it is necessary to strengthen measures in such institutions and communities. This problem, exposed during the pandemic, needs to be solved, too.

Inequalities in education also affect health. Health disparities exist as disparities in education exist. Inadequate education leads to inappropriate behaviour. This has also been a problem with the Covid-19 pandemic, and is true for AMR. According to a survey on the knowledge, awareness and behaviour regarding drug resistance and antimicrobials in Japan, adults in their 20s and 30s were less likely to have accurate knowledge about AMR and antimicrobials than older adults. Similarly, the rate of accurate knowledge of AMR and antimicrobials in Japan is lower than in European Union countries. This needs to be addressed.

Treatment should reach those people who require it on time and reliably. One of the critical problems of AMR is limited access to treatment. There are two aspects to this problem. First, there is an unstable supply of important antimicrobial agents. In recent years, Japan has been experiencing

recurring problems related to the supply of essential antimicrobials such as cefazolin, which have been attributed to the weak supply chain for manufacturing and supplying antimicrobials. Like other products, antimicrobials are products of global supply chains. Each country needs to take measures to ensure a stable supply, but it is also necessary to share awareness of problems and cooperate with other countries.

Second, research and development of new antimicrobial agents has slowed down worldwide. A major reason for this slowdown is that the investment required for R&D cannot be recovered in profits once antimicrobial agents are launched. The current economic model does not ensure a sustainable supply of new antimicrobials to combat the threat of AMR. G7 members are discussing the introduction of pull incentives. It is necessary to make this model successful and simultaneously establish a system to ensure that therapeutic agents reach patients worldwide.

Japan is currently revising its national action plan for AMR, which will serve as a guideline for concrete solutions to these issues. ▪

Norio Ohmagari has been director of the Disease Control and Prevention Centre at the National Centre for Global Health and Medicine in Japan since 2012. He also serves as the director of the AMR Clinical Reference Centre, which is commissioned by Japan’s Ministry of Health, Labour and Welfare. He previously served as chief of the Division of Infectious Diseases at the Shizuoka Cancer Centre, and completed his clinical fellowship in infectious diseases at the University of Texas-Houston.

Norihiro Kokudo is the president of the National Centre for Global Health and Medicine, and also president of the Asia-Pacific Primary Liver Cancer Expert Association and vice president of the International Association of Surgeons, Gastroenterologists and Oncologists. A fellow of the American College of Surgeons (Governor) and the Royal College of Surgeons of England, he is past president of the Japan Surgical Society, the International Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association and the Japan Liver Cancer Association. He is also co-editor-in-chief of Global Health and Medicine and associate editor of Liver Cancer.

ncgm.go.jp/en

NORIHIRO KOKUDO

NORIO OHMAGARI

Brain health: the paramount investment

Our brains are the site of all our experiences and the agents of all our actions. Our brains will determine the future of humankind.

Without a healthy brain, quality of life wanes and actions falter. New threats have arisen with unexpected fury, thanks to the pandemic, the war in Ukraine and ferocious floods, fires and temperature extremes. The World Health Organization has noted a 25% increase in anxiety and depression as a result of the disasters arising from climate change.

The problems are interconnected. The urgent use of scarce resources to beat Covid-19 resulted in the neglect of other diseases and delays in attaining the Sustainable Development Goals. The war in Ukraine threatens more famine in Africa and has generated an energy crisis that is delaying tackling climate instability and fuelling inflation.

On the other hand, these changes have dramatised how interdependent and complex the world has become. These problems are examples showing that we need holistic approaches. Our ability to cope with such complexities determines our future – as individuals and as societies.

And the key to this is brain health. This in turn represents a complex

By Vladimir Hachinski, professor of neurology and epidemiology, Western University, and Detlev Ganten, founding president, World Health Summit

system. Already in the 19th century, Rudolf Virchow, a German doctor, pathologist, anthropologist, politician and successful social activist, stated, “Medicine is a social science and politics is nothing more than medicine on a large scale.” Many reasons suggest that the “medicine … on a large scale” for the 21st century is brain health.

OPTIMAL WELLBEING

Brain health is a state of optimal cognitive, mental and social well-being in a healthy, safe environment. To achieve this, we have to engage the best that we are capable of with our individual and collective brains, since our brains are our future.

Homo sapiens became the dominant species largely through the brisk growth of intellectual capacities. Understanding the evolution of life and of homo sapiens and the role we play as a species in maintaining a healthy planet earth and the health of the people means understanding that we have to take responsibility especially for maintaining

Achieving optimum brain health for everyone is the single best investment a society can make, but worldwide, countries are falling short

brain health. The importance of these aspects grows exponentially as we increase our living standards at the cost of using our habitats’ resources, with dramatic effects on climate and far-reaching consequences on our way of life.

The pandemic has taught us how closely intertwined cognitive performance and learning are to mental health and social interactions. The knowledge-based economy and the relentless digitalisation of our world require ongoing learning.

Crises come with silver linings

life years among diseases of the nervous system. These have become the leading causes of DALYs globally. Stroke and dementia are preventable by 80% and 40% respectively.

Although prevention is infinitely a better investment than acute care, most countries devote less than 1% of their healthcare budget to prevention. Moreover, prevention is usually advocated for units too large and diverse for effective implementation. Even countries with universal healthcare systems such as Canada are too diverse for a one-size-fits-all solution. New approaches could include:

25%

The pandemic has expanded communications and opened new possibilities for learning. Education has to be comprehensive and lifelong, given the accelerated pace of change. It must encompass cognitive, mental and social dimensions and develop a critical sense to be able to separate facts from falsehoods and spin, and truth from pernicious ideologies. Brain health matters to all – to live, to be productive and to tackle the growing global problems. Consequently, all need to be involved: individuals, families, communities, governments and society as a whole.

If we think not only what is best for ourselves but also for everybody, and if we understand that we have to take more responsibility as citizens and as scientists, then we will begin to understand that investing in brain health is paramount. Brain health is the basis for curiosity, for learning, for education and for understanding complexity and finding solutions.

The best single investment for oneself is having a healthy brain, a rich emotional life, and enjoyable and productive relationships. Similarly, the best single investment for society is to achieve brain health for everyone to the degree that it is possible. An immediate benefit accrues from healthy brains being more productive and more capable of introducing innovations. Behaviours that foster brain health also delay, prevent or mitigate chronic diseases, especially stroke and dementia, which account for 62% of disability-adjusted

Vladimir Hachinski is a distinguished university professor at Canada’s Western University and former president of the World Federation of Neurology. He has made major contributions to the understanding, diagnosis, treatment and prevention of stroke and dementia, and leads a dementia prevention/brain health initiative. He introduced the concept of vascular cognitive impairment – the vascular treatable and preventable component of most dementias – and devised a method of identifying it.

▪ Preventing stroke, heart disease and dementia together by promoting brain health and focusing on units small enough to have a sense of community;

▪Understanding that education is the best vaccination against these diseases;

▪ Realising that simple measures such as engaging in exercise, maintaining healthy nutrition, controlling blood pressure, and avoiding being overweight, smoking and consuming excess alcohol are very effective;

▪Working through existing government, community and non-governmental organisations for implementation and qualifying existing healthcare professionals with micro-credentialling for different aspects of prevention; and

DETLEV GANTEN

Detlev Ganten, a specialist in pharmacology and molecular medicine, is one of the world’s top scientists in the field of hypertension. He is the founding president of the World Health Summit, a former CEO of the Charité – Universitätsmedizin Berlin and founding director and CEO of the Max Delbrück Center for Molecular Medicine.

▪Changing the message from fear to hope. Instead of warnings about future catastrophes, foster brain health now, for immediate and long-term benefits. Brain health is essential throughout everyone’s lifespan. It is key to health, productivity and well-being. Science has a major role and responsibility in this.

Brain health can provide the focus, inspiration and promise that if we commit to the 17 Sustainable Development Goals and improve partnership for the SDGs we will have better brains for understanding what needs to be done for individual well-being and for a better world. ▪

VLADIMIR HACHINSKI

By John H Amuasi and Andrea S Winkler, co-chairs, The Lancet One Health Commission

Strengthening health and climate co-benefits

Globalisation, reflected in economic activities and social relations, is rooted in industrialisation and urbanisation, which have advanced human health. However, other problems have emerged as a result of anthropogenic pressure and its profound impact on the biosphere. Climate change and biodiversity loss increase the vulnerability of humans, animals and plants to various health threats, including infectious diseases and antimicrobial resistance, as well as non-communicable diseases. Those effects exacerbate food and water insecurity and increase socioeconomic inequalities and health disparities.

Scientists, civil society, politicians, the private sector and others agree on the need to slow down and mitigate the catastrophic and existential threat posed by climate change. Evidence has shown the health and economic implications of activities in one part of the world (such as deforestation of the Amazon in South America and the Congo basin in Africa, coal mining in India, China and the United States, and vehicular and air traffic pollution in Asia, Europe and North America) on other parts of the world.

The effects on health can be direct, as shown by changes that increase the transmission of vector-borne infectious diseases among both humans and animals: the number of people at risk of contracting malaria will likely rise by 3% to 5% based on a 2–3°C increase in the average global temperature. Increased temperature worsens recurrent airway obstruction in horses. Changes to precipitation are associated with consequent extreme weather events such as droughts, floods and wildfires – which damage and limit access to infrastructure, including health systems, and aggravate health effects and hinder recovery from those effects. Air, water and soil pollution directly affects various life forms, the environment and climate through different complex mechanisms, which highlights the importance and benefits of One Health approaches to mitigating the health and climate change impacts of pollution.

The indirect effects of climate change on human, animal and environmental health can also be significantly severe,

through ecological disruptions caused by climate change, loss of biodiversity, decreased crop yield and reduced availability of water. The economic impact of climate change and its resulting impact on health can also not be overstated.

A LATE AWAKENING

Climate change and the pandemics have forced a rather late awakening that no one is safe until we are all safe. As such, investing in Health For All, while intrinsically altruistic, is an urgent requirement to preserve life on Earth. However, this ‘all’ has largely been limited to humans (and even then overlooks those in the lowest socioeconomic quintiles), neglecting the inextricable interconnections among humans, other animals, plants and our shared environment – the true ‘all’. One Health, encompassing all animals and the shared environment, becomes the most pragmatic and effective approach. With climate change the foremost global health and sustainability challenge of the 21st century, investing in Health For All using One Health approaches can strengthen health and climate co-benefits, because the linkages between climate and health are informed by our understanding of the complex socio-ecological systems in which humans, other animals and the environment are inextricably interconnected.

Low-income and middle-income countries are disproportionately affected by the deleterious effects of climate change and global health concerns, and by some mitigation policies. Health inequity (particularly poverty) increases exposure, sensitivity and susceptibility to pathogens and contaminants, and affects the

The Covid-19 pandemic has placed immense pressure on already struggling systems. The release valve lies in solidarity, global access and the shared understanding that health is a basic human right for everyone

capacity of populations to adapt to adverse environmental conditions. The impact of the Covid-19 pandemic on poverty declined among high- and middle-income countries, but worsened among the poorest countries. Efforts to curtail coal mining to cut emissions put countries such as India, with vast reserves and populations reliant on cheap coal-derived energy, at a serious disadvantage. Therefore, One Health approaches are desirable because they inherently include equity and sustainability considerations both in conducting research (including choice of populations, geographic locations and generalisability) and in designing interventions to strengthen climate–health co-benefits, particularly where resources are inadequate.

BOTTOMUP APPROACHES

The choice to invest in health and climate co-benefits is political, and politics is influenced by the expressed desires of the populace. Bottom-up approaches to stimulating governments to invest in climate-resilient health systems are needed. The scientific community needs

to work with civil society and grassroots organisations to foster national discourse and create awareness of climate–health interlinkages using One Health evidence –and the urgent need for action (including One Health investments). Once governments understand that their citizens view climate and health as a priority, it stimulates further discourse on One Health and investments, and motivates intergovernmental – and hence global – action as the effects of activities deleterious to climate and global health are often transnational. The severe droughts in the horn of Africa, parts of Europe and China, the flooding in Pakistan and the US, and the wildfires in Australia, Europe and North Africa are hardly the result of human activity limited to those specific geographic locations. However, poor countries, which disproportionally bear the burden of the negative impacts of climate change and global health, often rely on international financing mechanisms. These funding schemes can constrain countries’ ability to finance climate change mitigation and health promotion. The recent establishment of the Financial Intermediary Fund by the World Bank, technically supported and staffed by the World Health Organization, is an important step. It will provide mainly low- and middle-income countries with direct financing and incentives for pandemic prevention, preparedness and response, including multi-sectoral One Health approaches. The FIF will also support integrated disease surveillance by enhancing data sharing, improving laboratory systems and their harmonisation, and supporting improvements in health workforce capacity, community engagement, essential medicines supply and distribution, and emergency communication. It would be a missed opportunity not to incorporate specific activities to strengthen health and climate co-benefits.

Global climate change governance is challenging, but could be facilitated by including climate-related issues into One Health governance structures, such as a permanent One Health body in the context of a pandemic accord or national and global One Health–related structures, in order to strengthen co-benefits. Such a body would provide technical and scientific support in the form of policy recommendations and guidelines, supporting and performing external evaluations, as well as capacity building for One Health approaches to implementing interventions that would yield climate and health co-benefits for all. ▪

John H Amuasi is co-chair of The Lancet One Health Commission, and head of the Department of Global Health at the Kwame Nkrumah University of Science and Technology in Ghana. He is also group leader of global health and infectious diseases at the Bernhard Nocht Institute of Tropical Medicine in Germany, and the Kumasi Center for Collaborative Research in Tropical Medicine in Ghana. Dr. Amuasi’s current research involves clinical and field epidemiologic studies on malaria, emerging and re-emerging infectious diseases, antimicrobial resistance, snakebite and other neglected tropical diseases using One Health approaches.

Andrea S Winkler is co-chair of The Lancet One Health Commission. She is a specialist neurologist and professor of Global One Health, the co-director of the Centre for Global Health at the Technical University of Munich and the founding director of the Centre for Global Health at the University of Oslo, Norway. She has been working in global health as well as One Health for more than 20 years.

JOHN H AMUASI

ANDREA S WINKLER

rise in the average global temperature is likely to increase the number of people at risk of contracting malaria to

Healthy people, healthy planet

By João Campari, global leader, Food Practice, WWF International

The world is in a state of flux and we are at the crossroads for our future. We face many challenges. Exacerbated by conflict and a pandemic, we are in the grip of long-standing food security, climate change and nature-loss crises. The reality is that these issues –often treated separately – are in fact fully integrated. We can only achieve human and environmental health for all if we address the challenges together. Transforming food systems is perhaps our biggest chance to do so.

What we are eating and producing is healthy for neither people nor the planet. More than 2 billion people are obese or overweight and food-related diseases are the leading cause of premature mortality. At the other end of the spectrum, more than 820 million people go hungry every day. Yet we are destroying our planet to maintain these inefficient, unequal

food systems. Food production is the primary driver of biodiversity loss (approximately 70% on land and 50% in freshwater) and the biggest cause of deforestation and conversion (approximately 80%), and it is responsible for around 30% of all greenhouse gas emissions. Perhaps most worryingly, perpetuating this destructive approach actually decreases food security further. In a warmer world, we are forecast to have less productive land, shorter growing seasons, lower yields and food of lower nutritional density. So we will have less food and it will be of poorer quality.

RECIPE FOR SUCCESS

This is a stark reality. But the good news is that food can be part of the solution – not just to reducing premature mortality and nourishing people, but also to limiting climate change and restoring nature. Food systems can provide benefits to

Food production is the primary driver of biodiversity loss, but with the adoption of planet-based diets and by taking an integrated approach, there is much we can do to tackle food insecurity, climate change and the loss of nature

people and planet if we adopt nature-positive production practices at scale, shift to healthier and more sustainable diets, and radically reduce the amount of food lost or wasted, because currently 40% of all food produced goes uneaten. For instance, if everyone adopted planet-based diets (which consist of a wide variety of foods all produced with nature-positive practices, a higher proportion of plants than animals, and as many fresh, low-processed foods as possible), we could reduce food-based greenhouse gas emissions by at least 30%, food-based biodiversity loss by up to 46%, agricultural land use by at least 41% and premature mortality by at least 20%. And because diets rely on local contexts and cultures, the development of local food systems can lead to community resilience by absorbing short-term shocks when global food supplies are disrupted – as happened recently with the Covid-19 pandemic and the war in Ukraine. Success lies in taking a full food systems approach to help resolve the interconnected crises of food insecurity, climate change and nature loss. This means that we need to transform the three parts of the food system: production, consumption, and loss and waste. Tackling just one part of the system will not deliver environmental and human health for all.

ONE SIZE DOESN’T FIT ALL

That said, there is no one-size-fits-all solution. The Sustainable Development Goals and Rio Conventions provide global targets for human and environmental health. But when it comes to food,

+2bn

people are obese or overweight, while

820m

people go hungry every day

40%

of all food produced goes uneaten

these must be downscaled to local contexts to enable the development of national pathways for food systems transformation. Every country is unique and national food systems exist in different cultural, culinary and social contexts. Countries need to gather evidence as to which levers across production, consumption and loss and waste have the most potential to deliver impact – for local environmental, public health and social goals. By and large, actions that are good for human health are good for environmental health. But in some instances, there will be trade-offs. Shifts in consumption could lead to challenges for farmers; economic impacts for countries and shifts in traditional values. It is imperative that such trade-offs are identified and impacts minimised and mitigated, with those affected supported through transitions. This can only be done by exploring solutions at a national and even sub-national level.

It is impossible to consider human and environmental health separately. Each is driven by the other, and significantly affected by food security, climate change and nature loss. Transforming food systems provides us with the biggest opportunity to concurrently address the triple challenge of nourishing everyone within planetary boundaries, limiting global warming to 1.5°C and restoring nature to historic levels. Health for all depends on a transformed food system that works for people as much as it does for the planet. ▪

JOÃO CAMPARI

João Campari is global leader of WWF’s Food Practice, leading the organisation’s efforts to enhance the sustainability of the global food system. His primary areas of focus are sustainable agriculture and aquaculture, sustainable diets, and food loss and waste. He was recently chair of the United Nations Food Systems Summit Action Track 3, on boosting nature-positive production.

Prior to joining WWF, he was special sustainability adviser at Brazil’s Ministry of Agriculture, where he was also president of the Low-Carbon Agriculture Platform and executive secretary of the Agribusiness Commission on Sustainable Development.

@WWFLeadFood panda.org/food

At the intersection of gender, health and climate change

By Soon-Young Yoon, chair of the board, Women’s Environment and Development Organization

What does gender equality have to do with climate change and health? We are all part of an interconnected global ecological system. Keeping the earth’s temperature below the critical threshold of 1.5°C simply will not be possible without women’s leadership because we are more than 50% of the world’s population. Without us, governments cannot scale up progress on climate change. Indigenous women in Latin America are already leading the way by protecting biodiversity and defending rain forests. In Europe, feminists are protesting to ensure healthier, greener cities for all. Young women and girls in Asian cities are marching in the streets for climate justice. And Arab women will speak up loud and clear at the next climate summit to be held in Egypt. Why are we mobilising? Preserving Mother Earth is a feminist issue. United Nations reports show that during natural disasters in developing countries, more women than men die. Violence against women and sex trafficking increases after floods and wildfires. Women produce up to 80% of the food in Africa but own less than 10% of the land, making it difficult for them to adapt to droughts. And household air pollution due to solid fuels used in cooking stoves is a top cause of female deaths from non-communicable diseases. But make no mistake. This is not just an issue for developing countries. In many industrialised countries, poor women and girls often have less access to social and health services and live in sub-standard housing. As a result, they are less resilient during and after extreme weather events such as floods. Migrants and refugees who flee their climate-affected countries face challenges as they are the first to lose their jobs in their new homes during financial downturns.

Gender equality and climate change are inextricably linked, and for positive outcomes both require the right elected leaders, funding for the feminist movement and a commitment from everyone to be a global citizen

Furthermore, climate-related emergencies add to the burden of women in the care economy. Women make up more than 70% of all health service providers. Underpaid and often overworked, this vital workforce is being put under extraordinary stress during climate-related emergencies. The impact goes far beyond these women: it threatens the viability of the entire health system.

How are these issues related to women’s rights to health?

Imagine how extreme heat affects a pregnant woman in a remote Indian village. She must travel on foot for kilometres for a prenatal check-up. When her nutrition needs are greatest, the climate emergency is disrupting the systems that deliver food and fresh water. Due to climate change, health services are damaged and vector-borne diseases increase along with heat-related deaths. These health risks increase for everyone, but more for disadvantaged women and girls.

How can governments make a difference?

If we are to fully participate to combat the effects of climate change, women must have equal social, legal and economic rights. One of the most universal challenges facing women and girls is gender-based violence, particularly sexual violence. It has a devastating effect for the entire society: those women are deprived of their freedoms – to get an education, to work where they want and even to run for public office. Beyond that, it imposes high economic costs due to an increased burden on mental and other health services.

To tackle this issue, governments have to address the power imbalance that shapes social norms, institutions and laws. Thanks to the UN, we have set global standards to make progress. This includes the Beijing Platform for Action, the Convention on the Elimination of All Forms of Discrimination against Women and the Sustainable Development Goals. The UN Framework Convention on Climate Change and Convention on Biodiversity also provide for gender equality and women’s leadership. Governments need to use these together, not as isolated plans.

The good news is that CEDAW can help change social norms even in a country like the United States, which has not ratified the treaty. Mayors in Los Angeles, San Francisco, Toledo and 70 other US jurisdictions have joined the Cities for CEDAW movement. They are changing laws to address violence against women. They are also defending women’s rights to fair housing, health care and clean environments while ensuring protection for women facing discrimination on the basis of religion, ethnicity, race, age or disability.

What can we all do today to make a difference?

When young environment activists ask me this question, my answer is simple: vote. When

SOON-YOUNG YOON

Soon-Young Yoon is chair of the board of the Women’s Environment and Development Organization and author of Citizen of the World—Soon-Young and the UN. She served on the Gender Equality Council convened by H.E. Ambassador Abdulla Shahid, president of the 76th United Nations General Assembly. As chair of NGO CSW/NY, the committee launched the Cities for CEDAW campaign of the Convention on the Elimination of All Forms of Discrimination against Women. She was a social development officer for UNICEF in Southeast Asia and is co-editor of the World Health Organization monograph Gender, Women and the Tobacco Epidemic Soon-young.com

feminist leaders ask, I say: vote. Put the wrong political leaders in charge and they can throw our movement into reverse by pulling out of the Paris Accord, withdrawing funding to the UN Population Fund for women’s rights to sexual and reproductive health and denigrating the Human Rights Council. The right elected leaders, on the other hand, can defend women’s human rights, universal health coverage and climate justice.

Funding the feminist and women’s movements is another key priority. We are the most powerful non-violent movement of the 21st century, capable of accelerating equality, development and peace in much of the world. But backlash threatens to undermine our efforts. Feminist foreign policies are a good step forward, but they lose momentum without strong, progressive social movements. More funders should make commitments to the Generation Equality Forum spearheaded by Mexico and France and supported by UN Women.

Finally, everyone should be a global citizen. I have spent a lot of time in rural communities and I know that villagers can make choices to benefit all of humanity. Global awareness and regard for all peoples means we put ourselves in the shoes of the most disadvantaged – the majority of whom are women and girls. As a first step, we should be grateful for Indigenous women leaders who risk their lives to protect a community of life and future for our children.

The Paris Accord process has made commitments to gender equality and health. The World Health Organization makes a convincing environmental health argument for climate action. But we need to go one step further and ensure that policies are in the hands of feminist leaders – men and women – who will make women’s human rights their guiding principle. ▪

“

Women make up more than 70% of all health service providers. Underpaid and often overworked, this vital workforce is being put under extraordinary stress during climate-related emergencies”

Climate-smart health systems

switching to renewables such as solar power would reduce operational costs, cut carbon emissions and ensure continuity of critical patient care in the event of extreme weather and blackouts.

If you have survived an extreme climate event such as a hurricane or cyclone, or perhaps you are ill or injured as a result of such a calamity, the last thing you need is for the health centre or hospital to be damaged and non-functional. That is why we need climate-smart health systems, with an informed and empowered community, that are better at anticipating, predicting, responding and recovering from climate extremes, with health facilities that are safer, greener and health promoting for staff. A key element of such a programme is under way in the Caribbean, in the PAHO Smart Hospital programme, delivering co-benefits to climate, the environment, and the health of residents and visitors.

Although climate change adversely affects health in many ways, the health system contributes an estimated 4.4% of global carbon emissions, greater than Japan or Brazil. Because the largest contributor is energy generation and distribution,

By C James Hospedales, EarthMedic and EarthNurse, and Dana Van Alphen, senior adviser, Pan American Health Organization

The Caribbean has some 30 small island developing states, including independent countries and territories of France, the Netherlands, the United Kingdom and the United States. The region is highly vulnerable to the negative impacts of climate change, as recognised by the United Nations and the G20. A landmark conference on climate change and health in Caribbean SIDS in October 2021 brought together more than 25 partners to explore the increasing impact of climate change such as hurricanes and floods, heat, drought and crop failures, air pollution, sea level rise, vector-borne diseases, damage to infrastructure, population displacement and migration.

The Pan American Health Organization estimates that two-thirds of health facilities are in climate-vulnerable areas, often near coasts, exposed to

Safer, greener health systems are the way forward for people and planet – especially in climate-vulnerable regions – and an initiative in the Caribbean is delivering co-benefits to climate, the environment and human health

The Chateaubelair Hospital, in St Vincent and the Grenadines, has been

storm surge and sea level rise, flooding and landslides. In the early 2000s, with increasing damage from storms, the PAHO Safe Hospital programme commenced with a focus on improving safety and resilience to hazards such as hurricanes and earthquakes. Since 2010, it has evolved to be smart and include greening, such as energy and water conservation. Smart Hospitals are strategically built or retrofitted to resist disaster events and provide services under emergency conditions, using resources more efficiently and reducing environmental footprints. The project is a partnership with the UK’s Foreign, Commonwealth and Development Office and various Caribbean countries.

Piloted in 2012 in Saint Vincent and the Grenadines and Saint Kitts and Nevis, it was extended to seven English-speaking Caribbean countries and has been instrumental in retrofitting at least 50 smart health facilities.

The expanding climate-smart health facilities programme to include measures to promote the health and well-being of staff, such as providing more green areas with trees, more plant-based diets and active transportation, such as walking and biking, would yield further benefits for health and the environment and may help with retaining staff through improved working conditions.

SCALING UP HEALTH FACILITIES

However, only 50 of the more than 500 hospitals in the Caribbean have been through the PAHO Smart Hospital programme. The key challenge is how to scale up rapidly from 50 to 500 by 2030. It could be done by establishing an expanded multi-stakeholder initiative for climate-smart hospitals. Clusters of Smart Hospitals as mentors and aspiring facilities could be established, matched by size, function and language, and supported by an online integration platform for each cluster of hospitals and health facilities, within and across countries and territories.

It takes approximately one year for a medium-sized district or regional hospital or polyclinic to go through the programme at an average cost of $1 million per facility. That includes calculating a hospital safety index and a green checklist that identifies areas that can conserve resources, cut costs, increase efficiency in operations and reduce a health facility’s carbon emissions. The programme includes

C JAMES HOSPEDALES

C James Hospedales founded EarthMedic and EarthNurse to mobilise health professionals to address the climate crisis. He chairs the executive committee of the Defeat-NCD Partnership and is a climate and health adviser to the Healthy Caribbean Coalition. He was previously director of the Caribbean Public Health Agency, and coordinator of chronic disease prevention and control at the Pan American Health Organization. He played a key role in the 2007 CARICOM Heads of Government Summit on non-communicable diseases leading to the United Nations High Level meeting on Non-Communicable Diseases in 2012, 2014 and 2018. @earth_medic earthmedic.com

DANA VAN ALPHEN

Dana Van Alphen has been with the Pan American Health Organization’s programme on emergency preparedness and disaster relief as a senior adviser since 1995. In 2009 she developed the Smart Hospitals initiative for environmental performance/climate proofing and disaster resistance for hospitals. A medical doctor, she has led disaster response teams in Haiti, Grenada and Jamaica and Dominica, Indonesia, Pakistan, Lebanon, Philippines and Somalia. She was a medical coordinator for Médecins Sans Frontières for 10 years in Afghanistan, Somalia, Bosnia, Nicaragua, Peru, Guyana and Brazil.

capacity-building training for staff, as well as for the construction sector – both designers and contractors. Specialised multidisciplinary training can also be developed to support the initiative by partners such as the Global Consortium on Climate and Health Education, and the EarthMedic and EarthNurse Foundation for planetary health, headquartered in Trinidad and Tobago, which has been running training courses on climate and health for the Caribbean.

COBENEFITS FOR HEALTH AND CLIMATE

There are so many co-benefits for health and the climate from such an initiative, including:

▪Enhanced strategic resilience of health facilities and health systems to advancing climate change and extreme weather events, including sea level rise.

▪Reduced carbon footprint for the health system, especially if the programme includes vehicle fleets and health staff.

▪Energy cost savings and reduced carbon emissions, for a region with some of the highest energy prices in the world, by scaling up use of renewables such as solar power.

▪ Improved community resilience and continuity of access to services after extreme weather events for residents and the 50 million visitors annually.

▪Possible economies of scale in procurement of products and services needed across countries; for example, Trinidad and Tobago has an industrialised economy and the region’s only engineering school, which can partner with other countries.

▪The opportunity to export the know-how to other countries, including SIDS, that would benefit.

Partners and stakeholders for an expanded smart health initiative could include the Caribbean countries and relevant regional institutions, private-sector entities in construction and renewable energy, civil society organisations such as EarthMedic, and academia. It could extend internationally to include France, the Netherlands, the UK, the US, Canada, Germany, Italy, Japan and beyond, and could include development partners such as PAHO and the World Health Organization, the World Bank and the Inter American Development Bank. ▪

Systems for planetary health

Our current way of producing and consuming food and the impact it is having on the environment are unsustainable.

We are living in a unique moment for our planet, a crossroads. The scale and speed of the transformation and degradation of Earth’s natural systems due to the impact of human activities are unprecedented. They may be surpassing our planet’s capacity to continue to provide the conditions to sustain life as we know it, including humankind. Climate change is no longer only a possibility. Maybe seen as distant in time and space by some people until recently, it is now an indisputable fact that is affecting people and life everywhere on the planet. Land-use change, deforestation, biodiversity loss, pollution of air, water and soil, and overexploitation of marine and terrestrial resources are some other results of the acceleration of human activities during the past few decades. Planetary health is a global movement and scientific field that brings some important insights: we may no longer be able to safeguard human health and well-being if we continue on the same path; everything is connected, all human activities and the planet; everyone, every sector, every community has a role to play to change course; solutions must address planetary health for all.

To achieve that, we will need to effect profound and urgent changes in how we live. That includes how we produce

By Antonio M Saraiva, Aline Martins de Carvalho, Dirce Maria Lobo Marchioni, Raquel Santiago, Tatiana Camargo and Carlos Nobre, Planetary

and consume food, energy and manufactured goods; how we design and live in our cities; and, maybe underpinning everything, how we relate to nature and other human beings.

GLOBAL CALL TO ACTION

The São Paulo Declaration on Planetary Health is a global call to action from the planetary health community delineating a path forward to support a more equitable and resilient post-pandemic world. Drafted during the 2021 Planetary Health Annual Meeting, in São Paulo, Brazil, it has recommendations addressed to everyone, but especially to 19 sectors of society.

One sector is recognised in the declaration as central to planetary health: the agricultural and food systems sector. It has the possibility of “meeting our global food needs, achieving social justice, and decreasing our footprint on natural systems”, and so “how this sector moves forward with agricultural practices and food options will determine the future of human health and well-being”.

That is because the current way of producing food by the agricultural sector and the entire food system is having a negative impact on the environment, as it degrades forests, pollutes air, land and water, and drives pressure on biodiversity, directly and indirectly.

Pinpointing where connections and co-benefits exist in agriculture, climate and health is key to our survival

More than one-third of the Earth’s land surface and nearly 75% of freshwater withdrawal is taken or caused by agriculture, including livestock production, yet access to healthy, safe, affordable and sustainable diets is still precarious. In Brazil, for example, agricultural production is responsible for about 70% of the greenhouse gases emitted in the country, the vast majority due to deforestation and livestock, especially beef. The importance of agriculture as a driver of environmental change, including climate change, is clear.

In addition, climate change also affects people’s health, food security, malnutrition and obesity, especially in vulnerable populations, which are more affected by extreme weather events that produce heatwaves, droughts and floods, loss and reduction in food production, especially fruits and vegetables and increased food-borne illnesses.

However, the issue is not restricted to agricultural practices in the field. Human diets have an impact on our health and on the environment. Currently, malnutrition, nutritional deficiencies and overweight are a triple burden for many populations, associated or not with diet-related non-communicable diseases. Climate change may intensify the situation by affecting food production and security, thus adding another synergy to the problem.

ADAPT AND MITIGATE

Adaptation and mitigation actions are essential. Recent studies have shown that global dietary patterns need a transition to healthier and more sustainable diets, based on low environmental impact, rich biodiversity, high socio-cultural values of food, food waste reduction and positive local economic returns.

That means increasing consumption of diversified plant foods and reducing animal source foods (mainly meat) and the few plant foods driving deforestation (for example, soy in Amazonia), as well as integrating local biodiversity into food-based interventions.

Public policies can have a crucial role in every part of this complex issue. It is worth highlighting policies in Brazil that act in a systematic and intersectoral way, such as the National School Feeding Programme. It guarantees free healthy meals for students in public schools, provides educational activities in conjunction with professionals from the Primary Health Care System, and stipulates that at least 30% of food must be acquired from family farming, favouring organic and highly diverse agro-ecological foods.

Family farming has a crucial role in Brazilian development, since it aggregates sustainable development, employment and income generation, food security, local development and especially biodiversity conservation as an alternative path to food sovereignty. This is an important step, because Brazil lives with the paradox of being one of the major food producers and exporters, and at the same time has 33 million people facing hunger, now reversing the previous trend of decrease.

These are some of the many links among agriculture, food systems, human diets, human health, environment, biodiversity and climate. Others might be added, such as the role of propaganda and communication on diets and on society’s choices regarding those topics. Be it at the personal level or at the country level, food systems and their impacts on agriculture and health are, indeed, political choices. ▪

ANTÓNIO MAURO SARAIVA

António Saraiva is an electrical engineer and agronomist, and a professor at the University of São Paulo and has been viceprovost for research, among other positions. He is the head of Planetary Health Brazil and has represented USP in the Planetary Health Alliance since 2016. He is a member of the PHA steering committee and chaired the 2021 Planetary Health Annual Meeting and Festival.

ALINE MARTINS DE CARVALHO

Aline Martins de Carvalho is a nutritionist and professor at the School of Public Health at the University of São Paulo and coordinator of Sustentarea, an extension programme in sustainable diets and food systems at USP.

DIRCE MARIA LOBO MARCHIONI

Dirce Maria Lobo Marchioni is a professor at the University of São Paulo, with experience in nutrition epidemiology, with emphasis on dietary assessment, working mainly on sustainable diets, diets and health.

RAQUEL DE ANDRADE CARDOSO SANTIAGO

Raquel Santiago is a nutritionist and gastronome, and associate professor at the Federal University of Goiás in Brazil. She coordinates the Centre for Culinary Science at FANUT-UFG as well as Sustentarea UFG and the Planetary Health Ambassadors Programme.

TATIANA SOUZA DE CAMARGO

Tatiana Souza de Camargo is a biologist and associate professor at the Federal University of Rio Grande do Sul. She is an education fellow at the Planetary Health Alliance at Harvard University.

CARLOS NOBRE

Carlos Nobre is an earth system scientist with the Institute of Advanced Studies at the University of São Paulo. He chaired the Large-Scale Biosphere-Atmosphere Experiment in Amazonia and is the author of several reports for the Intergovernmental Panel on Climate Change. He was director of the Center of Weather Prediction and Climate Studies, and creator of Centre for Earth System Science and the National Centre for Monitoring and Early Warning of Natural Disasters.

SaudePlanetaria / @ph_alliance

saudeplanetaria.iea.usp.br/en and planetaryhealthalliance.org

First Nations–led health solutions

Chief Perry Bellegarde,

In Treaty 4, my home territory in Canada, the regional hospital is governed by a board of directors with most members from First Nations. Not only that, the All Nations Healing Hospital in Fort Qu’Appelle, Saskatchewan, provides patients a choice of traditional Indigenous and Western healing methods, whether the patient is Indigenous or non-Indigenous. When I walk through the doors of All Nations, I feel a tremendous sense of pride. For me, that hospital demonstrates what can be accomplished when governments make the political choice to invest in

First Nations–led health solutions.

The All Nations Healing Hospital is not alone. There are numerous cases across Canada of First Nations reclaiming control of our own health care. They range from urban clinics such as the Wabano Centre in Ottawa to the full-fledged First Nations Health Authority in British Columbia. Unfortunately, however, such cases remain exceptions rather than common practice. That needs to change.

There is a profound gap between the quality of life of First Nations people and the standard of living enjoyed by non-Indigenous people in Canada.

That includes a deep gulf in all aspects of health and wellness. First Nations people have a shorter life expectancy than non-Indigenous people. The most recent statistics put that gap at almost ten years (8.9 years for First Nations men and more than 9.6 years for First Nations women). Furthermore, First Nations people have been found to be more than twice as likely to die from avoidable causes. Rates of chronic disease are much higher, including highly preventable diseases such as tuberculosis that are rare in most communities.

UNHEALED TRAUMA

This gap is the direct result of the political choices of past and current governments. Canada’s efforts to forcibly assimilate First Nations people through the residential school system and related policies caused profound intergenerational trauma that remains largely unhealed. The federal government, which has constitutional responsibility for services in First Nations communities, has systematically underfunded not only health care, but also housing, sanitation, drinking water, family services and other supports that are key components of the social determinants of health. In addition, decades of theft and

When governments make the political choice to invest in in First Nations–led health, progress can be made in ensuring everyone enjoys the highest attainable standard of physical and mental health

By

former national chief, Assembly of First Nations, Canada

destruction of Indigenous territories have created barriers to healthy living and the betterment of our communities.

In 2019, after visiting First Nations territories such as Grassy Narrows and Aamjiwnaang that are suffering from industrial contamination, Baskut Tuncak, the United Nations special rapporteur on human rights and hazardous wastes, concluded that Indigenous peoples in Canada “find themselves on the wrong side of a toxic divide, subject to conditions that would not be acceptable elsewhere in Canada”.

There has been a long history of substandard care and overt abuse at the hands of the Canadian healthcare system, including documented medical experimentation during the

PERRY BELLEGARDE

residential school era and continued forced sterilisation of Indigenous women and girls. Systemic racism has caused profound harm. The failure to treat patients with dignity and respect leads to needless suffering, prolongs the debilitating impacts of illness, and – as we have seen – can lead to early and unnecessary death.

In 2008, a First Nations man, Brian Sinclair, died in a hospital emergency room after being ignored for 34 hours. In 2020, a First Nations woman, Joyce Echaquan, died in a Quebec hospital after recording a video documenting how staff were verbally abusing her and ignoring her pleas for help. These are far from isolated incidents. A recent independent investigation into the provincial healthcare system in British Columbia by Mary Ellen Turpel-Lafond found “widespread systemic racism against Indigenous peoples” resulting “in a range of negative impacts, harm, and even death”.

IMPROVING THE SYSTEM

First Nations have worked for decades to improve the Canadian healthcare system. We have made important gains, particularly in expanding access to primary care and in the design of crisis intervention services and addictions treatment. Growing numbers of First Nations health professionals are making a difference in every field of medicine. In fact, the new head of the Canadian Medical Association, Alika Lafontaine, is an Indigenous physician of Métis, Cree, Anishinaabe and Pacific Islander ancestry.

These accomplishments are real and meaningful, but we have a long way to go. Last year I participated in a national symposium on systemic racism in

Chief Perry Bellegarde (Little Black Bear First Nation) served two terms as the national chief of the Assembly of First Nations Canada from 2014 to 2021. He has been awarded the Confederation Medal, the Saskatchewan Centennial Medal, the Queen Elizabeth II Diamond Jubilee Medal and the Golden Jubilee Medal. In 2018, he was recognised with the Saskatchewan Order of Merit, and in 2019, awarded an honourary doctorate of laws from Queen’s University for his extraordinary contribution to public service, arts, culture, law and government.

@perrybellegarde

Canadian health care. One thing that stayed with me was hearing First Nations health professionals describe the racism they have encountered throughout their careers. If these individuals who are highly trained and highly accomplished in the Western medical system can be belittled and dismissed, what chance do other community members have? And what is the likelihood that our own traditions and our own science will be taken seriously?

We need First Nations physicians, nurse practitioners, nurses and midwives and we need them to be treated with respect. More than that, it is vital that First Nations voices are included at the highest level of administration of all medical services accessed by our community members. These institutions must be held accountable for addressing systemic racism. Otherwise, they are failing in their responsibilities as healthcare providers.

Ultimately, however, what we really need is investment in health services designed, controlled and operated by First Nations, where our knowledge of our communities, our values and our science will help shape the care. Furthermore, First Nations–run health services must be available not only in our own communities, but also the urban centres where growing numbers of First Nations people make their homes.

Last year, Canada’s Parliament adopted legislation to fully implement the United Nations Declaration on the Rights of Indigenous Peoples. The declaration represents a global consensus on the minimum standards necessary to ensure the “survival, dignity and well-being” of Indigenous peoples. It includes an explicit affirmation that First Nations “have an equal right to the enjoyment of the highest attainable standard of physical and mental health”. More than that, the declaration recognises the right of First Nations to develop and determine our own healthcare systems.

What will this look like? One way we will know that Canada has successfully implemented the UN declaration is if all First Nations people have access to the quality of care that my family and I have enjoyed at the All Nations Hospital. This is not just a dream. This is something that can be achieved if governments in Canada make the choice to invest in First Nations–led health solutions. ▪

Real, urgent and present

By Fiona Armstrong, founder and strategic projects director, Climate and Health Alliance

Four floods in four months.

Choking bushfire smoke infiltrates hospital operating rooms and fills new babies’ lungs. A pandemic brings the global community to a standstill. These are some of the real, urgent and present impacts that Australians face from climate change.

The evidence of adverse health impacts from global warming has been documented in Australia by scientists for at least two decades. Despite this, engagement by policymakers and political actors has been glacially slow – until the past three months.

Climate politics in Australia have changed drastically – and we hope irreversibly. It is worth reflecting on the political forces that stagnated progress for decades, lest they rear their head again.

A toxic political environment, with conservative political parties captured by corporate interests and disinformation vigorously promoted by Murdoch-owned media outlets, has led to the grindingly slow development of climate policy in Australia.

UNWILLING TO ENGAGE

Politicians in Australia’s national parliament have been famously unwilling to engage with climate science. As recently as 2018, Deputy Prime Minister Michael McCormack dismissed the Intergovernmental Panel on Climate Change as “some sort of report” to which Australian policymakers were not obliged to pay attention. His colleague Environment Minister Melissa Price asserted scientists were “drawing a long bow” in calling for a fossil fuel phase out to limit global warming. Prime

Minister Scott Morrison and then Angus Taylor, minister for emissions reductions (in name only), repeatedly claimed Australia was “meeting and beating” its commitments under the Paris Agreement. This was untrue: emissions rose under this conservative government.

At the Climate and Health Alliance, we have seen first hand how political attitudes can influence the public service. In 2010, the Australian Tax Office told our charity that “climate change is a highly contentious issue among lawmakers and the community, with both believers and skeptics putting forward their evidence to support their contentions”. The office contended the health impacts of climate change were “not yet established”, and were “speculatory [sic], depending on which view one supports”.

The health impacts of climate heating have been documented in Australia for at least 20 years, but engagement from those who can drive change has been glacial – until now

This was despite the World Health Organization and The Lancet declaring climate change the biggest public health challenge of the 21st century.

Decades of inaction in Australia have had repercussions around the world. Australian inaction provided cover for other recalcitrant governments, and has allowed climate denial to be normalised for other conservative governments. It has stymied bureaucracy, confused the public and contributed to an outbreak of climate anxiety, particularly among young people.

Lives have been lost unnecessarily. Between 2006 and 2017, around 36,000 premature deaths in Australia were caused by extreme heat. At the same time that emergency services were seeing more incidents linked to dangerous extreme weather, their funding was cut.

No wonder, then, that advocates for evidence-based policy are relieved at the results of the recent federal election. The newly elected centre-left government, led by Prime Minister Anthony Albanese, has wasted no time. In just a few months, his government has:

▸ updated Australia’s commitment under the Paris Agreement;

▸ drafted, introduced and secured support from the House of Representatives for a climate bill, articulating the new targets and reporting; and

▸ reaffirmed its commitment to develop a national strategy on climate, health and well-being for Australia.

Health is a political choice. By ignoring the science, and refusing to engage in either mitigation or adaptation policy to address the health impacts of climate change, Australia’s former government put lives at risk. They blithely dismissed repeated warnings of the dangers by advocates and researchers. For those who lost their lives in climate-related disasters, one could argue their deaths were the results of calculated, self-serving, political choices.

PRIORITISING SCIENCE

There are always choices. Choices to listen to science, to listen to the community or to listen to those with vested interests in the status quo. By developing policy targeting climate change and health, the Albanese government is making a choice to prioritise scientific evidence over ideology.

The health and medical community has actively advocated for an integrated response to climate and health policy in Australia. This has included the development of very detailed guidance in the form of a framework for the national strategy, “Healthy, Regenerative and Just”. The framework has more than 200 specific policy recommendations under eight action areas that span multiple portfolios and all levels of government.

36,000 250,000

A political choice has been made by the Australian government to heed this advice.

In August 2022, Minister for Health Mark Butler reconfirmed the government’s commitment to develop and implement a national strategy on climate, health and well-being, saying: “The World Health Organisation estimates that between 2030 and 2050, 250,000 people every year will lose their lives as a direct result of a warming planet. And the impact in Australia will be profound. In a continent that already pushes us right up against the limits of human tolerance.”

The minister has identified three key objectives for Australia’s climate and health policy:

▸ maximising the synergies between good climate policy and public health policy,

▸ ensuring the healthcare sector is prepared to respond to the challenges of climate change, and

▸ reducing the sector’s contribution to global warming by reducing emissions in health care.

Peter Doherty, Australian Nobel Laureate for Medicine, said, “The window of opportunity for effective action on climate change is narrowing. We have just one decade to apply all the strategies available to us to give us a chance to hand on a habitable planet.”

We hope the leadership of the new federal government will provide us all a chance to contribute towards that goal. ▪

FIONA ARMSTRONG

Fiona Armstrong is founder and strategic projects director of the Climate and Health Alliance, based in Australia. Architect of the world’s first Framework for a National Strategy on Climate, Health and Well-being, she has led the development of “Australia in 2030: Possible Alternative Futures”, and the “2020 Healthy, Regenerative and Just” policy agenda among other CAHA initiatives. She was a lead author of the Queensland Government’s Human Health and Wellbeing Climate Change Adaptation Plan. She was named one of Australia’s 100 Women of Influence (2016) and is a recipient of the Tony McMichael award (2017), the Frank Fisher Award (2018) and the ProBono Impact 25 Award (2022).

@farm_strong / @healthy_climate caha.org.au

For those who lost their lives in climate-related disasters, one could argue their deaths were the results of calculated, self-serving, political choices”

premature deaths in Australia caused by extreme heat 2006–2017 people every year estimated by the World Health Organization to die as a direct result of a warming planet between 2030 and 2050

Plugging into digital health

DIGITALLY ENABLING ENVIRONMENT

By Alain Labrique, Garrett Mehl, Derrick Muneene and Natschja Ratanaprayul, Department of Digital Health and Innovation, and Soumya Swaminathan, World

The experience of countries around the globe in combating the Covid-19 pandemic has been heterogenous. Aside from innovations in diagnostics, immunisations and treatment, one novel health technology stands out as a game changer, when compared to prior pandemics: the mobile phone. Part of a quiet revolution that has been transforming the landscape of health systems for high- and low-income populations alike, digital health innovations have been at the heart of numerous national efforts to manage this global health emergency. Success has been quite variable in how effectively countries leveraged ubiquitous phone ownership and widespread access to the internet to improve access to testing, track infections and transmission patterns, increase vaccine coverage, establish verifiable certificates of Covid-19 status, and fight disinformation and misinformation. Common factors across the most successful digitally responsive systems might arguably be the sophistication of the digital-enabling environment, appropriate governance and policies for health data and information systems, and, most importantly, the political will to use digital health solutions in a time of crisis.

Although few countries can currently boast a digitally ideal environment, several did have key components in place – ranging from the existence of a widespread national unique identifier system to carefully maintained, trustworthy and up-to-date registries of facilities, health workers and even centrally monitored stock levels of essential supplies of medicines and diagnostics. Prior to the pandemic, some countries had built or begun investing in national interoperability ‘backbones’, including clear interoperable standards for sharing aggregate or individual patient information across facilities and regions, linked to robust, connected and adaptable point-of-care digital systems. Local capacity for adapting software or generic reference applications – rapidly made available by the international community as ‘software global goods’ –was predicated on the existence of trained developers, informaticians and business process analysts. wThese professional cadres were capable of translating public health system needs into user-friendly software solutions that could scale up nationally, or regionally, and support changing public needs over the course of the pandemic as new scientific evidence became available.

HEALTH DATA GOVERNANCE

In the early response to the pandemic, some countries encouraged digital health solutions to scale up rapidly by streamlining the review and approval process, or by clarifying classes of digital interventions that could be deployed without extensive oversight, including software functions such as symptom screening, referral and even wellness. Allowances were made, in some settings, for clinical providers to leverage digital channels previously not thought adequate for telemedicine consultations, which lowered barriers of technical complexity to allow for more widespread virtual access to providers under conditions of social distancing or mobility restrictions. In some geographies, the existence of strong privacy and health data protection laws fostered an atmosphere of public trust for digital

Digital health is a public health opportunity, but one that is predicated on political will and bold, forward-thinking leadership

solutions. The converse was true for countries where national data protection laws were either absent or weak, leading to low uptake and use of digital systems by citizens. Surprisingly, some countries with a high digital ‘opportunity’ (i.e., near-universal phone ownership, reliable networks and sophisticated technology ecosystems) have not been as successful in deploying some digital health solutions because of inadequate or absent digital health data policies and governance.

POLITICAL SUPPORT

Lastly, the importance of political leadership and cooperation cannot be understated in bringing different stakeholders to work together, especially in a crisis. Digital health is characterised by the diversity of disciplines required for successful solutions to be developed, tested, implemented, monitored and maintained in real-world settings. Public-private partnerships and cross-sectoral collaboration have been at the heart of much successful implementation, leveraging the agility and capacity of private-sector technology to tackle large-scale problems of public importance. Although most countries today have successfully crafted national digital health visions and strategies, the resources required to implement these are not available. Digital health investments must now be seen as much more than stand-alone projects or programmes, but really as part of an infrastructural transformation of health systems. From increased efficiency and transparency to the speed with which health system performance data are available, numerous fiscal arguments can be made for robust financial support for digital health infrastructure. Bold, forward-thinking

ALAIN LABRIQUE

Alain Labrique is director of the Department of Digital Health and Innovation at the World Health Organization. An infectious disease and population epidemiologist, he is the founding director of the Johns Hopkins University Global mHealth Initiative, and was the inaugural associate chair for research in the Department of International Health at the university’s Bloomberg School of Public Health. He chaired the WHO Digital Health Guidelines Development Group. In 2018, he was awarded the Excellence in International Public Health Practice Award from Johns Hopkins University.

GARRETT MEHL

Garrett Mehl is a scientist and unit head of the Public Health Technologies Unit of the WHO’s Digital Health and Innovations Department. He led the development of the first WHO guidelines on digital health, digital health classifications and digital implementation investment guide, and is responsible for the WHO SMART Guidelines, digital clearinghouse and digitally augmenting the international certificate for immunisation (Smart Vaccination Card) initiatives. He also co-leads the Health Data Collaborative Working Group on Digital Health and Interoperability.

political leadership is necessary to realise a future of connected digitalised systems facilitating outbreak response and person-centred care to everyone, everywhere and every time it is needed.

CONCLUSION

The digital transformation of global health is inevitable. Lessons learned from prior decades of successes and, more importantly, failures, have helped to create a roadmap, enshrined in the World Health Organization’s Global Digital Health Strategy 2020–2025, which identifies the key milestones required for equitable progress. The Covid-19 pandemic provided the experience and evidence needed to convert even those sceptical of technology that digital innovation can

DERRICK MUNEENE

Derrick Muneene is head of capacity building and collaboration of the WHO’s Digital Health and Innovation Department. He was the regional mHealth and eHealth adviser for the WHO regional office for Africa, where he supported 47 African countries with the adoption of eHealth strategies and eHealth solutions. Previously, he served with the US Centers for Disease Control and Prevention as acting branch chief for health informatics and health systems analysts.

SOUMYA SWAMINATHAN

Soumya Swaminathan was appointed the WHO’s first chief scientist in 2019. A paediatrician from India and a globally recognised researcher on tuberculosis and HIV, she was previously secretary to the Government of India for health research and served as director general of the Indian Council of Medical Research from 2015 to 2017. From 2009 to 2011, she was coordinator of the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases in Geneva.

NATSCHJA RATANAPRAYUL

Natschja Ratanaprayul is a technical officer in the Public Digital Health Technologies Unit in the WHO’s Digital Health and Innovations Department. She is responsible for coordinating the SMART Guidelines programme, working with internal and external partners to support the digitisation of WHO’s clinical, public health and data content. She is also coordinating work on digital documentation of Covid-19 vaccination certificates and test results. Prior to joining the WHO, she worked in strategy consulting in health and public service, financial services, products and more.

improve the quality of individual care as well as help choreograph public health responses and continuity of care during a crisis. Enabling future pandemic resilience and stronger health systems through digital transformation is a technical challenge, but also a financial and political imperative. ▪

“Digital health is characterised by the diversity of disciplines required for successful solutions to be developed, tested, implemented, monitored and maintained in real-world settings”

It is hard not to notice how the topic of global infectious diseases increasingly pervades or even dominates the geopolitics of national governments and international relations. In 2022, Covid-19 transmission remained strong, despite being the third year of the pandemic – the global death toll is approaching 20 million people. We also saw how monkeypox spread from the African continent to cause widespread illness across the Western Hemisphere and much of Europe. Now, poliovirus has been detected in the United States and United Kingdom, with the first US case of acute flaccid paralysis in decades diagnosed in a suburb of New York City. These phenomena piggyback on serious epidemics that arose immediately before the Covid-19 pandemic, including the return of measles in Venezuela, Ebola virus infection in West Africa and the Democratic Republic of Congo, and emerging neglected tropical diseases including leishmaniasis in the Middle East and East Africa, schistosomiasis on the French island of Corsica, and mosquito-borne virus infections on the US Gulf Coast and in Southern Europe. Today, among the most frequent questions I am asked is whether these disease occurrences represent random events or are somehow connected. The answer is not straightforward. Increasingly it appears that something indeed has been happening over the past eight years or so to cause a significant rise in global infections, especially vaccinepreventable diseases, neglected tropical diseases and catastrophic respiratory infections. Moreover, the pace and strength of these epidemics and (in some cases) pandemics are accelerating.

COMBINED FORCES

Despite the increasing recognition of the importance of climate change in promoting infectious diseases – it is

By Peter National School of Tropical Medicine, Baylor College of Medicine

A new world order of global infections

tempting to compare such shifts in planetary health to worsening and devastating weather events – the reality is more nuanced and less obvious. Yes, climate change has a role, but in concert with some key social determinants. I benchmark the years 2014 and 2015 as times when we began to see infectious disease events sharply accelerate. Here are three brief examples of how these new 21st-century social and physical forces combined in unique ways:

▪ The Arabian Peninsula and the Middle East. The ISIS occupation and the wars in Yemen slowed or interrupted

childhood immunisation against measles, polio and hepatitis A. The halting of insect vector control programmes resulted in a large resurgence of leishmaniasis, a disfiguring parasitic infection transmitted by sandflies, sometimes known locally as ‘Aleppo evil’. Then, a massive cholera outbreak erupted in Yemen. Plus unprecedented high temperatures caused populations to abandon ancient agricultural lands and emigrate into crowded cities such as Aleppo and Damascus. This aggressive urbanisation accelerated both political unrest and illness.

A confluence of political instability and rising anti-vaccine activism is having deadly consequences around the world and causing the return of vaccinepreventable diseases that we have not seen in decades

c20m

PETER HOTEZ

Peter Hotez is professor of paediatrics and molecular virology and microbiology, and dean of the National School of Tropical Medicine at Baylor College of Medicine, where he is also chair of tropical paediatrics at the Texas Children's Hospital and co-director of the hospital's Center for Vaccine Development. He co-led the development of low-cost Covid-19 vaccines, including Corbevax produced by India’s Biological E. An elected member of the US National Academy of Medicine and American Academy of Arts and Sciences, in 2022 he received the Scientific Achievement Award from the American Medical Association, and an honorary doctorate in science from Roanoke College.

@PeterHotez peterhotez.org

200,000

▪ Venezuela and Central Latin America. The socioeconomic collapse of the Maduro regime brought back insect-transmitted infections such as malaria, leishmaniasis, dengue and Zika virus, fuelled partly by expanding populations moving into recently deforested areas or seeking employment in the insect-infested gold mines. Declines in vaccination produced a resurgence in measles, subsequently transported by populations fleeing the country and entering the Amazon regions of Brazil and Colombia. New contact with Indigenous populations caused serious and deadly epidemics of vaccine-preventable diseases. Food insecurity from decreasing rainfall and depleted water reserves from prolonged drought compounded these effects.

▪ Texas and the US Gulf Coast. Warming temperatures, altered rainfall patterns, hurricanes and other weather events combined with urbanisation to create hot, sweltering cities vulnerable to emerging neglected tropical diseases including dengue, Zika virus infection, West Nile virus infection, typhus and helminth infection. In the past decade Texas and the Gulf Coast became an epicentre of anti-vaccine activism in the US that is bringing back measles and other vaccine-preventable infections.

In each case, the rise of these diseases resulted from a confluence of political instability, urbanisation (and deforestation) and other major social determinants, together with climate change. Similar forces also drive Covid-19 (and likely future coronavirus infections), monkeypox, polio and Marburg virus infection. Among our great challenges is sorting out the attributable risk to each of the underlying social and physical determinants, in part because we lack predictive algorithms or models due to an absence of meaningful dialogue among the biomedical scientists, mathematical modellers and epidemiologists and the social scientists – economists, sociologists and political scientists.

SOCIAL THREATS TO HEALTH

Superimposed on these determinants is anti-vaccine activism and other social threats to our health and scientific infrastructures. Beginning in the 2010s the anti-vaccine movement in the US pivoted from alleging links between vaccines and autism to focus instead on ‘health freedom’ propaganda adopted by American politics on the far right. As a result, the US is now haunted by the reality that an estimated 200,000 Americans lost their lives unnecessarily to Covid-19 because they refused to take a vaccine even after safe and effective vaccines became widely available in 2021. Most of those deaths occurred along a partisan divide in conservative US Southern states.

An empowered and well-organised American anti-vaccine movement now targets all immunisations, especially routine childhood vaccines for measles and polio. This will not stop at US borders. The American style of anti-vaccine aggression has contaminated Canada and Western Europe, and even low- and

middle-income countries in Africa. We could see the widespread return of all vaccine-preventable diseases and even slow or reverse progress towards the global Sustainable Development Goals. Also in the US, the increasing attacks from the far right not only discredit the science but the scientists themselves, who are falsely and unjustly accused of taking pharma industry money or deliberately cooking up the Covid-19 virus in secret laboratories. Authoritarian regimes in Latin America and Eurasia now emulate such practices.

NO OBVIOUS ROADMAP

Any type of fix will be complicated by the fact that many of these 21st-century forces are new and unprecedented. There is no obvious roadmap. To begin, we need a new generation of health scientists and diplomats to assist the global policymakers understanding how these new social determinants, including anti-vaccine activism, work hand in glove with climate change to promote pandemics or the resurgence of vaccinepreventable illnesses and neglected tropical diseases. Especially alarming are the activist groups and even some authoritarian governments targeting public health experts, healthcare providers and biomedical scientists. We must recognise the magnitude and danger of such threats: in the past few years hundreds of thousands of people globally have lost their lives by refusing a vaccine or failing to heed the warnings of public health experts to implement nonpharmaceutical interventions. In this sense, anti-science aggression kills more people than global terrorism, nuclear proliferation or cyberattacks. Yet we do not currently frame anti-science as a significant deadly force. This too must change. ▪

deaths from Covid-19 worldwide

Americans estimated to have lost their lives to Covid-19 after refusing the vaccine

Democratising access to health

Covid-19 has been a generation-defining challenge filled with incalculable human costs and long-term impacts that remain unclear. Like many, I have been reflecting on how the pandemic will shape medicine and public health in particular for generations to come.

The pandemic severely tested public health. Many places around the world could not keep pace with the demands of disease surveillance and continue to see challenges with vaccination rates. Still, public health rose to the occasion. Public health officials quickly interpreted evolving science to provide guidance that kept individuals and communities safe. There were also live-saving scientific advancements – from realising the promise of mRNA vaccines and adaptive clinical trials to using real-world clinical data to inform regulatory processes.

Underlying some incredible gains were public-private partnerships – particularly between the technology and health sectors – which I believe will continue to flourish. These partnerships have made the wider dissemination of public health messages, better data and surveillance systems, and faster interventions possible.

For our part at Google, we adapted to accommodate this hopefully once-in-a-lifetime event by launching more than 200 new products, features and initiatives, in addition to providing in-kind donations totalling more than $1 billion.

By Karen DeSalvo, chief Google

Surfacing quality information is part of our core mission. During the first weeks of the pandemic, we recognised the opportunity to provide the right information, at the right time through the reach of platforms such as Search and YouTube that amplified health messages to billions of people, encouraging them to “flatten the curve” through non-pharmacologic interventions. We donated Google Search Advertising and offered assistance to organisations, such as the World Health Organization, to provide more than two billion Covid-related public service announcements that connected nearly 100 million people to high-quality information.

ISSUES MASKED BY THE PANDEMIC

Today, as we conceive of a time when Covid-19 is endemic, we must turn our attention in earnest to other global challenges that the pandemic masked or even exacerbated. For our part, we'll continue to use our products, technologies and expertise to help people, their caregivers and their communities, focusing on areas that align with the United Nations Sustainable Development Goals, such as mental health and maternal health.

The Covid-19 pandemic energised public-private partnerships and strengthened the role of technology towards democratising access to health to help billions of people everywhere live healthier lives – but fresh challenges are emerging from its shadow

Graphic: Google

During the first year of the pandemic, anxiety and depression increased by 25% across the globe.1 Searches for "mental health therapist" and "mental health help" reached record highs2 in the United States in 2022. To make it easier to access mental health services and resources – such as clinically validated mental health self-assessments and crisis hotlines – we’re enhancing information resources on Search and YouTube, partnering with organisations including the National Alliance on Mental Illness in the US, the Samaritans in the UK and iCall in India.

The pandemic also made it clear that existing healthcare gaps need to be filled so people can access the best care no matter where they are. At least half of the global population lacks essential health services3 , such as immunisations and paediatric care. Technology can help fill these capacity gaps – especially artificial intelligence. Already, AI has demonstrated promise not just as a tool to support significant gains in health care, but also as a means to eliminate disparities and improve health for everyone, everywhere. We are invested in the research and development of these technologies, and doing so inclusively and ethically.

For example, the global maternal mortality rate remains high, with an average of 152 deaths per 100,000 live births. The vast majority of deaths occur in low- and lower-middle income countries. We're partnering with Northwestern Medicine to expand access to foetal ultrasound, validating the use of AI to create more automated and accurate evaluations of maternal and foetal health risks. The goal is to train providers and community health workers to conduct ultrasounds and assessments in the field.

Another area where AI can be helpful is cancer screening. Breast cancer is the most common form of cancer with 2.26 million new cases 4 occurring each year, yet early screening and detection can improve long-term outcomes. We have been researching how AI can reduce the time to diagnosis and improve the patient experience.

THE FULL PICTURE

As we support health service providers across the globe, we are uncovering ways to make sure they have the information they need to care for patients. Today,

KAREN DESALVO

Dr Karen DeSalvo is chief health officer at Google where she leads the team of health professionals who provide guidance for the development of health research, products and services. She is a physician executive and public health expert who has served in US federal and local government roles.

@GoogleHealth health.google

healthcare workers use smartphone applications to manage data specific to certain diseases, for example malaria and tuberculosis. But that data is often stored across multiple applications and formats, making it hard to have a full picture of a patient’s needs. To provide access to advanced mobile digital health solutions, we’re working with the WHO to build an open-source software development kit, or SDK.

We see these innovations as important steps on the road to democratising health care. There are more on the horizon, fuelled by AI and cloud computing, that can bring more meaning to the data and unlock innovation. A great example of this can be found in emerging efforts at the intersection of public health and climate change5 where we are beginning to see patterns and associations among climate, weather and health.

Technology is just one tool to solve these public health challenges and its effectiveness depends on robust public-private partnerships. When we look back at the Covid-19 pandemic and all of the related health crises it brought awareness to, I believe that we’ll recognise it as a moment that energised our ability to collaborate. And that spirit of collaboration and partnerships will transform public health and democratise its benefits for everyone, everywhere. ▪

1 who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25increase-in-prevalence-of-anxiety-and-depression-worldwide

2 blog.google/technology/health/mental-health-month-2022/

3who.int/news/item/13-12-2017-world-bank-and-who-half-the-worldlacks-access-to-essential-health-services-100-million-still-pushed-intoextreme-poverty-because-of-health-expenses

4 wcrf.org/cancer-trends/breast-cancer-statistics/

5 blog.google/technology/health/dr-von-nguyens-temperature-check-onpublic-health/

the pandemic, we recognised the opportunity to provide the right information, at the right time”

Health in the digital age

By Nanjia Sambuli, co-chair, Transform Health

As with other aspects of digitalisation, the transformation of health care is well under way, and has been turbocharged by the Covid-19 pandemic. Data-driven approaches are increasingly being introduced or aspired to in operating health systems in developed and developing countries alike, increasing the availability of health data.

The potential benefits are exciting – from improving medical research to informing effective policymaking and budgetary allocations for more efficient health response systems. But the risks and dangers are just as important to reflect upon and mitigate right from the start. These are not only technological, but also political.

To illustrate, although scientists were able to sequence the genetic code of the SARS-COV-2 virus at an unprecedented speed thanks to the technical abilities to share the data, the benefits of this technological feat have not been equitably distributed, despite citizens in developing countries participating in the clinical trials that made the vaccine rollout possible. As well, the emerging technologies applied in health care are already driving discrimination and inequities in health outcomes, right from the information realm where misinformation and disinformation have been runaway challenges to the nascent digital health infrastructure in which, for instance, algorithms trained to use health-related expenditure as a proxy for health needs concluded that Black patients are healthier than white patients because white patients spent less on health care.

These are not mere exceptions; they are a timely reflection on the need to bypass technological solutionism and situate digital transformation within the complexities of a politically, economically, socially and culturally unequal world.

HEALTH DATA GOVERNANCE

Thus, to further realise the transformative potential of digital technologies for healthcare systems, and the resulting data generated, it is imperative that stakeholders centre policy and governance, along with technological innovation and requisite investments, on influencing the determinants of success and minimising harms. How health data are generated, processed, analysed, stored and reused is both a technological and political challenge. This is why health data governance ought to be on the international policy agenda. The guardrails required to govern the collection and use of health data must be updated to keep pace with the digital innovations that will inevitably demand and generate more data. However, this health data economy will need to protect the rights of individuals and communities, even as the data are used for public health. In an age of digital interdependence, health data governance frameworks must reflect the diversity of norms the world over. They must buck the trend of global governance approaches taking a ‘West to rest’ model, where decisions are made in Western capitals and focused on Western contexts, and then exported to the rest of the world.

The digitalisation of health care is putting Health For All within reach, but additional technical and socio-political investment is required to bring it firmly into the world’s hands

NANJIRA SAMBULI

Nanjira Sambuli is co-chair of Transform Health, and a member of the board of The New Humanitarian, Development Gateway and the Digital Impact Alliance. She is also a fellow in the Technology and International Affairs Program at the Carnegie Endowment for International Peace. She served as a commissioner on the Lancet and Financial Times Governing Health Futures 2030 Commission, and as a member of the United Nations Secretary General’s High-Level Panel on Digital Cooperation. Her work focuses on understanding the unfolding, gendered impacts of adopting information and communications technologies on governance, diplomacy, media, entrepreneurship and culture.

@NiNanjira nanjira.com / transformhealthcoalition.org

BUILDING NEW SOLUTIONS

The digitalisation of health care has excited many people, especially since the Covid-19 pandemic began. In developing markets such as Africa, digital technologies present an opportunity to not only digitise health systems, but also to build new solutions that benefit from the potential of digital tools. Innovation is often invoked; indeed, we need innovations to drive the achievement of universal health coverage by 2030, and in a digital age. However, innovation is needed on both the technical and the socio-political front. To fully leverage the potential of digital technologies towards universal health coverage, the investments needed for health systems is an equally important innovation as any emerging technology. Be it the mobilisation of domestic or international funding, investments into providing health care in a digital age need to be coordinated, and they must factor in how to ensure the equitable, inclusive and sustainable digital transformation of health systems, aligned with the national plans and policies of countries.

The prospects of Health For All in a digital age are within reach. We will do well to invest both technically and socio-politically to ensure that we inch closer to universal, equitable and sustainable health systems everywhere in the world. ▪

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Health data governance frameworks … must buck the trend of global governance approaches taking a ‘West to rest’ model, where decisions are made in Western capitals and focused on Western contexts, and then exported to the rest of the world”

Access to information is a health equity issue

The pandemic has shown us the critical role that information plays as a driver and determinant of health. Access to high-quality information about health is an equity issue, and one that is as important to global health as tackling the proliferation of health misinformation. Technology platforms and healthcare experts alike have key roles to play to ensure that everyone has the opportunity to be informed about their health

As anyone who has worked in public health knows, education is a core pillar of how we strive to help communities live healthier lives. Effective communication is at the heart of improving people’s health – we want people to better understand the ways that our individual and community actions affect our own health and the health of those around us.

The degree to which information and communication impact health outcomes has been brought into sharp view over the past two years as the world battled a misinformation epidemic alongside the Covid-19

By Garth Graham, global head, YouTube Health

pandemic. I believe that to advance health equity in 2022 we need to consider where and how people access information about their health, the quality of that health information, how easy it is to understand and how it helps people to take action.

This is particularly the case when it comes to communities who may feel underserved by traditional healthcare approaches to communication and education.

OUTSIDE THE DOCTOR’S OFFICE

The reality is that the majority of

healthcare decisions are made outside the doctor’s office, in the everyday lives of our patients. As physicians we only have limited opportunities to connect with people within the exam room – how can we better show up at many more points within a patient’s day, bringing health information into their lives through the spaces they already visit?

How can we connect with them through the messengers they trust?

Google Search and YouTube are already a part of a patient’s journey, when they turn to us for answers to their health questions, look for a community who understands what they are experiencing or find helpful videos that explain complicated medical information more easily.

We’re deeply invested in making sure our research, products and technologies can help billions of people live healthier lives – especially the communities that have historically been underserved by health care.

For example, Google Search has features that help people easily access care that’s right for them – from showing appointment availability to finding in-network care options. We’ve also updated our search experience to make it easier to navigate United States government benefits programmes, such as Medicaid which covers one in

Dr Garth Graham is global head of YouTube Health, where he leads the platform’s work to connect people with high-quality health information that is also culturally relevant and engaging. He is a cardiologist and researcher who has served in two US federal administrations and is an expert in minority health and health equity.

@YouTube health.youtube

four people including about half of all children in the US. Search also provides information for tens of thousands of Covid-19 testing sites worldwide, and has worked with dozens of partners to highlight more than 200,000 vaccination sites across the globe.

The shift towards more democratic means of mass communication, from blogging to social media to video-sharing sites like YouTube, has included health communication too. As health leaders, we have a responsibility to keep pace with these changes in where and how people find information so that we can meet people where they are and connect them with resources from credible sources.

OUR HEALTHCARE PARTNERSHIPS

That’s why YouTube Health has worked over the past two years to build partnerships with a wide range of credible, trusted experts across the healthcare industry. We have a responsibility to make sure that people are finding information from evidence-based authoritative sources, to help tackle the serious problem of medical misinformation.

We also know that health leaders also have a responsibility to keep pace with the changes in where and how people find information, and so YouTube Health is investing in helping the industry to learn the skills of video production,

so that health leaders can connect with people in ways that are not only scientifically accurate, but also culturally relevant and engaging.

Video is a particularly effective format for sharing health information in ways that are accessible and digestible not only to a professional audience but to everyone. Regardless of a person’s literacy level, location or language, video can be easy to understand – even on a mobile phone. As we strive to make public health information truly public, mobile video formats are a critical tool for reaching global audiences at scale and providing free and equitable access to the best and brightest thinking in science and medicine.

The scale and reach of platforms like Google Search and YouTube can radically increase equity of access to high-quality health information, by breaking down barriers between the ivory towers of academia and the everyday people who want to understand how to take better care of themselves and their families.

Together, we can reimagine how health information is shared and help everyone, everywhere, to live healthier lives. ▪

“As we strive to make public health information truly public, mobile video formats are a critical tool for reaching global audiences at scale and providing free and equitable access to the best and brightest thinking in science and medicine”

GARTH GRAHAM

Strengthening science and innovation

The Covid-19

Around the world, every day, people are innovating. From improving daily life to collectively addressing the globe’s most pressing challenges, innovation is part of what makes us human. It stands at the core of humanity’s quest to live longer, healthier lives.

And yet innovation does not happen in a vacuum. It depends upon a complex ecosystem involving an open and collaborative environment, strong public and private institutions, vibrant civil society, the rule of law and respect for human ingenuity as well as human rights. Intellectual property and the

By Daren Tang, director-general, World Intellectual Property

laws that govern it are an integral part of this ecosystem. At the World International Property Organization, we strive to lead and maintain a balanced and effective global IP system that promotes innovation and creativity for a better and more sustainable future for everyone, everywhere.

The Covid-19 pandemic cast a powerful spotlight on the role of innovation in the health sector. The development of life-saving vaccines barely a year after the World Health Organization declared a global pandemic bears testament to this. Decades of investment, both financial and human, in scientific research enabled this unprecedentedly

pandemic cast a powerful spotlight on innovation in the health sector, and the power of innovation remains vital in addressing health crises and challenges of the future

rapid response. Strong national and international IP systems provided, and continue to provide, the base upon which such investment occurs.

HOW TO ENSURE EQUITY

We recognise that addressing our global health challenges requires market-based incentives and political will to ensure equity in access to innovative, life-improving and life-saving technologies. In situations where the market does not generate requisite investment in health solutions, for example in the case of neglected tropical diseases, public financing for research and development must fill the gap, and access strategies must be considered from the very beginning to ensure that those who need such innovation are able to benefit from it. This requires well thought through, coordinated and transparent commitments from governments as well as from universities (where many life-saving technologies begin their lives), the private sector and philanthropic entities (whose lines of accountability may not always be clear).

DAREN TANG

Daren Tang assumed his functions as director-general of the World Intellectual Property Organization in 2020. Previously, he served as chief executive officer of the Intellectual Property Office of Singapore. He also chaired WIPO’s Standing Committee on Copyright and Related Rights from 2017 until his appointment as director-general.

Twitter @WIPO

 wipo.int

Many global crises, including pandemics, present political, financial and solidarity challenges as much as they do engineering ones. History demonstrates that innovation, political commitment and collective action can produce unparalleled results. This trifecta must be supported by solid data, information-based systems, and institutions resourced and empowered to fulfil their mandates. Although crises that imperil our health and well-being rightly elicit strong emotional reactions, we must always strive to ensure that data and accepted, peer-reviewed science guide our public policy decisions. Our health and that of our planet require nothing less.

The power of innovation and the intellectual property that underpins it have proven vital in addressing Covid-19, and will remain vital in addressing future pandemics. Meeting the next challenge head-on will require the global community to put into practice, in a collective and transparent manner, the many lessons we have learned and continue to learn. ▪

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In situations where the market does not generate requisite investment in health solutions, for example in the case of neglected tropical diseases, public financing for research and development must fill the gap”

The Covid-19 pandemic revealed how fast modern scientific enterprise in the life sciences can respond to a global public health crisis to develop the tools necessary to manage such a crisis and save countless lives. However, this same crisis also revealed a severe inequity in global access to technologies that would have saved even more lives and enabled governments to manage the crisis better. A major cause of this access inequity was the synchronised global demand for Covid-19–related technologies, plus insufficient ramp-up in production capacity by the limited number of suppliers. Even countries with health systems that could effectively deploy such technologies did not receive deliveries in time to save more lives. As a result of this almost unique reason, Costa Rica – a middle-income country with a strong healthcare system – proposed the COVID Technology Access Pool (C-TAP) through the World Health Organization as a part of the solution to this ethical challenge. Managing a health crisis caused by a deadly pathogen that is easily transmissible from person to person is no small feat. Speed is of the essence

By Román Macaya,

Why C-TAP?

to minimise avoidable deaths and economic damage. An effective crisis response includes identifying and characterising the pathogen, understanding its natural history and life cycle, communicating timely and actionable information to the general population, diagnosing infected people and animals that can serve as host reservoirs, preventing infection and severe cases, protecting health workers and treating patients with proven therapeutics. In an ideal world, health authorities would have all the necessary tools in sufficient quantity and quality at their disposal.

FLOODGATES OF CLINICAL RESEARCH

For the first time in history, all the necessary tools for each of these actions were developed or were in production during the course of the pandemic. The SARS-CoV-2 virus was isolated and its genome was sequenced within weeks of the first case in Wuhan, China. Shortly after that, diagnostic kits were developed based on detection techniques. Dozens of labs in academia, government institutions, and the biotech and pharmaceutical industry raced to develop effective vaccines. The

When Costa Rica found itself in the frustrating position of having the capacity to do more in response to Covid-19, but unable to move faster due to an inadequate supply of critical tools, it launched a global initiative that pools intellectual property – and saves lives

former executive president, Costa Rican Social Security Fund, and Daniel Salas, former minister of health, Costa Rica

world witnessed the arrival and proof of principle of mRNA vaccine technology. In addition, the floodgates of clinical research opened, resulting in emergency authorisations for several new or repurposed drugs for Covid-19.

Some of these advances were so fast that they generated hesitation, such as the recurring question of whether vaccines are supposed to take longer to develop. The truth is that many of the platform technologies underlying these success stories had been in development for a decade prior to the pandemic, implying that the more time we have for science and technology to advance, the better prepared we should be for such crises. However, there is a caveat to this assertion: these essential tools must be truly available to health and government authorities, not just approved by regulatory bodies.

Most of these technological developments involve innovations and information protected through patents, data protection provisions and trade secrets. This reality limits the potential suppliers of the essential products to a handful of firms. The pricing policies, market prioritisation and logistical capabilities of these select firms significantly determine the equity among health system capabilities to manage a pandemic. The control of market conditions by firms during a period of exclusivity for a new drug, vaccine or other medical technology is nothing new. What has been fairly unusual in this pandemic is the reason behind the inequity in the access of Covid-19–related technologies: availability for delivery.

The issue of inequitable access to new medical innovations, particularly new drugs, often relates to pricing. When a new drug is launched, investors and management expect revenue and profits, expectations that result in pricing at the price point of maximum profitability. However, timely delivery to health systems or patients with the capacity to pay has usually not been the issue. But, in this pandemic, the global population had to be tested, vaccinated and potentially treated for Covid-19 because everyone was at risk of getting sick at the same time. This sudden and synchronised demand by billions of people overwhelmed the production and logistical capacity of even the largest firms. It is practically impossible to quickly produce billions of units of anything. This led suppliers of critical technologies to prioritise and stretch out deliveries. Some countries were left out

as production capacity was completely committed to prior purchase orders. Many other countries found themselves in the frustrating situation of having the institutional, operational and financial capacity to do more, but unable to move faster due to an inadequate supply of critical tools. This was no minor issue. Speed means life in a pandemic.

PIECEMEAL DELIVERIES

Costa Rica was in the latter category. The country had the political will, budget and operational capacity to do more, but had to adjust to piecemeal deliveries, or worse. This reality led Costa Rica to propose C-TAP through the WHO. The initiative was well received, as many member states signed on. On 29 May 2020, C-TAP was officially launched by the WHO and Costa Rica.

C-TAP is a vehicle through which rights holders can voluntarily license intellectual property into a pool for open use, with the intention of creating a freedom-to-operate commons that can accelerate innovation and expand the available supplier base of relevant technologies for the pandemic response. The Medicines Patent Pool, an organisation with the expertise and track record of negotiating voluntary licences to make drugs for specific diseases available in certain countries, was brought in to manage that aspect of C-TAP. So far, the parties contributing technologies to C-TAP have been primarily government laboratories, such as the announcement in May 2022 of an agreement between C-TAP and the National Institutes for Health in the United States for technologies applicable to the development of diagnostics, vaccines and therapeutics. This announcement is significant because NIH is the largest funder of biomedical research in the world.

C-TAP remains very relevant. The Covid-19 pandemic is not over, and the SARS-CoV-2 virus has demonstrated an impressive capacity to evolve. Science and technology, and the development of critical tools, must advance as fast as this evolving threat, and supply chains must be resilient enough to protect our species. C-TAP plays its role in both these needs. The final economic tally of the cost of this pandemic in terms of lives lost, disabilities and economic damage will certainly be in the many trillions of dollars. Never before has there been so much at stake in accelerating biomedical research and development, and in rolling out technologies in real time to meet the synchronised demand of the global population. ▪

Román Macaya is a Menschel Senior Leadership Fellow at the Harvard T.H. Chan School of Public Health. He recently concluded his term as executive president of the Costa Rican Social Security Fund, which provides all public healthcare services in Costa Rica. He led the healthcare response to the Covid-19 pandemic. He has served as Costa Rica’s ambassador to the United States and held multiple positions in the private sector.

DANIEL SALAS

Daniel Salas served as health minister for Costa Rica from 2018 to 2022 and joined the Pan American Health Organization as head of its Comprehensive Family Immunization Unit in May 2022. A physician and epidemiologist, he has served as director of health surveillance management in Costa Rica, surveillance coordinator of non-communicable diseases and director of social health marketing management. He was the national coordinator for surveillance on vaccine-preventable diseases and for the Preparation Commission for Influenza Pandemics and technical secretary of the National Vaccination Commission, and has held various positions at the subnational level.

ROMÁN MACAYA

Conflict zones: a war on health

By Ahmed Al-Mandhari, regional for the

Eastern Mediterranean

Covid-19 has again highlighted the low and inequitable investment in health by countries of the World Health Organization Eastern Mediterranean Region – a region long afflicted by emergencies. Over many decades, each new emergency has prompted calls to build stronger and more resilient health systems. The cost of inaction has been too high. This time we cannot afford to fail. In 2001, the WHO Commission on Macroeconomics and Health made the case for health in economic development. The 2013 Lancet Commission on Investing in Health found that reductions in mortality accounted for 11–24% of recent economic growth in lowand middle-income countries. The 2016 High-Level Commission on Health Employment and Economic Growth described multiple ways for investment in health employment to contribute to economic growth. Nevertheless, Covid-19 shockingly demonstrated

how a health crisis can erase the gains from decades of global development, challenging the mainstream view of health as a peripheral concern of economic policies. As the manifesto of the WHO Council on the Economics of Health For All says, “a healthy population must be the ultimate goal of economic activity”.

EYES ON THE REGION

The Eastern Mediterranean Region is home to 717 million people in 22 countries and territories with wide-ranging income levels. It is prone to emergencies. Of particular concern are the multiple conflicts and humanitarian crises affecting almost half its countries. In May 2022, more than 102 million individuals there needed humanitarian assistance – 34% of the global total, a 95% increase over the past seven years. The region is the source of over 60% of the world’s refugees, many of whom remain within its borders. It has been suffering from increasingly frequent outbreaks – H1N1, MERS-CoV and, lately, Covid-19 and monkeypox – and extreme weather events, including droughts and floods. In 2021, five of the 10 largest

In the emergencyafflicted Eastern Mediterranean, the fundamental right to health is in dire need of greater, higher-quality investment in health coverage and health security

natural disasters (as measured by people affected) occurred there.

HEALTH COVERAGE AND SECURITY

The region is a chronically low investor in health, with 9% of the world’s population but less than 2% of global health spending. Although public spending – a condition for universal health coverage and health security – has been rising globally, it stalled in the region between 2016 and 2019, partly due to limited fiscal space in many countries, but mainly reflecting the low priority given to health in their budgets. A significant share – around 40% – of health spending is paid out of pocket. Such payments are inefficient, inequitable and increase the risk of financial hardship. In 2017, 12.5% of the region’s population faced financial hardship due to out-of-pocket payments, an increase from 11.8% in 2015.

THE COST OF CONFLICT

The destruction of health facilities and deaths or injuries of healthcare workers during armed conflict represent unacceptable and shocking violations of international humanitarian law. They also undermine investments in health care. Joint external evaluations of the capacity under the International Health Regulations (2005) to prevent, detect and rapidly respond to public health risks ranged from 31 (out of 100) in Somalia to 90 in the United Arab Emirates between 2018 and 2020, indicating wide discrepancies and the vulnerability of many. Between 2016 and 2019, 19 countries developed national action plans for health security that have barely been implemented, mainly because of limited political commitment.

The investment case for increased expenditure on health security and

emergency preparedness could not be clearer. Covid-19 will cost the global economy $28 trillion by 2025 – a cost that could have been drastically lower if governments had invested in better health emergency preparedness.

Gross domestic product in the Eastern Mediterranean Region is projected to decline by 4–5% due to the pandemic, compared to the global estimate of 2%. The annual cost of improving health emergency preparedness ranges between $1.6 billion and $43 billion globally.

Low investment in health has hindered progress towards the Sustainable Development Goal target on universal health coverage. The 2021 UHC Global Monitoring Report estimated the service coverage index in the region at 57 out of 100 in 2019, below the global average of 68 and the second lowest among the six WHO regions.

MOVING FORWARD

In 2018, WHO members in the region endorsed a vision of ‘Health For All, By All’, to be achieved through solidarity and collective action. That year, the region committed to achieving universal health coverage by signing the UHC2030 Global Compact and endorsing the Salalah Declaration. The omnipresent emergencies call for building resilient health systems that ensure both health security and universal health coverage – a goal we are addressing in this year’s session of our governing body.

Spending on health is investing in people, societies and the economy. Protecting and building on health pays multifaceted dividends; eroding, delaying and underinvesting carry a heavy price. Policymakers should invest more in health from public sources and invest more strategically, based on evidence. Both objectives should

AHMED AL-MANDHARI

Ahmed Al-Mandhari has been the World Health Organization’s regional director for the Eastern Mediterranean since 2018, having served as director-general of the Quality Assurance Centre at Oman’s Ministry of Health. A specialist in family and community medicine, he was appointed director-general of Sultan Qaboos University Hospital in 2013, following appointments as head of quality management and development and deputy director-general for clinical affairs until 2010. Dr Al-Mandhari has also worked as a senior consultant in family medicine and public health in Oman since 2009.

@WHOEMRO emro.who.int

go hand in hand: more money for health and more health for the money. This could be achieved by addressing inefficiencies due to misuse, abuse, fraud, and capital destruction due to armed conflict and natural disasters. Covid-19 showed that health challenges and dividends transcend borders, calling for planning for health as a global good, through consolidating partnerships and resources – both public and private – and removing barriers between funding emergency preparedness and investing in people-centred, resilient and equitable health systems.

60%

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Investing in health is a political choice, and the choice reflects our understanding of health as a basic human right. Investment should include building all health system components, starting with the engine of every health system: the health workforce. This means higher budgetary allocations, efficient utilisation, and addressing inequities within and between countries.

Evidence from Covid-19 shows that the social return on investment will increase through strengthening essential public health functions including multisectoral approaches that address the broader determinants of health and building stronger and more resilient health systems. Health should be everyone’s business, requiring a whole-of-government and a whole-of-society approach. The health sector should also advance the peace agenda through health diplomacy, applying health and peace approaches. This is also a call to invest in a better WHO; recent evidence showed that one dollar invested in the WHO could return $35. ‘Health For All, By All’ – that’s our call to all leaders and communities. ▪

people in the region have needed humanitarian assistance

of the world’s refugees come from the Eastern Mediterranean Region

of the 10 largest natural disasters in 2021 globally were here

Hope for a healthy future

We all want children to live healthy and happy lives, safe from harm and hunger. But children today are facing a very different reality. Humanitarian crises are having disastrous effects on children’s health worldwide. The triple threat of conflict, Covid-19 and climate crises are reversing gains made in child survival in recent decades. The world is facing a child rights crisis on an unprecedented scale.

HEALTH SERVICE DISRUPTION IN CRISES

Children are affected most severely when essential health and nutrition services cannot be delivered. Child mortality is even higher in crisis settings. In 2019, child mortality rates in countries identified as fragile were on average almost three times higher than in non-fragile countries. With Covid-19 and the increased number of conflicts since 2019 these rates have likely escalated. Already weak health systems were overwhelmed by the pandemic, leading to the disruption of routine health and nutrition services, ill health and death. In

The world is facing a child rights crisis on an unprecedented scale, where a confluence of issues mean investing in children is now more critical than ever

By Inger Ashing, CEO, Save the Children International

2021, 25 million children missed out on routine vaccinations, making them more vulnerable to diseases such as measles and polio. Climate-related shocks, such as droughts, cyclones and heatwaves, pose dangerous threats to children’s health. Lack of water, sanitation and hygiene services make children more vulnerable to diarrhoea or cholera, two of the primary threats to children’s survival. Conflict is a driver of health risks to children: it puts children at immediate risk of physical harm, may

force them to move away from their homes, denies them access to healthcare services, and causes widespread damage to health facilities and infrastructure. In some contexts, conflict puts healthcare workers and facilities in the direct line of fire. In the first four months of this year alone, the World Health Organization recorded 160 attacks on healthcare facilities in 11 countries and territories, resulting in 97 deaths. Basic services become almost impossible to access, with disastrous effects on the health and well-being of children.

MOST VULNERABLE ARE HARDEST HIT

Afghanistan is facing one of the most significant humanitarian crises in the world. Over the past year, Save the Children has reached about 300,000 children with health services and about 230,000 children with nutrition services, but the remaining needs are significant. During a recent trip to the country, I met with staff from our mobile health teams who work in remote village locations, providing life-saving primary, newborn and maternal healthcare, nutrition and

Kristiana Marton; Charlotte Rose; Allan Gichigi / Save the Children

mental health services. I saw first-hand how we treated children for malaria and diarrhoea and provided routine vaccinations against diseases such as measles. Save the Children has talked to children in seven provinces across Afghanistan about the effects of the crisis on their lives and their access to health care. We found that children are increasingly unable to access or afford healthcare. Children told us that the reduction in household income was a big challenge because families simply could no longer afford transport and medication despite a nearby clinic remaining open. Children explained to our staff that even if they could go to a clinic to access services there were not enough doctors or medication when they got there.

Seven years of conflict in Yemen has had disastrous consequences on the health and well-being of children. Frequent attacks on health facilities and staff are putting the lives of children, parents and health workers at risk. During consultations with children and other community members they told us that people hesitate to seek much-needed health services at healthcare facilities because they are concerned for their safety. These attacks have led to the disruption of routine services, including urgent care for pregnant mothers, treating children for malnutrition, delivering vaccinations or providing for professional mental health and psychosocial support services. Parents of sick children are unable to reach medical care safely and in time, which can lead to deadly consequences.

THREE STEPS TO ENSURE ACCESS

To ensure access to health care and nutrition for children experiencing conflict and other crises, the following key steps are essential.

First, we need multi-year funding from the international community to ensure continuity in providing quality healthcare services for children and communities. We know this will have a transformational impact on the quality of health services that children can access in humanitarian crises. Funding should go as directly as possible to local and national organisations to strengthen systems to make them more resilient to respond to humanitarian crises, while striving to continue delivering essential health services.

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Second, we must reach the most vulnerable children. As part of this, we need to ensure that children can participate in and influence decisions made on the development and implementation of health services. Our work in Afghanistan and Yemen highlights that only then can we deliver informed health and nutrition services. Children know their own situation and needs best. Involving children and communities in our work helps to identify barriers to accessing health care and find effective and sustainable solutions to overcome them.

Finally, children can only access essential health services when healthcare workers can do their job without fear of attack. This includes adhering to international humanitarian and human rights laws for the safety of health facilities, health workers, ambulances and patients. We need to protect healthcare workers and make sure that there is accountability for attacks on healthcare facilities.

Let us move forward together – because health is a political choice for children. ▪

INGER ASHING

Inger Ashing was appointed chief executive officer of Save the Children International in 2019, having been associated with Save the Children for more than 25 years. Before 2019, Inger was director-general at the Swedish Agency against Segregation and also served as national coordinator for Youth Not in Education or Employment for the Swedish government, deputy director-general of the Swedish Agency for Youth and Civil Society, and CEO of the Global Child Forum. Inger is also a member of the Ethics Council at The Swedish Migration Agency.

@SaveCEO_Intl savethechildren.net

children missed routine vaccinations during disruptions caused by Covid-19 in 2021

“ services become almost impossible to access, with disastrous effects on the health and well-being of children”

Seize the moment

By Jagan Chapagain, secretarygeneral, International Federation of Red Cross and Red Crescent Societies

The Covid-19 pandemic has raged for more than two years, still killing people even as many communities and countries struggle to recover from its many impacts. The next global pandemic could be just around the corner, while smaller-scale disease outbreaks remain commonplace in some parts of the world. The time to start preparing is now.

We know that preparing and responding to disease outbreaks requires strong national health systems, better investments in community level health care, good surveillance and contact tracing, research and data, and a global supply chain of vaccines and medicines available to all.

Underpinning all of this is a need for strong and comprehensive legal foundations.

OUTDATED AND INADEQUATE LAWS

In emergencies, people do not often think much about legal issues, yet the debate about which rules to apply to governments, communities and the private sector has come to the forefront during the Covid-19 pandemic. Many governments realised their laws and policies were outdated or inadequate. New legal instruments were developed at lightning speed, often without adequate time for a robust debate or consultation with experts and stakeholders.

As we emerge from the crisis, we have an opportunity to invest in and improve our legal frameworks for public health emergency preparedness. Governments, lawmakers, donors, and the humanitarian and development sectors must all work to strengthen global health security with disaster laws and tools, such as a global pandemic treaty, that ensure more effective and equitable approaches to future emergencies.

As mandated by the parties to the Geneva Conventions, the International Federation of Red Cross and Red Crescent Societies has provided advice and expertise on disaster law and policy worldwide for decades and has now developed a Guidance on Law and Public Health Emergency Preparedness and Response based on a survey of legal frameworks in more than 100 countries at the beginning of the pandemic. It proposes nine considerations that lawmakers should take into account when revising legal and policy frameworks to support effective preparedness and response to public health emergencies.

The report finds that many states still rely on ad hoc measures, struggling with gaps between public health,

emergency management, social protection laws and institutions, and hindering their ability to build a comprehensive response to what has become a simultaneous public health emergency, global economic shock, and political and social crisis.

When roles and coordination mechanisms were not clearly defined in national law, we lost precious time and public trust. Clarity on everyone’s role in overcoming a pandemic is critical. Disaster laws must ensure that communities are fully engaged and enabled to act, particularly community volunteers, and civil society at large.

THE ROLE OF COMMUNITY ACTORS

This is vital because community actors make a big difference. With IFRC guidance and resources, National Red Cross and Red Crescent Society volunteers reached 1 in 12 people worldwide during the pandemic, demonstrating how a community-based approach can leverage existing capacity, produce substantial public health results, revive flagging public trust and address an extensive range of humanitarian needs.

While the effects of Covid-19 are still being felt around the world, now is the time to prepare our legal frameworks for the next pandemic

JAGAN CHAPAGAIN

Jagan Chapagain was appointed secretary-general of the International Federation of Red Cross and Red Crescent Societies in 2020. An engineer by training, he began his career as a youth volunteer with the Nepal Red Cross where he represented and advocated on behalf of communities. Prior to being appointed secretary-general, he served as under secretary-general for programmes and operations and was also chief of staff and director of the Asia Pacific region.

@jagan_chapagain / @ifrc ifrc.org

Unfortunately, restrictions introduced to curb the spread of Covid-19 also constrained humanitarian actors and other frontline responders such as Red Cross and Red Crescent Societies from carrying out their critical roles in responding to emergencies and reaching vulnerable populations.

To work best, we need to put communities at the centre of their own response. Governments must also recognise the unique mandate given to National Societies to support domestic authorities and communities to prepare and respond to epidemics and pandemics and to provide them with legal facilities such as exemptions from movement restrictions, authorisation to provide certain services during public health emergencies and priority access to pandemic response products including vaccines.

Sierra Leone learned this lesson in the 2014–2016 Ebola outbreak, and successfully put its experience to work in response to Covid-19. A national framework developed in the aftermath of that experience clarified how government, the private sector, non-profits and the Sierra Leone Red Cross could collectively prepare for and

respond to all-hazard emergencies. So when Sierra Leone’s first case of Covid-19 was identified, the Red Cross had already been working alongside the government to plan how to best prepare and respond. Because the National Society’s auxiliary role was recognised and specific services and expectations had been clearly articulated in the national disaster management preparedness plan before the pandemic occurred, they were able to quickly mobilise and respond.

Such legal frameworks are especially vital where public resources are thin at the community level, as they allow community actors to protect themselves and provide for vulnerable and last-mile communities that would not otherwise be reached, but which must be reached if we are to ensure global health security.

EXISTING INEQUITIES

The pandemic has both thrived on and aggravated existing inequities. Despite strong verbal commitments to global solidarity in supporting the most vulnerable, only 20% of people in low-income countries have received at least a single dose of the Covid-19 vaccine. In comparison, 67% of the world’s population has received at

least their first dose. The current negotiations of global legal frameworks must ensure that this never happens again, with respect not just to medical countermeasures, but also to the entire range of health countermeasures that are needed during any public health emergency such as access to services, information, contact tracing and surveillance.

During emergencies, marginalised and vulnerable people, including those suffering from violence, people on the move, detainees and people discriminated against because of identity are pushed further into the fringes where they struggle to access basic services and information. Disaster and public health laws can and should provide for their protection. We must act now and learn from our mistakes so that in the future we can avert the chaos and confusion that have marred the Covid-19 response. The IFRC and our 192-member National Societies stand ready to do our part in strengthening global health security, providing our expertise and advice to governments in developing domestic laws and our action on the ground to transform into reality. ▪

“

When roles and coordination mechanisms were not clearly national law, we lost precious time and public trust”

Protect our health, our rights

Healthcare in Myanmar has deteriorated rapidly since the coup in February last year, but with determination, commitment and the backing of the international community, the country’s healthcare personnel are protecting this basic human right in the face of conflict

By Ma Thida, activist and physician

Myanmar is now recognised as one of the most dangerous places for health workers. Since the coup in February 2021, targeted atrocities against health personnel, facilities, services and commodities in Myanmar have reached up to one-third of the global total. After more than one year, at least 36 health workers have been killed and 560 arrested, and the military junta has issued about 500 arrest warrants against striking doctors. There have been at least 126 raids on hospitals. The military junta has even used fake phone calls on a mobile healthcare team to trap health workers known to have started the Civil Disobedience Movement, which aims to paralyse the ability of the regime to deliver public services. About 60,000 people from the healthcare sector joined the CDM

following the military coup, but now only 45,000 workers still participate, according to the CDM Medical Network.

Although many CDM healthcare personnel try to operate free private clinics to continue providing public services out of military control, many clinics have been raided and shut down, and medicines and equipment have been seized, destroyed or banned from being shipped. A stethoscope is considered evidence of anti-military protest and many medical doctors have been dismissed, sentenced to long imprisonment, or transferred away from their posts; many have had their licences revoked, and their homes and properties confiscated, and sometimes their family members were arrested in their absence. Air strikes on some parts of the country have also demolished health facilities.

A FAILING HEALTH SYSTEM

In fact, throughout a history of consecutive military regimes in Myanmar, the health situation has never been good enough. Nonetheless, before the coup, the NLD government under the leadership of Aung San Suu Kyi functioned well enough to combat the first and second waves of Covid-19 with a vaccine programme, lockdowns and cooperation from the general public who trusted her government. The military coup put an end to the vaccine programme and has failed to re-establish a lockdown. It has caused more damage than Covid-19, as all of the gains in health of recent decades have been ruined in less than a year since the coup. Out-of-pocket healthcare expenditures reached 90% during the last military junta era but went down to 60% during the last five years under the NLD government. Since the coup they

11.6m 90%

people reached via the Ministry of Health’s online channels out-of-pocket healthcare expenses during the last military junta era

have risen back to 90%. The junta focuses only on consolidating power and not ensuring public health provision.

The junta has even tried to prevent people from gaining private access to oxygen. It has banned some private oxygen producers from selling to civilians and humanitarian groups. This has made people more resistant to the junta and more determined to help each other outside the military. Many groups of volunteers all over the country have raised private donations to organise oxygen, food, medicine and transport for the sick and dead. Families with ill members are asked to hang white and yellow flags from their windows to signal their need for food or medicine. Many CDM doctors and nurses in hiding have also been trying their best to treat people, either at private underground clinics or by telephone or online consultation via encrypted apps.

International organisations such as the Red Cross need permission from the junta to help in pandemic-afflicted areas and some areas under control by ethnic armed organisations are not easily accessible. It is recommended that international agencies cooperate with the National Unity Government, which has been formed by elected NLD members of parliament and includes members from ethnic minority groups. The NUG formed a task force to coordinate the prevention and treatment of Covid-19, including through vaccinations. It reached out to the Association of Southeast Asian Nations and the United Nations.

PROVIDING MEDICAL GUIDANCE

In July 2021, the NUG Ministry of Health launched four Covid-19 Telegram channels to give medical guidance during the third wave of the pandemic: 800 to 1,000 patients called per day.

Since then, the NUG Ministry of Health has been working on the ground with the ultimate goal of ensuring all the people of Myanmar have access to the health services they need during the period of the ongoing anti-dictatorship movement to return power to the people. The two guiding themes of this interim health

¹⁄³

strategy are universal health coverage and federal health principles.

The NUG Ministry of Health workforce includes 254 specialist doctors, 456 general doctors, 574 nurses, 1,554 basic health staff and 940 volunteers, and 78% of them are members of the CDM. These workers are distributed among all Myanmar’s states and divisions based on the priority of needs. Most are in areas with the most conflict, such as the Sagaing division and the states of Chin and Karenni. Currently, the Ministry of Health has 167 frontier healthcare centres, 51 temporary hospitals for secondary care and more than 250 mobile clinic teams. From April 2021 to July 2022, health services in one state had an average of 44,000 outpatients and had performed an average of 1,100 major operations and 1,300 minor operations. Of 330 townships in Myanmar, 198 townships – 60% – have Township Health Administrative Teams.

The NUG Ministry of Health together

The NUG Ministry of Health is also providing school health services, nutrition, mental and child health and disease control. It also has online healthcare services. The TeleKyanmar Clinic has been operating 20 Telegram channel clinics since June 2021, with 36 specialties. By the end of July 2022, it had received 87,874 visits from 319 townships in Myanmar and 21 other countries. The Ministry of Health also works on health education via Facebook and its website, where it has posted 275 health education videos and broadcast 80 live webinars; it has already reached more than 11.6 million people.

MA THIDA

Ma Thida is a Burmese surgeon, writer, human rights activist and former prisoner of conscience. In Myanmar, she is best known as a leading intellectual whose books deal with the country’s political situation. She was elected recently chair of the Writer in Prison committee of PEN International. She was the president of PEN Myanmar and a board member of PEN International. She was a visiting research associate at Yale University’s Southeast Asia Studies programme. She is currently a fellow at the Martin-Roth Initiative in Berlin.

Protecting health in the face of conflict and when democracy and the humanitarian system are under strain is such an enormous challenge for a developing country such as Myanmar. However, with determination, commitment and enthusiasm, the healthcare personnel and people of Myanmar are doing their best, and will keep doing so until we win the fight against the military junta. Of course, we need practical support from the international community. Please do not look at our fight as an internal conflict. As long as health – a very basic human right – is concerned, our rights should be protected. Please fight for us, and protect our health as part of global health. ▪

“

The military coup … has caused more damage than Covid-19, as all of the gains in health of recent decades have been ruined in less than a year since the coup”

The global story of health access is one of a growing divide. Although health indicators have improved overall in the past 30 years, access to life-saving interventions remains a challenge for the world’s most vulnerable populations. Health outcomes in humanitarian settings – places affected by conflict, climate-driven disasters and political fragility – lag far behind even stable lower-income settings, with stark disparities in routine immunisation coverage, maternal mortality and access to primary care.

Fixing this problem requires active political choices and bold leadership to drive innovative solutions to scale, reinvent systems to extend their reach and end impunity for those using attacks on health systems as a weapon of war.

CHILDHOOD ACUTE MALNUTRITION

Childhood acute malnutrition is a health crisis where the solution is known, but a decisive political choice to deliver it at scale is still needed. Each year approximately 50 million children suffer from acute malnutrition, a scale larger than any single humanitarian crisis on the planet. Malnutrition is an underlying cause in nearly 50% of under-five mortality.

But we know how to treat wasting. With a daily dosage of fortified peanut butter paste, the vast majority of wasted

Health equity for fragile contexts

children recover in just weeks. This heat-stable, ready-to-use therapeutic food with a long shelf life is transformational.

The problem is that 80% of acutely malnourished children do not get the help they need. This is a delivery problem enabled by political ambivalence, inefficient systems and insufficient financing.

Treatment is delivered through a bifurcated system that treats severe and moderate forms with different products, through different supply chains, at different delivery points. In addition, children are admitted and dosed according to complex weight-based calculations, primarily through fixed health facilities. This approach is difficult to coordinate and impossible to scale.

A growing body of evidence, led by the International Rescue Committee’s research, shows that simplified approaches – including a combined protocol for diagnosing and treating both moderate and severe acute malnutrition – is equally effective and more cost-effective than the current, more complex model.

By David Miliband, president and CEO, International Rescue Committee

To scale up this feasible, life-saving intervention, the nutrition sector should: 1) support national programmes in adopting simplified approaches as best practice for scalable delivery;

Closing the vast gaps in health outcomes around the world requires active political choices – to deliver known solutions where they exist, to adapt funding and delivery systems for vaccinations, and to end impunity for attacks on health in conflict situations

2) align behind nationally led evidence-based strategies to expand treatment; 3) hold ourselves accountable for progress; and 4) pile in the funding needed to make it happen.

We have a historic opportunity to scale proven interventions and save millions of children suffering from wasting in the Horn and Sahel regions of sub-Saharan Africa. United Nations agencies, including UNICEF, the lead UN agency on wasting, and the World Food Programme together with the US government, which has made a historic $200 million commitment to wasting treatment, play vital roles in leading these practice changes.

LASTMILE VACCINATIONS

Political will has already driven a life-saving solution to delivering childhood immunisation on a far greater scale. Public and private donors made the political and financial commitment to scale immunisation through Gavi, the Vaccine Alliance. Gavi has delivered routine vaccination to more than 888 million children, preventing more than 15 million deaths, and increasing coverage of routine childhood immunisations from 59% to 78% in the countries it supports.

However progress has stalled and deep inequities in access continue to threaten children in fragile settings. In 2021, 25 million children received no routine

50m

children suffer from acute malnutrition every year – a scale larger than any single humanitarian crisis on the planet

50%

has malnutrition as an underlying cause

80%

of malnourished children do not get the simple treatment they need

immunisations, the highest total since 2009. These zero-dose children are disproportionately, and predictably, clustered in fragile and conflict-affected settings. Their families are mobile, in many cases displaced or moving frequently across political borders. And they are systematically beyond the reach of traditional immunisation programmes funded almost entirely through governments.

To address this inequity Gavi is testing a new approach that directly engages non-governmental organisations and civil society to reach zero-dose children in displaced communities and fragile and conflict-affected settings across 11 countries. Under this $100 million project, IRC is leading a consortium in the Horn of Africa to deliver vaccines and integrate immunisation with key nutrition and primary health services to communities in areas out of the reach of governments. Impacts and learning from this effort should inform the approaches that engage civil society to deliver vaccinations to vulnerable children who cannot access government systems.

ATTACKS ON HEALTH IN CONFLICT

Protecting health in conflict is not only a matter of political leadership to expand new services equitably, but also a matter of accountability for those who attack health systems as a weapon of war. The Safeguarding Health in Conflict

Coalition’s recent annual report documented attacks on more than 1,400 health workers and 450 health facilities in 2021. The World Health Organization acknowledged more than 100 attacks on health care in Ukraine in the first 100 days of this year’s war alone.

This is not collateral damage. It is not the result of a stray bullet or a military mistake. It is often a deliberate part of the war strategy that severely compromises the safety and effectiveness of humanitarian actors. If not met with swift accountability, these attacks reinforce a culture of impunity that can only sow chaos and further empower bad actors.

DAVID MILIBAND

David Miliband is the president and CEO of the International Rescue Committee. He oversees the agency’s operations in 40 crisis-affected countries and its refugee resettlement and assistance programmes throughout Europe and the Americas. The IRC’s mission is to help the world’s most vulnerable people, whose lives and livelihoods have been shattered by conflict and disaster, including the climate crisis, to survive, recover and regain control of their future. He previously served as secretary of state for foreign affairs for the United Kingdom.

@DMiliband / @RESCUEorg rescue.org

The IRC and our partners are working to bring to bear all the international system’s measures of accountability and censure to better protect health services in conflict settings. But our efforts are only as strong as the sticks brandished by the international system and the state actors that comprise it.

Protecting health in conflict is a massive technical and operational challenge that becomes nearly impossible in an environment of impunity. From Syria to Ukraine, recent conflicts have revealed the deadly impacts of our failings and underscored the urgency of holding combatants accountable for attacks on health systems.

Achieving health equity, including in the most fragile and conflict-affected contexts, is a political choice – one that leaders must make decisively, with the full weight of their power. ▪

“[Immunisation] progress has stalled and deep inequities in access continue to threaten children in fragile settings.

In 2021, 25 million children received no routine immunisations, the highest total since 2009”

Returns on health investments

By Hans Henri P Kluge, director, and Muscat, director, country health policies and systems, for Europe

The past three years have been a watershed moment in our collective European and global community. The seismic shocks brought about by the Covid-19 pandemic have shaken the foundations of our health systems, leaving us with one clear lesson: if we fail to invest in preparing our health systems, we will pay in the long run.

The pandemic has taught us that countries that had invested in preparedness and showed strong leadership and flexibility in reacting to the first Covid-19 waves were also able to come up with a comprehensive response to address the spread of infection, and could count on the trust of their populations. Those that

Amid global political and economic turmoil, failure to invest in bolstering and bettering our health systems will be costly – both financially and in terms of health and well-being – in the long run

did not were more likely to go into crisis mode, fearful that their health systems would be overrun and their societies would collapse. Investing in health systems

is like an insurance policy: countries can take a risk by not paying the premiums, but in these uncertain times they are taking a gamble with the lives and well-being of their populations.

The risks are even higher if we consider that the current spotlight on health is not necessarily a constant. With new security, political and energy challenges emerging, political leaders in countries may be tempted to shift both capital and commitment away from health and towards other sectors.

But this is not the time to disinvest in health – especially since health and the economy are inextricably linked.

INVESTING IN HEALTH MEANS INVESTING IN THE ECONOMY

Last year, the Pan-European Commission on Health and Sustainable Development called for necessary investments to allow countries to build more resilient health systems, while preparing for future crises that pose a severe threat to health and the economy.

The World Health Organization estimates that the initial Covid-19 shock was worse than that of the 2008 global financial crisis. All country income groups in Europe experienced a deeper fall in gross domestic product in 2020 compared to 2009, although the difference between the two periods is particularly marked in middle-income countries.

There is evidence that investing in health and health systems is clearly beneficial for achieving economic objectives. A healthy population is a precondition for sustainable development and a strong macroeconomy. At the same time, a strong economy is necessary to generate sufficient resources for health systems.

In the current global situation, marked by security and economic challenges, high energy costs and labour shortages, many finance ministers face difficult choices as they seek to balance their books while meeting other calls on their budgets, including defence. This makes it all the more important to protect and, where possible, to increase health budgets to safeguard populations and ensure that health systems are resilient to inevitable future challenges.

A DRIVER OF ECONOMIC GROWTH

We know that healthier populations are happier and more productive ones. This is especially important in advanced economies, where ageing populations and falling birth rates mean that more and more working-age people are supporting pensions through taxes on their wages.

We also know that health care has expanded to include prevention measures and the management of long-term chronic conditions, also thanks to people’s longer life expectancy.

But this is not all. Health is now a key component of the economy, in several ways. One is through the rewards of scientific innovation, recognised by those countries that have adopted ambitious life science strategies. Another is through the benefits that health facilities bring to their local economies, by creating employment opportunities

HANS HENRI P KLUGE

Hans Henri P Kluge began his term as the World Health Organization’s regional director for Europe on 1 February 2020. A native of Belgium with more than 25 years of experience in medical practice and public health, he first joined the WHO in 1999 as project manager for tuberculosis, hepatitis B and HIV at the WHO country office in Russia. After serving as medical officer and team lead with the country office in Myanmar between 2004 and 2009, he moved to the Regional Office for Europe, and the following year was appointed director of the Division of Health Systems and Public Health.

@hans_kluge

– especially for women – and as local suppliers of goods and services.

THE ROAD AHEAD

We must invest now if we are to prepare our health systems for future crises. This is especially the case if we look at some of the areas that have usually attracted fewer resources, such as primary health care and mental health. Investing in health also means investing in health workers –in their training, education, career paths and leadership.

Today – and in hindsight – we know that if countries had invested more in preparedness, the pandemic would have left less pain and suffering in its wake. But this requires a new way of thinking, based on One Health.

NATASHA AZZOPARDI MUSCAT

Natasha Azzopardi Muscat is the director of country health policies and systems at the World Health Organization’s Regional Office for Europe. A medical doctor by training and a specialist in public health, she has worked in various areas in Malta’s health sector, including maternal and child health, mental health and primary care. Between 2001 and 2013, she occupied various senior positions in Malta’s Ministry of Health, including as chief medical officer. Before joining the WHO in 2020, she served as president of the European Public Health Association from 2016 to 2020.

@natasha_azzmus

euro.who.int/en/home

One Health means looking at the relationships between the health of humans, animals and the environment as one interconnected system. Wealthy and poorer countries will need to work together to pool resources and development assistance towards research, procuring vaccines and medicines and to tackle rising antimicrobial resistance. Most importantly, both high- and low-income countries need to pool resources to make good on their promises to invest in health systems – with investment in their health workers as key. Only with motivated, cared for and well-resourced health workers can we create truly resilient health systems. Governments have the power to make choices today that will decide the future of generations to come. We know what it takes. The time to act is now. ▪

A healthy population is a precondition for sustainable development and a strong macroeconomy. At the same time, a strong economy is necessary to generate systems”

Time for reform: local and global health governance

The Covid-19 pandemic plunged the world into a formidable global health crisis in 2020. It has claimed millions of lives and affected more than 200 countries. As of 15 August 2022, there were 587 million confirmed cases of Covid-19 and 6.4 million reported deaths, excluding deaths from the disruption of services, especially for life-threatening non–Covid-19 conditions. While there has been slow progress in ending the pandemic due to limited access to Covid-19 vaccines in Africa and the continued emergence of variants, the large human monkeypox outbreak has had no clear link to endemic countries. Of the 44,503 cases reported, 99% have been reported from locations that have not historically reported monkeypox. Despite low mortality, this has raised serious concerns about a possible change in transmission that could pose a greater global threat.

The negative impacts of Covid-19 have been felt across sectors and at all levels. Inequities and inequalities have been laid bare and continue within and among countries. Covid-19 has further exposed the vulnerability of individuals and communities, the interplay with other infectious and non-communicable diseases, and the disproportionate effect on ethnic groups, the poor and informal sectors in countries of all incomes. The threats to human, animal and environmental health are inextricably linked, and have consequences on economic activity and disruptions. Economic recovery is inequitable: the gross domestic product per capita of developed countries is forecast to recover fully by 2023, but remains elusive elsewhere. Developing countries in Africa foresee a gap of 5.5 percentage points of GDP per capita compared to pre-pandemic projections. More crucially, systems caved due to fragility and associated threats. In the health sector, the health crisis revealed poor surveillance and weakened health systems, scrambles for supplies and lack of access to medical countermeasures. In the environmental sector, planetary emergencies are increasing with intensified droughts, floods, extreme temperatures and wildfires. More broadly, shortcomings in political and societal resilience across the globe have been exposed. At the United Nations Glasgow climate conference in 2021, global efforts to hold countries accountable for reducing greenhouse gas emissions and promoting adaptation were inadequate, with more challenges than solutions being reported.

By Precious Matsoso, director, Health Regulatory Science Platform, University of the Witwatersrand, and Viroj Tangcharoensathien, co-founder, International Health Policy Program, Thailand’s Ministry of Health

Shortcomings in political and societal resilience have been laid bare by the Covid-19 pandemic, but by taking a systematic and fair approach to pandemic prevention, preparedness and response – and with the right investments – the world is capable of finding effective solutions

PRECIOUS MATSOSO

Precious Matsoso is director of the Health Regulatory Science Platform and honorary lecturer in the Department of Pharmacy and Pharmacology at the University of the Witwatersrand and a member of the Independent Panel for Pandemic Preparedness and Response. She has served as director-general of the South African National Department of Health, and held several leadership positions at the World Health Organization. She chaired the WHO executive board and the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme, and was a member of the United Nations High-Level Panel on Access to Health Technologies.

VIROJ

TANGCHAROENSATHIEN

Viroj Tangcharoensathien is co-founder of the International Health Policy Program, affiliated with Thailand’s Ministry of Public Health. He received his PhD in health planning and financing at the London School of Hygiene and Tropical Medicine in 1990. He won the Edwin Chadwick Medal in 2011 for his contributions to improve health systems in the interests of the poor, the Sam Adjei Distinguished Public Service Award in 2018 by the Alliance for Health Policy and Systems Research and Health Systems Global for his engagement in health systems development and research, and the WHO DirectorGeneral’s Health Leaders 2019 Award for his outstanding leadership in global health.

A LEGALLY BINDING INSTRUMENT

There have been calls to improve local and global health governance for a globally coordinated response to a future pandemic or public health emergency. However, the debates have no traction. The pandemic has fast-tracked decisions for bold moves by World Health Organization members to adopt an international instrument or agreement through inclusive engagement by countries and other relevant stakeholders.

The recent discussions in the intergovernmental negotiating process were preceded by a systematic approach that entailed developing a digital platform to identify substantive elements to include in a WHO convention, agreement or international instrument (CAII) on pandemic prevention, preparedness and response. Extensive deliberations and written submissions created a basis for global governance mechanisms and collaboration for a collective response to pandemics. The proposed technical solutions will likely be negotiated through global health diplomacy, although the imbalance of negotiating power between North and South has shifted through coalitions among the Global South. Ultimately, the CAII must be an efficient global and national governance mechanism that aims to end the current crisis and prevent similar crises from happening again. This requires joint action of the health and non-health sectors, public and private health sectors, communities, and civil society at the country level through the whole of society, to engage many different stakeholders and all of government to facilitate cross-sector problem-solving. Strengthening the global health architecture requires synergies in efficient global health governance through the WHO, United Nations agencies and bilateral organisations; in effective global governance for health through the World Health Assembly, UN General Assembly, World Trade Organization, Human Rights Council and other global health initiatives; and in governance, which refers to the institutions and mechanisms established at national and regional levels to contribute to global health governance and governance for global health.

SUBSTANTIVE ELEMENTS

The technical contents of the CAII have been proposed on preparedness, prevention and response capacity, health systems resilience, the vital role of primary health care and universal health

coverage. There has also been a focus on strengthening surveillance, including on potential zoonoses in wildlife and domesticated animals, as well as on genome sequencing and sharing real-time data for global risk assessment and timely responses to prevent small-scale outbreaks from spreading into an epidemic or pandemic. Strengthening public health laboratory and health workforce capacities – the backbone of preparedness, prevention and responses – requires maintainable and adequate funding, from sustainable domestic sources. Nonetheless 28 low-income countries require significant funding support from development partners.

One highly contentious issue is addressing the global inequities in access to pandemic response products, including vaccines, therapeutics and diagnostics. The WTO’s decision on intellectual property rights in June 2022 focused on Covid-19 vaccines, rather than all pandemic response products. The CAII must synchronise with the WTO to address this inequitable access to pandemic response products.

Indeed, equitable access can be resolved by increasing manufacturing capacities to match the demand of a global population of 8 billion in pandemic situations, through transferring technology and know-how from high- to low- and middle-income countries. The availability of products in the market requires efficient application of novel WHO and national regulatory pathways and emergency-use procedures. In addition, ensuring synergies and alignment with other international legal regimes and the International Health Regulations, including gender equity and human rights, should be the primary principles of the CAII.

Recognising the WHO as a primary actor during a pandemic, the CAII should reside in an institution with a strong track record, and a competent authority with good governance arrangement. It should be subject to periodic review of its relevance and effectiveness.

The substantive elements of the new CAII should be informed by scientific evidence on what works and what does not. They should fill the gaps and address the failures of the current pandemic responses, especially the stark inequity across countries. Of course, these scientific technical solutions will be shaped through global health diplomacy in negotiation, reconciliation and consensus building.

How to prepare for the next pandemic

The Covid-19 pandemic was a stress test that brought to light the lack of preparedness for major health crises around the world. In many low- and middle-income countries health systems struggled to save lives and meet the needs of citizens.

Disruptions to basic health services, such as maternal health and routine childhood immunisations, put women and children especially at risk of preventable illness and may have life-long consequences for many of them. The treatment of non-communicable diseases also suffered a serious blow.

The impact has been severe thus far: the World Health Organization recently reported that global excess mortality associated with Covid-19 was around 15 million, one of history’s worst death tolls and far higher than official estimates.

New disease outbreaks are threatening to inflict more human and economic suffering. Climate change, urbanisation, deepening poverty and

By Mamta Murthi, vice president for human development, World Bank

conflicts are only compounding these stressors, contributing to a rise in acute shocks to health systems worldwide.

A big lesson from this pandemic and past health emergencies, including Ebola and Zika, is clear. Countries must prepare better for the next pandemic. Not doing so runs an extreme risk to a country’s human capital – people’s lives, their health and their skills – and to the economy. Moreover, preventing pandemics costs far less than controlling them. A recent G20 high-level independent panel report highlighted the fact that while global economic losses from Covid-19 exceeded $20 trillion, the estimated financing for prevention, preparedness and response measures would just be a fraction of this amount.

So how can countries better prepare?

First, governments must prioritise foundational, long-term investments in resilient health systems for all

citizens in order to break the “panic and neglect” cycle. In most countries, pandemic prevention, preparedness and response remain vastly underfunded, siloed and insufficiently integrated within service delivery systems. Joint World Bank–World Health Organization studies estimate that the total annual financing need for pandemic prevention preparedness and response is $30 billion, with the largest capacity gaps in low- and middle-income countries.

Most of this funding will need to be raised domestically. Yet World Bank research also shows that the projected increase in government health spending in 2026 will cover only about 60% of the necessary annual investment needed to strengthen and maintain public health preparedness and response capabilities in lowand lower middle-income countries. Considering this reality, significant international financing will be needed to support poorer countries.

Second, sound governance of the health sector is crucial to the success

Preventing pandemics costs far less than controlling them. To get there, we need long-term political support, sustained financial commitment and effective governance of the health sector

of pandemic prevention, preparedness and response. Countries need evidence-based decision-making processes, and agile, risk-informed planning and budgeting processes that mobilise government at the national, sub-national and local levels. They need quality legal and regulatory frameworks and strong public health institutions.

This kind of robust governance is especially key to ensuring that a One Health approach really works, bringing together human, animal and environmental sectors for interventions that ultimately save lives.

SETTING AN EXAMPLE

In Uganda, thanks to existing emergency response structures, the government quickly activated the country’s emergency operations centre and the national task force, well before the first Covid-19 cases were detected there. The Philippines also exemplified effective cross-sectoral actions by leveraging both disaster and public health legislation, and inter-agency emergency coordination mechanisms for the country’s Covid-19 response.

Crisis preparedness is integral to the mission of the World Bank Group, and we have long been supporting developing countries in building stronger health systems. Our $30 billion global health portfolio includes more than 200 projects that help countries take a comprehensive approach to improving health outcomes, especially for poor and vulnerable people, by strengthening primary health care and key public health functions.

For example, in Africa, through our Regional Disease Surveillance Systems Enhancement and the Regional Sahel Pastoral Support projects, we are helping to improve regional cooperation on public health, to upgrade veterinary laboratories and to prevent antimicrobial resistance. Our investment project to support the Africa Centres for Disease Control and Prevention is enhancing disease detection capability and enabling health authorities in the region to pool resources.

Research shows that the projected increase in government health spending in 2026 will cover only about 60% of the necessary annual investment needed to strengthen and maintain public health preparedness and response capabilities in low- and lower middle-income countries”

15m +$20trn $30bn

The new Financial Intermediary Fund for Pandemic Prevention, Preparedness and Response – to be housed at the World Bank and working in close collaboration with the World Health Organization – is a further, important step to help strengthen country systems. The fund will bring additional, dedicated resources to the task, incentivise countries to increase their investments, enhance coordination among partners and serve as a platform for advocacy.

The world already failed a major test in preparing for and responding to the Covid-19 pandemic. It is in everyone’s best interest that we learn from this and take immediate action. Pandemic prevention, preparedness and response anchored in strong health systems that reach everyone, everywhere –especially the most vulnerable – are critical to ensuring people can live out their full productive potential and countries can build more resilient, inclusive and prosperous futures. It takes long-term political support, sustained financial commitment and effective health sector governance to get us there. ▪

MAMTA MURTHI

Mamta Murthi is vice president for human development at the World Bank. She oversees the Global Practices for Education; Health, Nutrition and Population; Gender; Social Protection and Jobs; and the Human Capital Project. An economist by training, she has published extensively on poverty, demography, education, pensions and skills, and is known for her econometric studies on fertility in India. She was deputy director of the World Development Report on Development and the Next Generation in 2006 and MacArthur Fellow for Poverty and Inequality at King’s College, Cambridge during 1998–2000.

@MamtaMurthi worldbank.org/hd

By Ricardo Baptista Leite, president, UNITE Parliamentarians Network for Global Health

Seven rules for getting the politics right

Here are seven rules for getting the politics right to ensure Health For All.

1. KNOW WHERE YOU ARE GOING. The politics of government tend to be shortsighted due to the limits imposed by political cycles. Moreover, bureaucracy tends to perpetuate trends. Just like the Titanic, turning a health system around is slow and meets with resistance. Therefore, those who have the power to implement reforms must understand that the current standard model of healthcare governance is bluntly wrong. Most countries possess systems that simply react when the health of each individual person is affected, thus leading to ever-growing burdens of disease. Leaders need to promote long-term strategies focused

on the quality of life and well-being as the main endpoints of all political activity. Living needs to be more than simply surviving. All reforms must be implemented based on this vision.

2. BE PROACTIVE, NOT REACTIVE. Political leaders need to transform the current ‘disease reaction systems’ into governance models capable of proactively promoting the well-being of all citizens. Every time a healthcare worker treats a person with a disease that could have been avoided, or diagnosed earlier, represents a failure of that health system. New governance models must be more efficient at: a) promoting lifestyles and environments that generate well-being, including mental health; b) implementing measurable indicators of compassion and humanism as

From reducing the ever-growing burdens of disease to recognising health as a driver of economic development, there is a roadmap we can follow to achieve Health For All

main pillars of the healthcare system architecture; c) avoiding preventable diseases; d) ensuring timely diagnosis; d) curing all curable conditions; e) controlling chronic diseases; and f) minimising suffering and malaise when no other options are available. Naturally, for governments to proactively move in the right direction, based on science and real-time evidence, data must be used as an ally, sustained by an underlying technological infrastructure across the health ecosystem.

3. STOP TREATING HEALTH CARE AS IF IT IS CHARITY.

Historically, health care has been embraced as part of the social response provided by government to citizens. This is the main reason why health is always perceived by finance ministers (and most of government) as a cost and not an investment. The evidence is clear that when a system is capable of generating better clinical and social outcomes, health becomes a driving force for economic development. The opportunity cost of not reforming or investing in health is the inevitable decline in people’s quality of life and an increase in all forms of social inequities. Investing in health, including in research and development, provides citizens greater opportunities to rise up the social ladder and, for all, from rich to poor, to provide a better future for generations to come.

RICARDO BAPTISTA LEITE

Ricardo Baptista Leite is the founder and president of UNITE Parliamentarians Network for Global Health. He is serving his fourth term as a member of Portugal’s parliament and is vice-president of the Social Democrats Parliamentary Board. A medical doctor trained in infectious diseases, he is also head of public health at Católica University of Portugal, vice-president of the Parliamentary Network on the World Bank and International Monetary Fund, a city councillor of Sintra, and the former deputy mayor of Cascais.

@RBaptistaLeite / @UNITE_MPNetwork unitenetwork.org

By building partnerships that involve and interconnect all stakeholders in each community, governments can generate a health-friendly environment that promotes the well-being and improvement of the quality of life of all citizens.

6. GET SUSTAINABLE.

The current healthcare model leads to increasing burdens of disease and, inevitably, costs to a point where health systems will be financially unsustainable. Recalibrating the whole health ecosystem to focus on making people healthier, happier and more prosperous can avoid such a dim future. Beyond the aforementioned overarching reforms, concrete transformations to be implemented within the health system should each be designed to fix a clearly defined problem. A ‘key in hand’ approach is ideal so ideas become reality. Decision makers must answer for each initiative: who does what, where, when, how, with whom, with what technology (if applicable), where does the money to finance the initiative come from, and how to ensure funding in the years to come. Pilot projects should be designed so it is clear how and when to scale up, if the goals are met.

7.

POWER TO THE PEOPLE.

4.

MEASURE, COMPARE, INCENTIVISE, REWARD.

Political leaders have no idea what the return is from their expenditure in health systems. Every year, trillions of dollars are poured into hospitals and clinics around the world, yet few can say if their patients are better or worse off than when they first stepped through the door. Governments are driving blindfolded at high speed on a curvy highway, at the expense of the taxes and health of the people they serve. This needs to end. Any major health reform needs to focus on the capacity of health systems to collect data and apply analytics to measure clinical and social outcomes. Digital technologies are critical in ensuring access to this

information in real time, paving the way to developing new financial models that incentivise healthcare workers and institutions to provide better care. A wider application of such technologies will foster comparability in tools so those with worse outcomes can learn from the best. Reward mechanisms can drive performance in communities focusing on prevention and health promotion that can lead to measurable health outcomes. With such an approach, well-being can be a concrete, measurable goal achievable by all. In that spirit, one must acknowledge that at a global level, using gross domestic product to measure development and economic growth leaves out factors such as the quality of life of citizens and inequities within each country. It is time to change the macroeconomic metrics to focus on the well-being of all people.

5. CREATE AN ECOSYSTEM FOR HEALTH AND WELLBEING.

Due to the siloed organisation of most governments across the globe, health ministers tend to focus exclusively on the services provided by conventional health institutions. But this approach is outdated and insufficient if the broader vision of ‘health and well-being for all’ is to be achieved. Governments need to involve all resources available in their cities and regions – whether managed by public, private or social initiatives – to optimise all policies.

The people who politicians represent and swear to serve are the direct beneficiaries of such reforms and investments in health. To achieve the ambitious goals of Health For All, governments and parliamentarians must ensure that citizens are not only heard, but also empowered and are part of decision-making. It is not enough to say that patients have a voice. Mechanisms need to ensure that patients have real power when it comes to deciding on policies that will affect their lives. True change can only happen if grassroot bottom-up movements are engaged and capable of keeping governments accountable. This means governments and political leaders must be willing to make processes more transparent and open to participation. In sum, politicians, to better serve the people, need to give power to those same people who got them elected. It is about time.

Bridging people with their right to health

The right to health was established by the Universal Declaration of Human Rights and has been enshrined in many international and national frameworks. However, its implementation has been unequal, with vulnerable and marginalised populations disproportionately affected by ill health and facing significant obstacles to accessing health care.

The Covid-19 pandemic has affected people’s livelihoods and education prospects, increasing poverty, malnutrition and inequalities. The consequences for the societies and economies of countries have been so far-reaching that response and recovery measures have often had an economic character. Beyond science and evidence of the disease itself, the political response has shaped the trade-offs between the health sector and the economy, and the allocation of resources determining sectors and groups to be prioritised. Within this context, it is important not to lose sight of the right to health. In 2019, the Inter-Parliamentary Union, bringing together 178 national parliaments, adopted a landmark resolution on universal health coverage that called on parliaments to ensure the right to health in law and in practice. This means not only enshrining this fundamental right into national constitutions and legislation, but also removing remaining barriers to access to health – be they legislative, financial, cultural or others.

THE ROLE OF PARLIAMENTS

Parliaments can ensure universal health coverage is high on political agendas in their countries, support legislation that expands access to priority health interventions and ensure that relevant parliamentary committees address health financing issues to prioritise health in their annual budgets. Reports from parliaments in 2020 and 2021 show a mixed picture. They highlight disruptions of essential health services such as immunisation and maternal health services, as well as parliamentary work on universal health coverage, due to the diversion of attention and resources. Health equity was a major challenge, including for countries with established health systems. The pandemic further increased inequalities, including through misinformation and inequitable distribution of vaccines. However, parliaments have also been stepping up to the challenge, remaining

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When only about 26% of parliamentarians worldwide are women, with slight increases over the years mainly due to well-designed quotas, half the world’s population remains underrepresented”

Health For All is a shared responsibility, and parliaments are situated crucially at the meeting point of health, governance and accountability

Martin Chungong, secretarygeneral, InterParliamentary Union

committed to universal health coverage and the right to health. Legislation is being debated or passed in different countries to improve financial protection for accessing healthcare services. Parliaments are further conducting inquiries into their countries’ Covid-19 response from the human rights and gender perspectives.

The IPU pays particular attention to women’s, children’s and adolescents’ health as these groups globally face considerable social, economic and cultural challenges that have profound implications for their health and well-being, with significant variances in health status between and within countries. Although the translation of political commitment into legislative and policy frameworks is an essential first step, equity is not automatically achieved with the implementation of policies and strategies for universal health coverage. Parliamentarians must play a robust role in identifying and targeting those who are being left behind by complementing official data through engagement with communities and local stakeholders to assess the impact of existing laws and policies. Parliamentarians can and must further ensure that the needs and concerns of women, children and adolescents, who often do not have a political voice, feed into decision-making processes. Making parliaments more gender sensitive includes strengthening instruments and mechanisms for mainstreaming gender into law-making and budgeting, and also increasing women’s political participation. When only about 26% of parliamentarians worldwide are women, with slight increases over the years mainly due to well-designed quotas, half the world’s population remains under-represented.

INSTRUMENTS IN PLACE

All the instruments to ensure the right to health are in place at the global level through human rights frameworks, the 2030 Agenda for Sustainable Development, universal health coverage and other health commitments. In spite of this, Health For All remains a promise. The IPU continues to support parliaments to strengthen their capacity to carry out their many important roles in serving and representing diverse constituents, holding governments accountable, and passing and resourcing legislation to ensure the well-being of their people. This means promoting equal representation of men and women and political participation of youth for

MARTIN CHUNGONG

Martin Chungong made history by becoming the first African and non-European elected secretary-general of the Inter-Parliamentary Union in 2014. He previously served as deputy secretary-general and director of programmes. He spent 14 years in the Cameroonian Parliament before joining the IPU. He is also on the steering committee of the Global Partnership for Effective Development Cooperation and the board of the Partnership for Maternal Newborn and Child Health, and chairs the Global Board of the International Gender Champions.

@MartinChungong @IPUparliament ipu.org

more inclusive decision-making; reiterating the centrality of the 2030 Agenda as the global framework to implement recovery plans that deliver social and environmental sustainability; and promoting dialogue at the national and global levels to build solidarity and share effective strategies for better health outcomes. National parliaments are leading the way: in 2021, the Parliament of Uganda passed the National Health Insurance Scheme Bill to address high rates of out-of-pocket expenditures; Australia prioritised investment into women’s health to improve gender equity and health outcomes for women and girls; and Thailand’s parliamentary Committee on Public Health started an investigation into people’s rights under universal health coverage to make policy recommendations on pressing public health challenges, to name just a few examples. Much more needs to be done.

Health For All cannot be achieved by one actor alone – it is a shared responsibility, and parliaments are crucially placed at the interface of health, governance and accountability. ▪

Child & Youth Working Group

World’s leading advocacy network for better global mental health

This working group was established to champion the lived experiences of young people, providing opportunities to amplify youth voices and see the actionable change in local, national and international contexts.

youth mental health and bridging low-middle and high-income countries for greater equity, this working group acts as a platform for the creation of actionable opportunities across the network membership.

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