The challenge of funding global health public goods

Robert Yates

Hello, good morning, good afternoon, good evening, from Chatham House in the heart of London. My name is Robert Yates. I’m the Executive Director of the Centre for Universal Health at Chatham House and also Head of the Global Health Programme here. This is an event that we’re hosting with our colleagues from the Global Economy and Finance Programme at Chatham House, with kind support from the Bill & Melinda Gates Foundation. And we’re here today to talk about some an extremely important topic and that is the need to secure political commitment to fund global health public goods. By global health public goods, you know, what we’re really talking about are the types of health interventions that benefits everyone, benefit all countries, and – but they also require strong international co-ordination and collective public financing at large scale. So, really talking about, sort of, multilateral financing of health.

And we have to recognise, I think, that in our discussions today, that despite us having experience, or experiencing, you know, this tremendous health crisis, the track record has not been particularly impressive, in terms of raising sufficient multilateral financing. We’ve seen frequent calls to raise in the order of about $50 billion to save the world economy $9 trillion. This has been pointed out before the G7 last year, by the IMF and many organisations coming together, and this has led to key commentators calling this “the deal of the century,” or “a complete no-brainer” that we should be coming up with this money as a society. But unfortunately, it hasn’t happened and if we look back to the G7 last June, there was some additional money raised, but the Nobel Laureates, Esther Duflo and Abhijit Banerjee, in a recent piece in Foreign Affairs, said, “This really marked the low point of the West’s support to the pandemic, because really insufficient money was raised.”

So, we’re here today to look to the future, I think, really, because we’re not through this crisis yet and we need to increase multilateral financing. So, what are the lessons that we’ve learnt from the past, as well, to ensure that we do get sufficient public financing, multilateral financing, with important things like the CEPI Replenishment coming in, in March and the discussions around the long-term financing of WHO, that benefits everyone, extremely important as well.

So, I have a fantastic panel with us this afternoon to discuss these issues, from the worlds of health and economics and politics, and I’ll very briefly introduce our panellists. We have President Tarja Halonen, who was the President of Finland from 2000 to 2012 and who works very closely with the UN as a member of the Secretary-General’s High Level Advisory Board on Mediation, and also as a UN Land Ambassador. And, also, I believe was a Former Health Minister, so has been used to arguing the case for health finance in the past.

Professor Kelley Lee, who’s a Professor and Research Chair in Global Health Governance in the Faculty of Health Sciences at Simon Fraser University in Canada and, also edited the Oxford Handbook of Global Health Politics, which I think, obviously, is going to be highly relevant for our discussions today.

Then, from the world of economics, then we have Professor Lars-Hendrik Röller, who was the Director General of the Economic and Financial Policy Division of the German Federal Chancellery from 2011 to 2021. He was also the Chief Economic Advisor to Chancellor Angela Merkel and was the Germany’s – was Germany’s sherpa for the G7 and G20 Summits, so he’s had lots of experience of these discussions at that level.

And finally, we have Dr Osman Dar, who is a Consultant in Global Health to the UK Health Security Agency and is a Fellow of the Royal College of Physicians and a Fellow of the Faculty of Public Health. He was also on a Working Group Co-Chair of the United Nations’ One Health High-Level Expert Panel, but we emphasise today he’s speaking in a personal capacity, not on behalf of the UK Government. Should say, Osman, as well, is also one of our Associate Fellows at Chatham House.

So, welcome. I’m delighted that you could join us all today and I’m going to ask you to make some introductory remarks, you know, on this vital topic and really, sort of, try to, sort of, get down into why we haven’t been more successful in raising sufficient multilateral financing for health. And if I could perhaps start with you, Professor Lee. You’ve got tremendous experience in this field and you perhaps can, sort of, give us some of the historical perspectives of, you know, previous attempts to raise sufficient funds. 06:09].

Professor Kelley Lee

Thank you, and hello to everyone. Thank you, Rob Yates and Chatham House for this invitation. To kick us off, I think it’s worth recalling that the concept of global public goods emerged during the early 2000s, led by Dr Inge Kaul and her team at UNDP, who did a lot of work to conceptualise and advocate for their funding. The ideas were taken forward by an International Task Force on Global Public Goods and people like Nick Drager and Professor Richard Smith, and others, took the concept forward within WHO. So, we’re following on from a lot of work done by others previously.

Strictly speaking, Economists define, of course, public goods as ‘non-rival’, which means that one person cannot – can use the public good without diminishing its availability to others, and ‘non-excludable’, which means it’s available to everyone, whether they contributed to the funding of it or producing it, or not. And so, defined in that way, there’s actually very few pure public goods. I guess the classic example people give is a lighthouse, where we are – if you use the lighthouse, it doesn’t diminish its availability to others and it benefits everyone. So, we talk a lot about impure public goods and so on. There’s a whole academic literature around this.

In global health there is a few areas that are generally recognised as qualifying as global public goods. Things like international standards, guidelines and protocols, what WHO often describes as ‘normative activities’. Those are generally seen as global public goods. Others are R&D, research and development, for things like neglected diseases or, you know, knowledge translation and so on. And the other area that often comes up is communicable diseases, surveillance monitoring and reporting, for example, again, research on treatments and interventions that benefit everyone.

So, there’s been a lot of thinking, as I say. For the purposes of this discussion, I think what’s potentially useful about the concept, in a world where we’re always facing competing priorities and donor fatigue, it helps us to identify those goods that are essential to underpinning a well-functioning society or a global community of societies. It’s helpful for priority setting. The concept is useful for getting people to recognise that these public goods will be undersupplied if you’re leaving them to individual countries or individual – or to the market. They inherently need collective action to produce them. So, it helps explain why we need to have these institutional arrangements that we’re going to talk about today.

And the concept did prompt a lot of important conversations about global health financing and the need to support these essential functions that keep us healthy and safe. But also, it’s been a mixed blessing, because although the concept can be potentially powerful and martial arguments about collective self-interest, it also has suffered, I think, from loose definition. So, people tend to throw a lot of things under the public goods umbrella and that has, kind of, weakened its leverage. It also led to a reallocation of existing resources, rather than growing the pie bigger overall, and it tended to attract funding to vertical programmes, rather than health system strengthening.

So, that’s what, sort of, happened in the past and I – just to conclude my opening remarks, I would say that beyond the conceptual fuzziness that we often find with global public goods, we also find incredible political challenges, and this is because, really, that public goods, getting them on the agenda is really a political challenge, rather than a conceptual one. So, we need to have, for example, really – a clear political process for deciding which public goods should be funded as a priority. We could come up with a long list. We need to get a shortlist and focus our funding priorities accordingly.

We also need to think about how we communicate this concept to people. So, this is at a time when I think, you know, people are going to have a lot of spending to do in the next little while because of the pandemic and so, we need to communicate very clearly why these are really essential, and we’re also coming at a time when people don’t want to pay high amounts of taxes and so on, and we’re battling, you know, this kind of thinking. So, we need to reframe this issue again and refresh it and I think there is some potential to do that and to then attract greater funding for these key things. I’ll stop there, Rob.

Robert Yates

Perfect. Thank you very much, indeed, Kelley. That was a spot-on five minutes and extremely useful to get that historical – historic perspective and to discuss the utility of the concept and some of the tactics that we might be using on key stakeholders.

If I can maybe turn to Osman now. Osman, you’re a sort of, world authority on, sort of, ‘One Health’ issues and I’m sure have been, sort of, trying to think of imaginative ways to talk up the benefits of that to economic and political leaders. But what’s your take on this as a concept that – to secure additional financing for help?

Dr Osman Dar

Thanks, thanks Rob and thanks for the invitation to be on this panel. I – from a ‘One Health’ perspective, of course, ‘One Health’ is – it looks at issues at the interface between human health, animal health, ecosystem and environmental health and I think, really, that’s a good way for us to frame the issue of – around global public health goods. Particularly in the context of things like the pandemic, other emerging infectious disease outbreaks, ‘cause a lot of these originate in animals and then spill over into humans. And the way we manage our ecosystems, the technologies that are at play there, the way we manage our animal health systems, again, the technologies that are at play there, there’s obviously inequitable access to those, as well. And so, perhaps when we start thinking about equitable access to these global public health goods, we should think about the technologies and interventions in the animal sector and the environmental and ecosystem sector that also need to be – where we also need to, sort of, foster that equitable access.

And I was just thinking, when we – when I heard about this panel, that okay, we have a President, we have a Professor, we have policymakers, so what ‘P’ is missing in this discussion? And I – and then I – and I settled on a Preacher, and I think that’s part of what this comes down to. When you look at the failures that we’ve seen over the last couple of years in, sort of, trying to enable access to the technologies that have been produced to try and – to try to deal with this pandemic, they’ve been fundamental failures in a sense, in the human condition and I – and it comes down to some of these Seven Deadly Sins that a Preacher might talk about. And I think the ones that are most at play here are pride, greed, a little bit of gluttony and a little bit of sloth, really.

Pride because, you know, there are nation states and corporations that want to say, “We were the first to develop the vaccine. We’ve been leading the way.” Greed, because obviously, there’s a lot of profit to be made and there’s always been this issue around people and planet versus profit and where’s the balance? And it seems that the balance is not sufficiently dipped towards people and planet. Gluttony, because even though the – gluttony because there’s a limited supply of these goods and countries and regions are hoarding the products that have been produced, sometimes even when there’s no – not that much more marginal benefit to keeping, you know, an extra X million supplies of vaccine, and they’re allowing them to even become expired without that access being, you know, facilitated for people in low and middle income countries.

And then, what was the other one? That was gluttony, then there was sloth, yeah. So, sloth, because there’s a lot of wealthy developing countries, there’s – oh, I mean, I’m talking, for example, your Gulf Arab States, you know, countries that are high income, but where they haven’t invested in the technologies, in the development processes, to become manufacturing or production hubs themselves. Likewise, in a lot of low and middle income countries, there are a lot of wealthy people who are able to, you know, facilitate access or perhaps think more expansively about how they can build capacity for development and manufacture within their own settings, but choose not to do so. They invest in other things.

And so, I think that that’s a good way for us to think about this, ‘cause fundamentally, that’s what it comes down to. It comes down to these issues and that’s why we haven’t seen the, kind of, facilitated equitable access that we would all aspire to see and perhaps that we should be trying to focus on some of the virtues of – that we all share or that we all aspire to, to try to do, so if it’s charity, humility, temperance and a bit of diligence. So, I’ll pause there, but you know, look forward to discussing…

Robert Yates

Fascinating…

Dr Osman Dar

…this.

Robert Yates

…Osman. Thank you so much for bringing that, sort of, evangelical ethical perspective and about the sort of, the virtues, and you know, perhaps, you know, this is a tactic we should be thinking about of, sort of, selling the virtues of it more and, sort of, addressing it from that, sort of, normative point of view, like you’re saying there.

I should be saying that we are recording today’s session. We are on the record, as well. So, we’re not following the Chatham House Rule. We’re very – in fact, we’re very keen that people participate as much as possible and after our introductory remarks, we’re going to be having some discussions within the panel, but I’m very keen to bring you, the audience, in as well and would ask audience members to use the Q&A function to ask your questions. So, if you just drop a question into the Q&A and we very much encourage you to come on camera, come on mic, to actually pose your question to the panel. You would be promoted, temporarily, as a panellist yourself. If you don’t feel comfortable in doing that, I’m more than happy to ask the question on your behalf, but do please start firing your questions in through the Q&A, rather than through the ‘chat’ function, which we won’t be checking as regularly.

So, Lars-Hendrik, if I can, sort of, come to you now. You’re a veteran of many G7 and G20 Summits, where I’m sure these things have been discussed over the years and, you know, obviously, most recently through this pandemic, as well. You’ve been in the room when, you know, these big asks have been – are being made and countries have been looking at each other as to who’s going to be paying for all this stuff. But what’s your take on the under-in – the clear under-investment in global public goods for health and what we can do differently going forward?

Professor Lars-Hendrik Röller

Yeah, thanks very much and I want to thank, also, Creon Butler, for inviting me, and Chatham House. Creon, we’ve done lots of battles in the G7 and the G20 over the last years, so I think that’s important. And I’ve, sort of, been in it for ten years and now I’m out of German Government as of December, so these are my private comments, but I do want to look back at maybe what has worked and hasn’t worked, in the five minutes I have, which is not going to be easy.

I think that, you know, as was just said, I think the pandemic is, sort of, a super global event. I think it’s actually got some points, which go beyond the other issues which we’ve discussed at the G7 and G20. One was always trade, climate. Climate, of course, has also got aspects, as was said, for public good, but I think health is particularly global and can only be solved globally, and I think that’s why this no-brainer is actually there and the question, which you’re asking today, is very important.

I have a couple of remarks, at the end, of what I think we could do better, but it’s a no-brainer and one reason is that needs to be solved everywhere, I think the variants and the Olympics, and all these kinds of events show us that we don’t solve it in other countries, we’re not going to solve it at all. That’s true, to some extent, in climate, but I think in a pandemic, it is, sort of, what I call a “super multilateral, super global event,” which I think needs a response.

Second point, I think the response, if I’m, you know, beg to differ a little bit, actually, compared to other global goods, hasn’t been all that bad. It’s not sufficient, but actually, you know, the G20 Actor A, or the Actor A COVAX thing we generated, we started in the early 2020s, the financial support, I think Germany was over a billion just to COVAX. I think it’s close to two billion and I think, globally, was, I think, and Creon can correct me on that, over 20 billion, or somewhat 20 billion, we’re still short as the budgets are there. But I think it’s actually been a pretty remarkable global response, yet there have been some negative sides to the global response. If you think about trade restrictions and production. I was chairing a International Committee at COVAX, thinking about how we can increase localised productions in South Africa, where we’re building a hub now in other countries. So, I think these fairness issues were not handled very well. I think WTO is doing a lot of work in this area and WHO, as well, to try to, you know, improve that for the next pandemic.

So, I think there has been light, but also shadow, in terms of the response, but it hasn’t all been that bad. The worst thing has been a lot of it has been a national response. If you think about this manufacturing part, which I was very much involved in, there have been a lot of National Task Force. I’m pretty sure the UK have that, as well, Germany had one, France, the EU has one, America has one and China has one. And I think the multilateral approach has been – you know, should be improved and I think the WHO is working on that, that we make it more into a multilateral response.

With regard to financing, as you said, there is a gap and what can we do to close the gap? So, that’s my third and final point. I think the first thing we should do is make sure that the commitments, which have been given by G7 and G20, and there’s a tracker ,which the UK Government put forward, in terms of our commitments on vaccine sharing and distribution. But also on financial contributions, that it is actually being delivered and actually be delivered there and not just promised and put into a table, but actually being delivered. I think that’s always very important. The question of accountability is very, very important. It doesn’t solve all the problems, but if you don’t do that, you won’t solve the problem, either.

Another strategy is naming and shaming. This is a very old strategy. You know, who’s doing what, in terms of financing? I think Germany has been relatively good, I think the UK, as well. US has, sort of, come online under the Biden administration, but there are other countries who should do more. So, a careful strategy, either by governments, or by the NGOs, in terms of making clear who does and who does not contribute. It’s an old strategy, but my experience is it works. Nobody wants to be isolated, especially the big countries don’t want to be isolated.

NGO pressure, very important. I could go on for a long time, because I’ve been working with the NGOs on the G7 and G20 for many, many years. I think they could be better co-ordinated and speaking more with one voice and having a simple message. So, is it financing or is it something else? So, I think it’s very dispersed, this NGO activity, that has its strengths, but I think a more precise strategy on NGOs might be worthwhile.

Advocacy, this is what you’ve been discussing. I think that the no-brainer argument, I think that’s very important, and I think, you know, Nobel Laureates, if they say certain things matters, but I think that, you know, the more advocacy there is, the better it is. The IFIs, the international financial institutions, you’ve put into your little page, “National jurisdictions about budget problems with development and health agencies.” That is true, but I think we also need to think about a reform of the international financial system, and I know there’s been some discussion on that at the UN. Mr Guterres, for example, has put forward an idea of global leaders putting forward a new governance structure. There’s lots of issues on financing between the World Bank, IMF. What is their mandates, particularly with regard to health and climate and also development issues, as you know? And, also, the WHO, and we had a long discussion, also, in the G20 in November about additional funding, where should it be put? Should it be put in the WHO, or should it be put at the World Bank? There are different views about that.

So, I think this prop0sal by the UN to think about some kind of Leaders Panel to rethink the global governance of financing, multilateral financing, is very important. I think two issues there. One is competencies, I think you’re meant to think about who does what, I think this is getting blurred and the institutions themselves, I think, are mindful of that. And the second one is streamlining the architecture. I think it’s relatively complicated. Also, if you think about wealth, the amount of actors and players involved, I think some streamlining might be important.

So, I think that’s my proposal, is to think about these things and maybe to support this UN effort and I think that’s also what the G7 and the G20 this year could be doing. The Health and the Finance Ministers, I think, have been tasked to look at that in the G20. Germany has the G7 Presidency, and I think rethinking, also, the global governance on health, and actually, goes beyond health and goes, also, into climate and the two things are somewhat even related, I think that’s a very important aspect. And then, if you get that right, that also gives you quite a bit of headway for getting the financing right. Thank you.

Robert Yates

Terrific, that’s excellent. Thank you so much, Hendrik, and some real practical solutions there, and I think, also, very important to stress issues around accountability. You know, there’s one thing leaders talking up their political commitments, but they need to deliver on them. And I think that we have seen, you know, since the G7 last year, I think you were alluding to this, you know, some countries making commitments and then flagrantly not meeting them, and you know, how important it is for the credibility of the system that that happens. And I think very reassuring to hear you say, you know, how effective CSO and NGO advocacy can be in these debates, as well, because I know that we have quite a lot of people from CSO/NGO backgrounds on the audience today, who’d be very glad to hear that this pressure is having an impact.

Glad to see some questions are coming in now, that’s fantastic. We’ll be bringing you on – one or two of you online in a moment or two to pose your questions to the audience. But next, I’m absolutely delighted that we have with us President Halonen, who obviously, has been Head of Government, Head of State for over a decade, who has plenty of experience of these types of issues and having to weigh up priorities, sort of, across different sectors. And so, I’m very keen to, sort of, get your perspective, your political perspective, about our abilities and tactics to, sort of, talk up investment in global health. So, President Halonen, if I can get your views, please, thank you.

President Tarja Halonen

So, yeah, thank you. I guess that when I noticed that you Academic Researchers and experts that you will say that that’s the system and I’m that poor one who – with response that why we have not succeeded. I have – I admit, I have been half a century, 50 years, about being with the health industry point of views. But anyway, I think that it’s easiest to say, very typically, so, so common, that I have noted many times during this pandemic, now, that if – I have compared it with the house with the leaking roof. The roof should be fixed when it’s not raining and when it starts to rain, it’s too late. But the problem is that when sun is shining, we hardly remember the leaking roof. And I will say that that will be, also, facing us in the next future. I think that all the Politicians, why not taxpayers will be allergic the – with the whole world, COVID-19, or coronavirus, as it’s called, so and, also setting in Europe.

So – but I will say that pandemic could be, also, a realistic possibility for a long time, because now, we might have these previously lacking sense of urgency, at least with the Europeans and Americans, who have been a bit arrogant with some other pandemic, because they thought that they happen somewhere there, but not in my country. And that’s why now we are facing the fact that it’s not an outside enemy, but it is something which is a global, which is common, and we have to be prepared to face, also, to the future.

So, I had, already, some parts what I thought to say, but Osman that has already mentioned it, that – and so, I don’t go within the details. But I think that that’s one of the things, both in the health, but also in other sectors of the society. So, we are always afraid of the free ride, which means that we think that perhaps we pay more than the others, and I think this is not that hard in the Nordic countries, where we have – used to have this, kind of – the common good systems in many other fields, but for instance, what I have been shorter times in US, so I have the – I had a feeling that they also have very, very strong feeling that – whether I pay something for the others.

And so, anyway, I was – last year, I participated in the World Health Organization’s Pan-European Commission on Health and Sustainable Development, what you will call the Monti Commission, and I was responsible for the resilience of the society, which is a quite tricky question, that why some societies will do it better than the others and then, what’s the – how could we adopt it? So, I think that it’s very good to remember that we will achieve a – at the G20, they had a lot of money, but they have not succeeded very well in this COVID-19. So, I think that the models should be seen, also, perhaps in Nordic countries, but also to see that, for instance, the people have managed earlier with the pandemic in Africa or in Asia. You might be astonished when I say in that way, but anyway, to learn it that how we can be together when it’s a pandemic.

But I very strongly underline the holistic approach, not only in one society with the health and other sectors of the society, and then, also, in – globally and concerning the 2030 Sustainable Development Agenda. And I think that that have – we have learnt now, also, during this pandemic, we remember that we have the animals, and we have the plants, and we are all together and I hope so that we help us to build more holistic system. But then, I don’t go now to the mechanics to raise funds for the COVAX, but we could, because I think that you might be, some of you, better on that, even the Monti Commission, to propose some ideas. But I really – I’m ready for the further discussions concerning that, that in which way we can see possibilities to use this certain type, still a little bit shock by the COVID-19, because that has shown us that it’s not an outside enemy, like they said in the bit – in the earlier stage concerning China, so, but – so, that it’s something what is inside in every country and we have to do it together. So, let’s see all the sectors of the Agenda 2030, too, even we have not too much time for that.

And then, the issue what I don’t raise is that why the female leaders of the countries seem to make a better success. I might only say that perhaps we have the experience of the society in so-called soft sectors, like on health, social or culture, cultural or education, more it has been in the hands of the women, especially the countries where women have had, a long time ago, in that might have worked little bit about that, I don’t know. Thanks.

Robert Yates

Thank you. Thank you very much, indeed, yeah, and interesting that point you were raising there about female leaders performing better through the crisis. That was something that we very much picked up in our work on solidarity and I think you do see a number of countries prioritising health more where there are women leaders and I think giving a sort of, greater emphasis to health and wellbeing in budgets. You know, one thinks of Iceland and New Zealand along those lines and, you know, that’s very interesting and I think coming back to what Osman was saying about, sort of, the virtues of investing in health.

I’d just like to maybe just pose a question to all of you, actually, which I think is very pressing, before we bring in our audience, and I’m glad to see, you know, questions are rolling in now. And that’s that eve – I think we all recognise that, from a whole of humanity perspective, it is a no-brainer that we should be, sort of, ramping up these investments, but tactically, where do you think that we should be collectively focusing our attention? Should it be on Finance Ministers, you know, sort of, working through them and looking at the economic arguments, you know, about the returns on this investment? Or should we be going for the Head of Government, the Head of State, you know, thinking more about, sort of, some of the political arguments, the societal arguments, or maybe a combination of the two? Because at the moment, you can see there are all these structures being set up to put Health Ministers with Finance Ministers, or should this be done at the UN through a Head of State level? And I think there is a bit of confusion at the moment as to where – you know, where we should be concentrating our efforts.

So, if I can maybe ask you in turn, where do you think that we should be, sort of, focusing our advocacy, you might say, and what do you think are the messages that are more likely to resonate and be successful? Perhaps thinking historically about how we might have done relatively well in, say, raising financing for HIV/AIDS, where a lot of money was raised, and one thinks through the likes of the Global Fund. But are Researchers, sort of, shown areas where there have also been no-brainer investments, like antimicrobial resistance, where we just weren’t so successful? So, if I can just ask you each in turn that tricky question, you know, where should we be focusing and what arguments should we be using the most? So, if I go back round the panel as we started, and so, Kelley, and I’m just wondering what your thoughts are about tactics.

Professor Kelley Lee

Yeah, it’s a great question. I guess I would go the route of both, but I think focusing on finance is really important. Ministries of Finance hold the purse strings, of course. With colleagues, they always obviously discuss priorities, but I think the problem is that, and maybe learning from HIV, is that funding needs to be framed in particular ways. It’s – in global health, it’s often defined as development aid, or charity, or donations to multilateral institutions and other actors and we need to change that. We need to use, maybe, the global public goods concept to shift how we define these funds. They’re not a form of charity. They’re not an optional extra that we put a hat around and ask people to pay for out of the goodness of their heart, or some moral obligation. This is, you know, much more than that. This is about all of our, sort of, self-interest, I suppose, is how Economists would argue.

And, also, to shift away from thinking it’s a competition between domestic spending and global health spending or international foreign policy. There’s a perception, I think, that after the pandemic that we’ll have these demands on domestic spending, but really, it’s a false dichotomy to think that if we spend on WHO or we spend on global public goods, that we’re somehow diminishing domestic capacity and the two we need to link together, so that we are stronger, domestically, if we spend on these things.

And then, finally, I would target Finance Ministers, who are, you know, fatigued, in terms of constantly being asked for these donations, replenishments and so on and, of course, there are finite resources, but I see – what we’re seeing now is a situation where there’s a competitive market for donors. They’ve created this competitive market where we have so many initiatives and every so often, they have to go back to donors and ask them, “Please support us.” So, it becomes this marketplace where donors can vote with their wallets and this is problematic, because global public goods are always under-supplied by a market. You need to have collective action and you need to – you know, and otherwise, you’re going to end up, again, with always shortfall, that we discussed already.

And so, we need to shift, I think, the thinking around are there other mechanisms? We’ve always talked about innovative financing mechanisms, and I think that conversation is a lot about trying to avoid the bad word, ‘taxation’, and different forms of levying and taxation. We find these innovative, you know, all sorts of ways that we can create the funding out of non-taxation, and I think we need to maybe think, you know, again, is this the way we should fund public goods that we all agree are no-brainers? And I think Finance Ministers are the place to start.

Robert Yates

Fantastic, thank you, and I couldn’t agree more, the good old-fashioned taxation that, you know, certainly has its role, but at a national and, potentially, an international level and, you know, this great interest in innovation can sometimes lead to some, sort of, pretty inappropriate ways to finance help on things of the debacle over things like user fees and community health insurance, you know, they’re – which have proved not to work. So, yeah, thanks very much, indeed, for that Kelley, that’s excellent. Osman, would you – what’s your thoughts about where we should be targeting and what messages should we be using?

Dr Osman Dar

So, I’m going to be slightly more combative in my response and I’m going to try and, I suppose, speak from a low-middle income country perspective. And I think, certainly, yes, we need to be targeting, sort of, Heads of Government, Ministers of Finance, but also thinking about what leverage do low and middle income countries have in the space? And I’m thinking back to, like, the example of Indonesia in 2007 where they refused to share avian flu samples because they were, you know, they were sharing the samples and then, you know, other countries – companies are producing the diagnostics and – or – and vaccines and then selling them back to them, an unfair state of affairs. And so, by refusing to share samples, that really got the global system engaged and you ended up at a – in a process where you ended up with the Pandemic Influenza Preparedness Framework and the creation of manufacturing hubs in other low and middle income countries, but it was only because they refused to share those samples and use the leverage that they had. They used, you know, the sovereignty principle under the Convention of Bio – the CBD. So, they were able to say that, you know, “We own these samples and so we should have a share in whatever is produced from them, share in the commercial benefits, share in the academic benefits.”

And it’s only through that that there was the propulsion to, sort of, share the technologies, build this manufacturing thrust in other countries and low and middle income countries need to be able to get together and do similar things, if that’s the case. You know, we had this issue with Omicron and everybody put in place travel restrictions on Southern African states, even though they had shared the samples and shared the information in a timely way, you know, supported that global solidarity and, I mean, I think countries need to start looking at, you know, what is – especially low and middle income countries, need to start to looking at what is in their own interests and if they need to play hardball like that and say, “Okay, we won’t share samples,” or whatever it is, then they need to be able to do that. And that’s the – and that – and I mean, I think that then stems – that then leads into the wider arguments around intellectual property and what needs to happen at the WTO. You know, South Africa and India put in a request for an IP waiver and where has it been blocked? It’s been blocked by the EU/the UK, with some, you know, mild support from the US.

So, these are really problematic issues, and it always comes back to the same argument. Yes, it’s going to stifle innovation, but really, is it? I mean, a lot of the innovation is funded by the public sector, by national governments. The blue skies research is done in universities, in Oxford and wherever else it’s done. It’s only after that process, when the pharmaceutical companies know that they’re going – that they’ve got guaranteed purchases at the end, they’ve been indemnified against any, you know, lawsuits on side effects, that they buy the products and then they make a huge profit. So, not even the science is being developed by Big Pharma. It’s being developed using public money in public sector institutions. So, I think the reason for…

Robert Yates

Okay, thank you, and very important issues around power that you’re bringing up there and the different power relations and the, you know, the need for greater power to be given to low-middle income countries. And I think, you know, obviously, what you’re referring to there is the enormous inequalities and inequities that were being seen in the distribution of these, you know, essential public goods, the vaccines, and we’ve yet to see it, of course, in the medicines, as well, and how these are absolutely vital issues to be discussed by the WTO.

Now, just before I come to Hendrik and President Halonen, we are having – we’re being swamped with questions now, which is fantastic, but we’re obviously going to struggle to answer all of them. So, might I ask the audience members that if you look up and down the list, if there are any particular coun – questions that you like, if you can upvote them with the thumb sign, and this is a way that we’re very democratic, and that the most popular questions will then get promoted to the top of my little list. I mean, I’m going to bring a couple of people in to ask questions who asked nice and early, to reward them, but I think in terms of the other questions, we’re going to have a sort of, democratic process to choose them.

So, Hendrik, if I can come to you now, and you’ve been giving us some really useful tips, as a Sherpa, and the Economic Advisor, about the, sort of, the types of approaches that we should be adopting. But where do you think we should be concentrating our efforts and what messages do you think resonate the best?

Professor Lars-Hendrik Röller

Yeah, I don’t want to – I think I mentioned some of those things. It’s not only who, but also how. I think both Finance Ministers are important, Heads of States ultimately make the decisions unless, of course, the governments. You know, there’s a government behind that. Some countries, you know, your coalition government, like in Germany. So, making these decisions are, you know, complicated domestic processes, without going into details. But I think both are fine, Finance and Heads of States. I think that again, the NGOs, want to reiterate that, are – you know, are important. If you think about climate, why we’re making such big progress on climate, you know, has a lot to do, not only with the no-brainer argument, but also how, you know, governments, in various countries, in particular in Europe, have been confronted with that issue, domestically.

I think that’s – you know, all politics, in a way, are domestic, so in a way, these NGOs work in all the countries, to the extent that they can link themselves up and speak more with one voice on this issue, I think it matters. They – and, you know, I don’t want to, you know, tell you how you do your job, but you know, having been on the other side, I always found that a very important process, both in the G7, but this a problem, actually, for the G20. It’s not a G7 problem and one issue is actually, also, with last year, with the UK, is that you have to be careful that the G7, you know, doesn’t, and this is a strong word, but doesn’t contribute towards splitting the G20, because on both of these issues, as was just mentioned, the equitable issues, the low and middle income countries, both on climate and on health, there are major issues there in the rest of the world. So, I think a lot of these issues are development issues and not just the G7 issues, but the G7, of course, has to be mindful of that and I’m sure the German Government is.

So, I think this advocacy, it’s in their self-interest to make that point, but that’s the no-brainer. It’s not just the development moral issue. I think that needs to be made, but this is nothing new. I think we have to think about how you best do that this year. Indonesia has a G20 Chair. Note, this is an opportunity and you have three years with a developing country running the G20. So, it’d be India and Brazil after that. So, both for climate and for health, these are very important G20 opportunities. So, I think thinking about the very carefully is very important.

And the final point, I just want to reiterate that rather than thinking about how to, you know, how to influence others, think also a little bit about how we set up ourselves, or you set up yourselves. I talked about the global governance issues. It’s not only about money, but it’s also how its spent, it’s the effectiveness of the money being spent, whether it’s vaccination or buying vaccines, so it’s a lot of issues there, which need to, also, reform, I think, in the governance part, so that, I think, national governments can be very confident that, you know, the money is spent and effectively being spent elsewhere.

Robert Yates

Now, it’s very interesting that you mentioned the relative roles of the G7 and G20. I was conscious that after the G7 last year, Professor Jeffrey Sachs wrote a scathing piece in Project Syndicate saying, “We don’t need the G7 anymore,” the – I think because of the feelings of disappointment and a lot of people thinking that, just like you’re saying, because the G20 involves more developing countries and big countries, at that, that perhaps that should be more the focus. Would you say that, you know, were it a…

Professor Lars-Hendrik Röller

Well…

Robert Yates

…sort of, a choice between where these efforts should be focused, that…

Professor Lars-Hendrik Röller

Then…

Robert Yates

…G20 might be a better environment than the G7?

Professor Lars-Hendrik Röller

Yeah, I think it – the problem we’re discussing is a G20 problem, but I think the G7 is fundamentally important and that is because it’s about values. It’s democratic values and we had a long discussion in Cornwall precisely on that and I think, of course, one has to be mindful of being inclusive. But I think having that discussion about where, you know, liberal democracies are going and whether they have, I think, Prime Minister called it, “the better brand,” in the world, it’s also vis-à-vis third countries, which are not in the G20, I might add, and we had visiting countries in Cornwall, such as Australia, which is also in the G20, but other countries. I think that’s very important for the G7, but we should not be patronising the rest of the world. We should, in a way, lead, but also leading is a tricky issue because others don’t want to be led, they want to be included in it. But I think the answer is not less G7, the answer is actually more G7.

Robert Yates

Fantastic, thank you. President Halonen, just wondering what your thoughts are on the tactics that we should be employing and what’s more likely to resonate, particularly with Heads of States, Heads of Governments? And you’re very engaged in – at the UN now, so you’ll know what will fly more at the UN level.

President Tarja Halonen

Oh, yeah, and I’m in the Sustainable Development Network by UN and led by Jeffrey Sachs, so I know this. But I would say, once again, that it simply be so that if we take the structure of the economy and societies globally, so we need the private-public relationship, because the market economy is dominating, but also so that it doesn’t work alone. So, private-public is something what you should think, also, when you are thinking that how you raise the funds.

But – so, you came already in this rights – you came to this resilience of the society and especially with the democratic society. I think that this is something what is broader than the Ministers of Finance and the Ministers of Health and that’s why you have defined that what is, kind of, established in the democratic society or broader, in the world, with also its guarantee for the markets that they can work. And so, I would not choose, like you ask, that whether it would be the Ministers of Finance or whether it should be the Heads of the State or Governments. I will say that we need a broader aspect.

And when you ask that how we’ve succeeded in climate change, so I think that that there’s a combination of the public, private and also NGOs and we know that NGOs, how could I say, it’s more sensitive issue in the democratic society, where they are allowed to work, very strongly. They have a strong impact, and I, myself, I have used it sometimes, quite much. But – so, you have to keep this – well, we spoke about this holistic approach, and I don’t think that the poor Ministers of the Health can handle the Ministers of Finance. Very often, the Prime Ministers, how could I say, the back way is always the Minister of Finance and if you have the coalition governments, and like you have in many Western countries and we have, for instance, the coalition government of the five p0litical parties, all leaders are women, by the way, so, it is quite much work demanding system to keep it working. And if you get then, the access, you never know how – what happen, they are needed, but it’s also difficult.

So, I would learn more about the climate change and more about this approach, but then I would make a question, even it’s not allowed. I would say that whether the United Nation knows that whether it’s the headquarters in New York, Geneva, or is it those of the World Health Organization which should be used? And so, again, I heard many, many times, in the Monti Commission, this G20, because Monti is from Italy and Italy just happened to be, at that time, the – they happened to have the Presidency of the G20. And so, I think that you never know that, oh, you know, a little bit about that who is the next Chair and so, I think that we should have more stability in the system what we are working with, and I hope so that United Nations will find some kind of stronger goal, with its own special organisations to work, and don’t forget the NGOs.

Robert Yates

Excellent. Thank you very much, indeed, and one can foresee a big role for the United Nations if this summit goes ahead, you know, to bring all Heads of State together to discuss these issues. Well, fantastic, I’ll now turn it over to the audience. I think we’ve got about 20 minutes, so we should be go – able to get a few questions in. if I can ask audience members to keep your questions very short. I think we’ve lined up three of you to, sort of, come on screen, as it were, so Trudy, Felix and Nina. Trudy, if I can start with you and if you’d like to come on screen, or at least ask your question yourself?

Trudy

Thank you very much. What an extraordinary range of speakers and input. Thank you so much, everybody, for your amazing and enlightening presentations. And my question is, really, in relation to the vertical programmes that we know and what we have, really, is, in British terms, the Aston Martin of healthcare delivery in HIV, TB and malaria. The extraordinary resources have led to extraordinary bespoke delivery mechanisms and excellence and top-class innovation, but as a Pharmacist working around the world, first of all in the NHS, then with NGOs and the UN, what I see is that a lot of healthcare still is on a bicycle. So, we see the Aston Martins, we see the beautiful warehouses, the well trained staff, the extraordinary testing and facilities and then we see the general public who may, indeed, have their communicable disease treated and then die from a non-communicable disease because there’s absolutely no facility for blood testing.

So, looking at what’s been learnt, how can we really benefit from the learning from these vertical programmes and ensure that we can deliver SDG 3 on health and wellbeing and looking at universal health coverage, not detracting from what they’ve learnt, but it – but actually using what they’ve learnt as the basis for doing what we do better? So, my question was, can intentional leakage, from the funding that’s ringfenced for these three communicable diseases, lead to the development of a service which is less of a bicycle and not an Aston Martin? Thank you.

Robert Yates

Great, thanks. So, excellent question, in terms of the efficiency, particularly of, sort of, aid financing and the perils, but maybe the benefits, of vertical programmes, as opposed to health system strengthening. Kelley, can I maybe start with you on that? I mean, I’m sure that’s a topic that you’ve looked at a lot.

Professor Kelley Lee

Yeah, it’s a big problem, of course, it has been longstanding, and this goes back to that point I made, Trudy, about the marketplace of donors that we’ve, you know, we’ve – that has come about, that donors vote with their wallets, in terms of what diseases they think are needing funding and others get left by the wayside. This is not a global public goods approach, because really, it’s not about picking diseases. It’s about core functions or core capacities and so, you know, we need to get thinking about what are those core things, those essential functions that we need to – for a functioning global health system, if we can describe it as that, or you know, getting health systems functioning in low and middle income countries and all countries, really? So, we need to shift from disease focus to these core things, so disease surveillance for all diseases, not just the three that are favourite of donors. R&D and knowledge sharing and bringing together expertise, those are more functional, rather than disease focused. Now, that’s – we do need to shift away from the vertical programmes, definitely. We know that they’re problematic.

Robert Yates

Great, thank you, and would other panellists have views on this knotty subject? You know, sort of, particularly thinking of, sort of, going forward and people talking about reorganising the global architecture, you know, is this an opportunity to move away from the vertical approach and, sort of, have more systemic reforms? Osman, I see that you’ve unmuted, then I’ll come to President Halonen before I…

Dr Osman Dar

Yeah, and it’s – I mean, a lot of this goes back into the history of the World Health Organization and the International Sanitary Conferences and, you know, at that time there was a real colonial era push around specific diseases and so, that’s why even when the IHR were first conceptualised, it was just around four disease: cholera, plague, yellow fever. And really, that’s been a challenge across the – over the decades, do we go with this vertical disease control programme approach, or do we have more horizontal approaches? And you know, there was the meeting at Alma-Ata in the late 70s, which, sort of, emphasised that we should be taking this primary care health systems approach. And the tension has existed, sort of, ever since, because there – because the issue has come down to is this about global health and equitable access and a needs-based approach, or are we securitising the space and is this about donors protecting their own interests and looking at, you know, things that affect their economy or their commer – or commercial interests?

And I think that’s been an enduring issue and what – again, and it comes back to what low and middle income countries need to be doing, ‘cause that’s where the majority of these problems occur. You have to have strong national systems that are able to co-ordinate donors effectively and you have to have these really strong national donor co-ordination platforms, because it becomes an issue of sovereignty. In most low and middle income countries, donors can come and set up shop and do pretty much whatever they want at the provincial level, at the sub-national level, sometimes without even the involvement, or substantial involvement, of the Ministry of Health, or they can engage the private sector and this happens with the Global Fund and these other instruments. So, it’s really important that at the national level, you have a very strong Donor Co-ordination Committee and that things are done through that mechanisms, so that there’s, you know, appropriate resource distribution.

Robert Yates

Fantastic, thanks, Osman, and President Halonen, I think you had, sort of, views on this debate?

President Tarja Halonen

So, I fully agree. I agree very much what was just said, because I think that during the pandemic, when we come with an international organisation, so, when I told about this leaking roof, so I could say that it’s just so I could offer the umbrella for the – why – when you go away, so it’s exactly the same for globally. And so, that’s very much based, at least national, and perhaps some cases it would be also regional, but let’s say a national system and, so, this is a big, big problem, because the systems are very different, even in, for instance, in Europe, even in EU, which is not the Europe. And so, we should see that how, for instance, in Europe, where I saw that how the situation is in EU, how is it in Russia, how it is in [inaudible – 60:11], so on? And, so, this is a tricky problem.

But the second point is also that I think that with the vaccine, we noticed that this private-public combination can be very effective, even though in the history of the vaccine that it helped, also, but anyway, it seemed to be so. And while I on the – this pandemic, sorry to be so cynical, but as long as you have the feeling that you might face it, also, that you don’t see it only in TV, so you might be, also, more interested to try to raise the funds. And I say once again that even, of course, it’s a question of the information possibilities, also, but Europe and the USA has not succeeded so pretty well and not even it – you – your key groups. So, I mean, that in that way, we can also learn from each other and perhaps to avoid this old scheme of the colonialism in that way. But you need both, private and public, and then you need a little bit better organised UN and WH…

Robert Yates

Fantastic.

President Tarja Halonen

Yeah, okay.

Robert Yates

No, thank you very much, indeed. Maybe if I can go to the next question, please, unless it’s a finance related one, I think, maybe we’ll kick off with Hendrik this time round. So, Felix, would you like to pose your question, and I think you’re speaking to us from Nigeria [pause]? Felix, if you are able to unmute and even maybe if we can, sort of, get you on camera. Otherwise, I might have to dig his question out, I think, if you just bear with me. So, just while we try and – I think Felix was one of the first to ask, you see, so – right, so, I’ll ask on his behalf, I think. So, “What is the place or role of development aid for health in producing global public goods,” this is a very hot topic for all, “as opposed to investments that produce public goods whose intellectual property rights are exclusive and subject to the market forces that undermine local production?” So, who would like to start with that? Maybe Hendrik, would you like to start with that?

Professor Lars-Hendrik Röller

Yeah, I think that that is, indeed, a big issue, in terms of how we look at our development aid. This is also a discussion we’ve had in the G7, by the way and there’s a G7 initiative, which goes more into infrastructure investment and which, sort of, looks at how development aid can also contribute to economic development. I think that’s the – and you know, and therefore, not just being straightforward economic aid, but both. And that is also what is behind, if I understand this correctly, between the discussions between the, you know, the World Bank and the IMF. I mean, the IMF has been looking at many countries, which are in trouble, you know, without naming them now, which looking for major programmes and actually, a lot of it has to do with pandemic related issues and also climate related issues. So, in that sense, the economic analysis of the IMF, which has, sort of, been more short-run, looking at five years, if I am not mistaken, and looking at, sort of, hardcore economic issues, and I think this has even been said at the very top of the IMF, is difficult perspective, because if you don’t bring in these other long-term issues into that, it’s very difficult to think of how, sort of, economics and the other issues actually can be separated. And that’s, I think, what is also leading to this discussion that one may have to rethink about who does what and how it is allocated.

I think the German Government has also been looking, also in particular, on our programmes vis-à-vis Africa and looking at our development aid more in terms of private investment, these public-private partnerships, as the President has been talking about, and therefore, you know, that requires, of course, you know, careful rebalancing of our development aid. So, I was a big proponent, while I was in government, of doing that. If more economics and more long-term sustainable economic analysis into the development aid and I think that’s – but I think that’s a big issue to be discussed.

Robert Yates

Hmmm hmm, and do you have views, as well, on the vertical versus more, sort of, systemic financial…

Professor Lars-Hendrik Röller

Not really.

Robert Yates

…vis-à-vis this question?

Professor Lars-Hendrik Röller

Not really. I was listening carefully to the others on that one, yes.

Robert Yates

Thank you. Okay, thanks very much, indeed. So, I don’t know if others have – would like to address that question. I mean, don’t feel that you have to, because then, we can get through more questions. But on these issues around the role of aid financing, anyone else like to pick that up? Otherwise, I’ll go to Nina, who I think has got our next question. Nina, yeah, so, would you like to come on mic? I don’t think you can come on camera, but if you could come on mic.

Nina van der Mark

Yes, thank you very much to all panellists. My name is Nina and I’m with the Centre for Universal Health, I’m a Research Associate. I guess I’ll go with the most upvoted question, I was very enthusiastic. Very short, how do panellists feel about the structuring of global public goods for health? I know we discussed it a little bit, but you know, in the current scope of Germany’s G7 priorities, is this big enough for global health? I’d allude to Rish Lull’s question as well regarding health security on that, as well, and really, where the opportunities lie and through what? Sorry, I’ve a bit of a throat ache. So, is this through a new fund or structure? This has been discussed multiple times, is it through a treaty, is it through the strengthening of WHO or even looking at, sort of, different multilateral agencies, or reform of existing structures and, if so, at which levels? So, how optimistic are speakers about these pathways and how feasible do they consider it? It’s a big question, so feel free to…

Robert Yates

Yes.

Nina van der Mark

…take any of it.

Robert Yates

And a very, very topical one. Thank you very much, indeed, Nina. The – all around the global health architecture and where these funds should best be directed and, you know, we’re already seeing, I think, turf wars starting up here. So, just wondering, Lars-Hendrik, I can see you nodding, and would you like to kick off and then maybe if I could go…

Professor Lars-Hendrik Röller

Oh, I just…

Robert Yates

…to President Halonen.

Professor Lars-Hendrik Röller

Yeah, just very briefly, I think that it’s interesting when you ask about G7 and health, we started putting health on the G7 agenda in 2015. Nobody really wanted it at the time. We were talking about AMR and Ebola and other things at that time, and we were very adamant, the Chancellor was very adamant about having it on there and we kept it, also, on the G20, including our Presidency in 17. And every year, the question was asked, similar to what the question was asked now, “So, what are the topics on health and what does it have to do with economics, as far as the G20 is concerned?” And the answer always was, “The G20 is not about economics, it’s about everything which the leaders are currently interested in.”

So, then, we’ve always picked AMR as a topic, very much supported, also, by the British Government, by the UK Government, all the time, and then, of course, the pandemic came and then, of course, it was the number one topic in the G7 and the G20. I don’t know what Germany’s doing this year and I’m not allowed to talk about that. You should ask them. My successors are working on this hard, but I think these – this treaty issue, which has been pushed very hard by the EU, the architecture – Germany has been a big supporter of the WHO, as you know, and I’m pretty sure that the new German Government will do that, as well. But I don’t know exactly what they’re planning, except for they’ve just published, I think they’ve just published their statement and I think it’ll be smack in the middle of the German G7 Presidency.

Robert Yates

Great, and congratulations, though, for Germany for putting health on the G7 agenda, where it must’ve been extreme…

Professor Lars-Hendrik Röller

It was hard. It was very hard, by the way.

Robert Yates

We’re very grate – I’m intrigued as to the pushback that you’ve got, and one wonders what arguments that you were getting as to, “Oh no, that’s not important, we don’t want to discuss that.” But anyway, perhaps that’s for a separate conversation. President Halonen, what are your thoughts about the…

President Tarja Halonen

Oh.

Robert Yates

…impending discussions about the architecture?

President Tarja Halonen

I feel that I had to answer something, but I’m once again repeating, that Finland and all the other Nordic countries, we are not the members of the – of these G groups and that’s why I am prepared to say, even afterwards, that I said, also, at the Monti, sometimes, that “Try to remember at least the EU and the UN, because they are very interested both in G20 and G7.” But I say that you have the resources. You have a lot of resources, not only in economic, but also in other way, all human resources. That’s why, of course, if you do something, it has – it can have, also, very positive consequences to the others.

But I will take another point of view. I will say that let’s be positive that what has happened, so that the political will and sustained financial support to these global health challenges. So, some steps have already been taken. A lot of discussions are ongoing and pandemic treaty negotiations have started. Of course, we need more to do, but I mean that there is also now some basement on this side and then, of course, this is just concerning the pandemic, which so many times, have been repeated that it’s not what we mean normally, the common goods, more generally. But still, I mean, that if we see that in this situation and that we lost for the while, still, so perhaps they could state a little bit broader and I would repeat what it has been already with the other panellists, they said that so-called silent pandemics are all the time, going unequally underrun. That fact that even we can beat this pandemic, so will come from the health, it can come from the next time from other corners and let’s be also lucky and happy that in this time, the pandemic was just a pandemic and nobody tried to make terrorist attacks concerning the infrastructure, the global society, for instance. So, uncertainty is something in the future, but we can be sure that – and give the certain thing that’s how to do and this is – I think that more ways to see that all people should really treated somehow equally. I’m not romantic, but anyway, because this has shown us that as long as not everybody is safe, nobody is safe.

Robert Yates

Exactly, exactly. Kelley, have you got any thoughts on this, you know, thinking about the architecture?

Professor Kelley Lee

Yes, I mean, Nina listed a long list of things. It’s – if we think of global health as a house, as President Halonen said, you know, the house is really needing a lot of repairs, not just the roof. So, there’s a lot of work to be done, but I don’t think the global health, the – sorry, the global public goods concept’s going to cover them all, so we have to be using this quite strategically as a concept, because we can’t justify everything under this concept. It loses its weight, in a way. But I would say that going – just focusing on WHO, that is a huge first step. So, we can think of WHO almost as a global health public good in itself, by what it does, what functions it serves. So, if we take the analogy at the national level, you know, governments don’t hold replenishment conferences every year to fund national defence, or lighthouses or health services. They don’t ask for donations to fund fire services, so why are we doing this at the global level? Assessed contributions are essentially a requirement, a levy, for all countries to pay into and yet, we’re relying on funding WHO with these voluntary contributions.

So, we’ve got it – we’ve got to flip that around and recognise that we have to fund global public goods in an – with core funding, not with these development aid or donations and replenishments. And I say again, you know, we come back to this issue of taxation and I’m not saying – you know, people are pretty – you know, nobody likes to pay taxes, of course, and everybody’s, you know, feeling, you know, after the pandemic, pretty low, in terms of available resources. I would say who benefits from a global system that functions properly, and tax those transactions? Not individual people, ‘cause every time we actually ask for donations, we’re actually imposing a form of tax on individual citizens. What I’m thinking of is this whole debate around international tax reform, large companies who are dependent on operating within a healthy and safe and secure global system, those companies have actually paid far less. They’re freeriding on global public goods. And so, those are where I would start and thinking really pushing that agenda further and that way, you could address a lot of the things that Nina described.

Robert Yates

Fantastic, thank you. Yeah, very good to extend the public-private partnerships debate to around issues of corporate taxation and really is raising good, sort of, corporate taxation to pay for the likes of the World Health Organization. I’m delighted to hear you, you know, refer to, you know, WHO itself being, you know, perhaps one of our most effective global public health goods that desperately needs funding properly.

Now, if the panel will allow me, I would just like to ask one more – let Elen very, very quickly ask her question. I know we’re going slightly over here, but it is the most upvoted question, so I’d feel terrible if she didn’t get a chance to ask. So, Elen, if you can keep your question very quick and might only get very short answers, but Elen, if you’d like to come on.

Elen Høeg

Well, thank you very much for the opportunity. I’ve been listening with great interest. So, I’m Policy Director in CEPI and obviously, you know, my focus is on R&D. So, the question to the panel is, really, now that we’ve demonstrated the pivotal role of R&D in preparedness and response, how can we make sure that R&D is appropriately leveraged within future financing mechanisms, that being the new proposed ones or revised IFIs and so forth, both for the preparedness activities, but also for the very necessary surge response funding, such as for manufacturing? Thank you.

Robert Yates

Excellent question and very, very topical, of course, with the CEPI replenishment subject just round the corner. So, thoughts around funding of R&D, who would like to kick off with that [pause]? Osman, have you got any thoughts on that? We haven’t heard from you for a while.

Dr Osman Dar

Yeah, I do. I mean, I think one of the things that CEPI can perhaps look very closely at how they set up the IP related agreements with groups or companies that they start to fund. I feel that with a lot of – whether it’s CEPI of other funding initiatives, that the agreements have been lopsided in the past and the companies are able to retain a lot of the control over how those drugs, or products, are then priced, subsequently, in low and middle income countries. So, I think there’s a real amount of focus that needs to be put on that aspect of it.

The other thing that I would say is that rather than funding or focusing so much on funding new products that are there, there are a lot of existing products that are effective, but the local markets are not sustainable. The local manufacturing process, the ecosystem required for it to not just – to manufacture it to a good quality and standard and then sustain it within that local-regional market isn’t – the ecosystem requirements for that aren’t well established and I think a lot of investment can be put into that and perhaps that’s where the focus should now be, because it’s not so much an issue of bringing new products to market. It’s an issue of making sure that once that’s developed, that it can be equitably distributed, and I think that’s really where the focus needs to be.

Robert Yates

Super, thank you, and President Halonen?

President Tarja Halonen

I’m, again, perhaps too talkative. That’s my basic sin. But anyway, I think that concerning, also, the vaccine, that has been shown that we could develop very quickly, of course, because that was the part of the old tradition, SARS system and that’s why, of course, it succeeded. But anyway, we succeeded so quickly, I mean, we with the international community, that some people are even hesitant with that at whether the vaccine can be good, because it tested oh so quickly. But now, when – because we know, so, this system where we are also within that, we could also to give solidarity – show the solidarity for the countries and give the vaccine, even those, at least, which we have, how could I say, let what we have over, over both.

And so, it seemed to be so that what is this kind of system, how to deliver it? It’s really problematic, and then, of course, one thing what sometimes is with such kind of persons like me, who have worked a long time with the develop a COVAX, but is that it’s not so that everything in the North is bad and everything in the South is fine. I mean that you find that difficult and not so good and fair systems everywhere and that’s why we should, again and again, come to that, the basics of the house has to be solid. But why we are doing that, it’s also time to work with these resources we have today, because we cannot wait, like in the old religious, that one day we have the paradise. We can work now so that the situations would be better and people will start believing more that we can make and reform, because that’s also one way of the success that you feel that people are with the – you and onboard and that they might take a next step.

That’s all, but I do hope so that the Chatham House will continue with this item and, also, will use a different kind of the speakers, not only that the – we, quite experienced, but also some perhaps the new health activists, so that how they see the situation and then, it’s not become easier, but it can come, perhaps, more realistic. Thank you very much for the panel.

Robert Yates

And thank you very much, indeed. Henrik, would you just like to make a last comment, maybe, and then I’ll wrap up?

Professor Lars-Hendrik Röller

Yeah, well, I won’t be very long, but I think this is obviously to the question by Elen, I think that the replenishment conference has to be a success in March, and I think this would be important and presumably, everybody’s working on this, but I think that’s the point number one. And point number two, I think on the R&D, I think there are three aspects to it. One is the funding of the R&D, that is very much a public-private issue and how to share the potential, you know, gains, as was just mentioned. So, there you’re into these IP issues and we’ve been having these difficult discussions around waiver, which you know, we were discussing with South Africa. You know, the – at least the Chancellor’s position, I think that is important, that we calibrate this right. That, sort of, the incentives are there for the firms to do the investment, but at the same time, that the returns are justified.

And I think then, there was also a question just now on the chat as “Where is the R&D actually taking place?” Somebody from Africa was asking, you know, “Can the R&D actually be taking place in Africa?” So, that’s another question. I think, right now, this is mostly done in the G7 countries, probably, the R&D, if I’m not mistaken. And the final one is then the production and then you get into these vaccine production, localised productions, which we were working on in this Working Group for COVAX, where we are creating a hub now in South Africa. Because those countries rightfully say, “We don’t believe next time you’re not going to close your borders and we are going to be last in line to get potential medicines and vaccines and tests,” it’s all those three areas, and therefore, the production side is also very important.

So, I think all of that are cordial issues, which need to be resolved. Thank you.

Robert Yates

Thank you, and unfortunately, we – I’m sure we could talk all afternoon to try to resolve them, but this is, you know, the start of a process and I would very much like to thank our fantastic panellists and our audience, as well. I think this is a record number of questions I’ve had in a session like this. I do apologise we weren’t able to get to everyone, but at least I think we asked some of the more popular questions.

And just to refer to a point that President Halonen said, we are definitely continuing this work and research. This is part of a project that we’re undertaking to look at this chronic underinvestment in global public health goods and see what can be changed for the future. So, we’re going to be looking at the experiences of HIV and AMR and of the pandemic to date and recognise that so many of these issues are going to be coming up at the G7, G20, United Nations, WTO and what we’ve learnt today we’ll feed into that process. So, extremely grateful for you all for such a wonderful discussion and as I say, this is just the beginning of the journey. So, thanks very much, indeed, for joining us. Bye now.

Professor Lars-Hendrik Röller

Thanks, bye.