The geopolitics of global health funding

Creon Butler

Well, hello, everyone. My name is Creon Butler, and I’m the Director of the Global Economy and Finance Programme at Chatham House, and it’s my really great pleasure to welcome you all to this Chatham House discussion on The Geopolitics of Global Health Funding, and this is being organised jointly by Chatham House’s Global Economy and Finance Programme and the Global Health Programme.

As we approach the German G7 Leaders’ Summit at the end of this week, this is really, without question, a highly topical issue. On the one hand, the COVID-19 pandemic has very clearly demonstrated the enormous global costs of failing to invest adequately in measures to prevent and control pandemics, as well as other international health measures. And this provides extremely strong justification for coming up with the necessary funding, not just on humanitarian grounds, but also on economic grounds.

But so far, the international community has not managed to muster the commitments necessary, either for the immediate needs of tackling the pandemic, or for the long-term issues. And I just checked the ACT-A tracker, and I think at the moment we have 22% of the current funding need on the Access to COVID Tools Accelerator, the key vehicle for funding action on the pandemic, has been met, and the biggest shortfall is currently in the diagnostics area.

Now, at the same time, the global economic situation is worsening. We have the war in Ukraine, and the impending threat of climate change, and there are clearly other very high priorities that Finance Ministries and leaders have to grapple with, and there’s also the vexed question of appropriate burden sharing; how far should the G7 carry the burden on its own? They have, I think, it’s almost 76%, something of that kind, of the ACT-A funding has so far come from the advanced economies. How far should this be spread more widely, including to a number of the emerging economies?

And in the latter case, if it is to be moved forward to a G20 discussion, the G20 faces enormous challenges because of the war in Ukraine, you know, how can we address that? So, to address this and many other questions, I’m joined by a really excellent panel, and first to make their attri – introductory comments will be Amanda Glassman. Amanda is the Executive Vice-President and Senior Fellow at the Center for Global Development. She also serves as the CEO of the Center for Global Development in Europe. She’s a world-leading expert on international health financing, and prior to her current job, worked in various expert roles in the IADB, Brookings and USAID.

And following her will be two of my colleagues from Chatham House. First, Stephen Pickford, who is a Senior Consulting Fellow in the Global Economy and Finance Programme at Chatham House. And Steve has a long and distinguished career in HM Treasury, working on economic policy issues for most of the time, and his last post was as Managing Director for International Finance, which also involved being the UK’s G7 and G20 Finance Deputy.

And third, but by no means least, is Emma Ross, who is a Senior Research Fellow in Chatham House’s Global Health Programme. Emme has worked on, and written, I must say, extremely lucidly about an enormous range of global health issues and, prior to Chatham House, she worked at the WHO and the Associated Press.

So, I will shortly hand over to our three speakers for their initial comments, but first, just a few quick housekeeping points. This panel is on the record, and we will be making a recording of it for subsequent use. After the initial comments from the panellists, we’ll have a discussion among the four of us, and then there will be an opportunity for the audience to put questions, so, please start entering your questions in the Q&A function as and when you wish. Please also try and keep them as short and to the point as possible, and that will enable us to get as many in as we can.

And then I would also like very much to thank the Bill and Melinda Gates Foundation for their support, not just for this event, but for the wider project under which it comes in Chatham House, on the Political Economy and Global Health Financing.

So, great; over to you, Amanda, for your initial comments.

Amanda Glassman

Many thanks for inviting me to join you this morning. My goal with my initial comments is just to, sort of, give a scene-setter, so that we can have a great discussion later. I would echo Creon’s points that it’s been a very difficult three years, and that the contrasting approaches between what high-income countries did to respond to the economic and social health shock of COVID is very different from what was able – what low and middle-income countries were able to do, given their very constrained fiscal space, but also, an international response that, while it has been vigorous, has really not been larger than what was the response to the financial crisis earlier.

It’s been slow, it’s been inadequate, there has of course been the slow access to COVID-19 vaccines and treatment, and a failure to act on the problem of growing and unsustainable public debt, and from creditors different from the ones last time we had a debt crisis. These are non-Paris-Club debtors and a lot of talk, always an enormous amount of talk and very little decisive action, or slow action.

When we look at the health side in countries themselves, you know, public spending on health and social protection, with the support of some of the multilateral development banks, did increase very dramatically during the pandemic. The median increase, a colleague of mine, Sanjeev Gupta, has calculated, was about 16%, which is truly unprecedented. Most countries motor along, increasing their public spend on health at about the same rate as economic growth, or much – or lower, but unfortunately, you know, given this extraordinary boom in spending, the uses and effectiveness of that spending are not well known or well documented. And it’s true that the levels are really unlikely to be sustained, and worse still, COVID has critically scarred the future productivity of these countries and their workforces, which affects revenues again in the medium-term. So, the bottom line is that there’s really limited fiscal space to deploy in the wake of our current crisis, on top of the existing crises, which are the fuel, food and fertiliser price increases.

I think, you know, we’re all impressed by the incredible response to the needs of Ukraine, but the huge and rapid response to Ukraine just puts the response of the international community to the rest of the world in really stark juxtaposition. No-one begrudges or thinks it’s a bad idea to provide enormous financing to support Ukraine, but the question is, ability to do that on short notice undermines some of the arguments that the traditional high-income country donors have been making to low and middle-income country policymakers, saying, “Oh, our budgetary constraints are very binding, this isn’t prudal finance – prudent financial management, etc.”

Instead, we, you know we just see this huge contrast. If we look at COVAX and ACT-A, as you mentioned, Creon, limping along in fundraising despite, you know, huge numbers of disease and, you know, illness and death, two years to reach ten billion that was requested in March 2020, the gaps persist. We have the humanitarian catastrophes and food shortages in Afghanistan, in Yemen, in the heart of Africa and Sahel. These go unfunded, just, you know, they have shortfalls of a couple of billion dollars, you know, and yet we’re able to mobilise billions and billions to Ukraine so quickly.

And despite the very many international commissions calling for at least ten billion a year to prepare for emerging pandemic threats like COVID-19, two international summits and a year-long G20 process has led to only one billion in commitments for pandemic preparedness, even while a new infectious disease, monkeypox, spreads unchecked and vaccines are again hoarded in the high-income countries.

So, we obviously need a new approach, and everyone’s said we need a new approach. There’s enormous and obvious moral and economic arguments for dealing with what really is the worst health, humanitarian and economic crisis that has faced low and middle-income countries in three generations. But, that said, there’s also the self-interest of high-income countries themselves. Neither the next pandemic nor climate change can be dealt with without the co-operation of low and middle-income countries.

So, I think the question is, well, how to change the architecture of development, but also of global health, to recognise first that, you know, there’s this lack of trust and many countries had to do it themselves. If we look at the African Union’s effort with AVAT while they were waiting for vaccines to be donated and financed by COVAX, you know, and how well is the global health architecture taking into account these big changes? And then, you know, the multilateral development banks, I think, are a very interesting space to talk about this. You know, do they have a mandate that goes beyond just development, and development priorities of individual countries in the near-term, but also these global public goods like climate change, like pandemic preparedness, like response to infectious diseases?

I think none of us think that the G7 will have a huge and coherent public global health response, despite the fact that there are multiple asks on the table, and both Germany and the United States, as leaders of the group, have put forward very significant contributions to ACT-A, to, at least rhetorically, to pandemic preparedness, and certainly to the Global Fund replenishment that’s happening later this year.

But anyway, we can talk about that; G7 versus G20 and what it all means. I think on the domestic side, the question is, you know, given that there are these constraints, there really will be a need to protect essential spending, to look for efficiencies, to consider reallocation, and in that, how these external sources of aid work together with domestic monies to create more health. Maybe we’ll be facing a new era of reform, but I’ll look forward to discussing that with all of you. Thanks.

Creon Butler

Amanda, thanks very much, it sets the scene extremely well, and as you – one of the things you’ve really highlighted; there are an enormous range of players in this picture. There’s Health Ministries, Development Ministries, leaders, but also, crucially, Finance Ministries, and to some extent, they sit right at the heart of many of these decisions, albeit at, sort of, a higher level in some respects, in terms of the level of detail they get into.

So, it’s a good point to move onto Steve. You know, this is – this – there are enormous challenges facing Finance Ministries in choosing between them all, or making choices between these different priorities. How do you see the present situation and economic situation and that challenge?

Stephen Pickford

Well, thanks, Creon, thanks very much for the invitation. As Amanda said, the last few years have been extremely challenging, and with first of all COVID, the pandemic, which basic – which saw a fall in output in advanced economies in 2020 of nearly 5%. That’s an enormous loss of output, and the consequences that go with that for the public finances have been equally difficult.

Central – general government debt rose from about 100% of GDP to 120% of GDP in one year. Ukraine, the war in Ukraine has just made matters worse again. Growth prospects in – worldwide have worsened markedly. Just to give you a few statistics, in January, before the invasion, the IMF were forecasting that between 21 – between 2021 and 2022 world growth would be 1.5% lower, one year as against the next. By April that gap had increased to 2.5%. It’s anybody’s guess what the gap would be now, for anybody forecasting these things, but I’m, you know, for sure it will be worse than people were expecting then.

The mirror image is that inflation is rising rapidly. Some central banks are predicting double-digit inflation, on, primarily on the back of fuel and food price increases. But there are wider inflationary pressures rising and as a result, central banks are now raising their rates further and faster than they’ve previously done.

As a result, you’re seeing, in many advanced economies, what is generally regarded as a cost of living crisis. This is exacerbated by rising interest rates, by fuel and food prices going up. Put all that together and the fiscal positions that Finance Ministries crucially pay attention to are even more stretched. You’ve got the rise in inflation, which is going to be – which is going to have a growth effect. You’ve got rising debt service costs, you’ve got a lot of political pressures to respond to this cost of living crisis, pressure on living standards. We’re seeing that in many advanced economies now, with countries using different techniques, but essentially, they’re trying to offset some of the impact on the impact of living – on living standards that had been seen.

Add in the mounting costs of Ukraine, that support for Ukraine, and that adds – that gives you a very substantial fiscal hit. As you said, the bread and butter of Finance Ministries, and particularity Finance Ministers, is to try to juggle between competing priorities for fiscal resources. At the very – at the most basic, it’s about what should the fiscal stance be? I.e., should – how much should the country borrow? And borrowing is obviously simply a way of putting off the cost unto – onto future generations.

Once you’ve decided the overall fiscal stance, you have then a choice between cutting taxes or spending more money, and if you go ahead and increase public spending, what do you spend it on? Do you spend it on roads, airports, health, education, do you spend it domestically or internationally? So, this is the background against which we’re seeing these increased demands for spending. How does the Finance Ministry approach it? Well, typically, they would use reasonably sophisticated analytical techniques to try to calculate differential rates of return on different types of spending, and this is an absolutely routine way of approaching matters.

The problem is, of course, that what looks like an elegant technical system invo – almost always involves huge assumptions and huge uncertainties, and the demands for public health initiatives are equally uncertain. Take an example, if you’re saying, as – absolutely rightly, that it is – that the pandemic shows the importance of taking early action to head off future crises, the Finance Ministry will typically say, “Well, how probable is it that the health crisis will materialise, when will it materialise, what will be the impact and the severity of the crisis, and if we take preventive measures now, will they work?”

All of these are very valid questions. There are uncertainties throughout all of those and the essen – my – one of my – the lessons I draw from this is that you have to go through those technical assessments, in order to demonstrate the economic case. In many cases, the global health initiatives do have very strong economic cases, but it is important to recognise the uncertainties.

But the technical analysis on its own is, while it’s essential, is not going to – is not enough. All of these decisions ultimately are political. The – and the reality is that when you’re facing important priorities such as Ukraine, such as cost of living crisis, there – you have to make your case even more strongly if your priorities are elsewhere. The reality, I think, is that the – that Ukraine, to come back to the initial question, Ukraine crisis has made it that much more difficult to make the case for things like global health priorities, and that re – it has some lessons as to what we might do to try and cut through that.

Creon Butler

Great stuff. Steve, thanks very much. Yeah, I mean, it – that really gives a, kind of, insight as to how one thinks it through. There is – well, there are many questions we could come back to, but I mean, one of them is, I mean, Amanda flagged the issue of, “Well, if you can come up with so much money so quickly for Ukraine, why not for something so important as global health?” And then you get into the question of, well, you know, what is different about an attack on the global system of governance versus, you know, a massive threat that can cause a global drop of 5% in GDP? You know, this is – these are really difficult questions, but we’ll come back to that, perhaps briefly, perhaps later on.

Now, next, my colleague, Emma, over to you. So, we’ve been doing a bit of thinking about some of these questions. You may want to say a little bit about that, or other perspectives on this broader challenge. Over to you, Emma.

Emma Ross

Yeah, thank you, Creon. Yes, as both Amanda and Stephen have said, it is tough competition out there, for global health, and what it’s facing, and what Stephen was saying about the finance, what – how Finance Ministers think about being able to make the case and answer a lot of those questions he’s talking about, when we’re talking about what you might call global public goods that are, you know, that really demand international funding and political commitment on an international stage to get behind, a lot of those questions are not really answerable in a very comprehensive manner.

So, it’s hard to be optimistic about being able to be success – you know, if that’s the standard, to make the case, it’s really hard to be optimistic, and I think we’ve seen through our work, and everyone who’s worked in global health has seen what a struggle it is. Even during the pandemic there’s been a big hope that, you know, we’ve had this pandemic, see, you know, this is what we’ve been warning against, and if not now, you know, what more proof do you need that this can be so destructive that you need in invest in making sure this doesn’t happen again, or that we can respond. If this doesn’t push you, what will?

And, you know, there was some optimism that, you know, this is going to be the moment maybe, but I don’t think we’ve really seen it in the way the global health community would really like to have. And, yes, Creon, as you say, we have been doing a bit of thinking about this, as to why, time and time again, even, you know, it’s obviously – it’s well known that it’s not enough to make the moral case or everyone has a right to health or a right to access. That rights argument doesn’t tend to work. Economic arguments; I think they have been made, but maybe not good enough, and as my fellow panellists have said, it comes down to politics and competition.

But what we have done, in the little work we’ve started on this is, that a lot of it has to do with the global health communities, the way they’re approaching it and what they’re asking for; what they’re asking for and how they’re asking for it. So, the first thing is the ask. You know, it really – a lot of times there is creep. It gets bigger and bigger, it’s very elastic, but before you turn around, this part of the global health community thinks, you know, a) it’s a global public good, that should be financed. Then, before you know it, you’ve ended up with the kitchen sink, and that’s the ask.

And, to be honest, what we’re finding is there really needs to be a lot more discipline around this, and just like Politicians prioritise and everyone else prioritises, that really the global health community has not been great at prioritising what they’re asking for. You can’t ask for everything, you can’t expect the international community to pay for everything and, as Amanda said, there are issues around what is appropriate for domestic financing to cover and what’s appropriate? When does the international community, really do need to step in? And I think it’s going to be interesting to see this. The UN Secretary-General’s got this advisory group that’s charged with coming up with what are truly the global goods that we need to focus on? How – what are we going to prioritise? And they’ve yet to come back and say what that is, and I think global health issues will be in that, but it’ll be interesting to see.

And along with that is this whole discussion of domestic versus international, and also the role of middle-income countries. On the one hand, there’s been talk for a long time in global health that some of the middle-income countries that are benefiting from multilateral funding, maybe it’s time they graduated, they could graduate, but, you know, who’s pushing them to, and are there mechanisms and incentives for them to, you know, fend for themselves a bit more?

And even more than that, they – some of them are in a position to contribute and be donors, and maybe that’s why we’re seeing at the G7 them not willing to take on the burden of this whole thing. Maybe – I don’t know, Creon, what you’re hearing about whether the G7 intends to go as a bloc to the G20 to prod some of those G20 countries that do have the capacity to contribute, or at least take care of themselves, what’s going to playout there in Indonesia at the G20 to really put them on the spot to step up a bit more?

And I think, going back to the answer, it really does have to be disciplined and prioritised. We’re talking about, you know, is surveillance, you know, services, is it just products, what exactly is it, and how much are you asking for? Another one of our findings, actually, is that this whole model of the way global health goes around, replenishment cycles for things, and that normally covers things that are global public goods or, you know, priorities for the international community.

The stress and the panic and the work that’s involved and the politics, I mean, it’s all politics at the end, but this whole idea of funding – underwriting this by replenishment cycle, you know, is that really sensible, is that the way forward? I mean, other things that are public goods: fire services, Doctors, do you then decide, oh, well, we’re going to replenish, go for a replenishment round to see if we can fund our police force? I mean, we don’t do that, so why are we doing it for this? That, you know, that view is shared by many Analysts in the global health community.

And you could argue actually that over a longer-term, maybe decades, global health has not actually done that badly in scraping money out of the international community. Okay, now, not so good, but if you go back to, you know, the heyday of the turn of the millennium with the establishment of the Global Fund, all the money that was poured into HIV, that was a very different – and I think some of the expectations that the international community should step up now are based on that memory. But we are in a very different world now, we haven’t got – it hasn’t got the political clout or the urgency. There’s something that’s not there that was there before, and you just have to look at what’s happening with antimicrobial resistance and the efforts to get the commitment on that. It’s just dragging, it’s just not happening, it’s a different environment, different priorities.

So, I think, bottom line, what we’re finding is there’s a real need in the global health community to be sensitive to the political realities, and take account of governance issues, and confidence not only in the international financing systems, but in the global health architecture itself, of confidence of giving that money, of how is it going to be managed, where is it going to be spent, is it sensible? So…

Creon Butler

Emma, that’s really great, thank you very much. So, we’ve got an enormous range of issues there. One thing that came out of this was, you know, I think where Amanda started, you know, the ask to prevent something like COVID happening again, ten to 15 billion a year, this is really small, even for a single country like the UK this is peanuts for – you know, well, not quite peanuts, but anyway, it’s a small amount for a Finance Ministry, when thinking about it, and yet the entire global community, I think, Amanda, you were saying, has only so far come up with a commitment of one billion. This is – so, one of the ques – you know, a question I have is, if we dig into that, the reason for it, is it, you know, in Steve’s terms, that, you know, the analysis that treasuries expect to see isn’t there yet? Is it that they are, kind of, bemused by the uncertainty, not bemused but, sort of, blocked by the uncertainty and so, in those circumstances, well, you do all kind of things under uncertainty, why not this thing? Is it this G7 versus G20, you know, that they say, well, we’re putting – we’ve put nearly 80% into ACT-A so far, this is more the immediate response, we’re not going to come up with more money for the global picture until we see that China and others, you know, are going to play a part?

I mean, I just – and then, you know, there’s a recognition, as Aman – as all of you have said, that it’s not working and we need reform, but we can’t seem to make much progress. So, could you – if you could come to that specific PBR question, what do you think the blockage is, and if we had no other concern in mind, that is the one thing we want to do, where would we start? So, Amanda, maybe I could come back to you on that point, and it may link to some of your views on, you know, the new World Bank funding and so on.

Amanda Glassman

Yeah, thanks. And, well, I mean, first, the other thing to reflect on, you know, when we look at – we don’t have 2021 data yet, but in 2020, IHME estimates that 15 billion was added on to global health aid during the COVID-19 crisis, and it was all COVID-19, and we know what it was for; it was buying vaccine basically. But if we put all the replenishment asks together, plus the pandemic fund, so, really the set of asks that are being put forward the to G7, that comes to just an additional 13 billion. So, really, if the global community could sustain its COVID-19 level, we’d be fine, at least, you know, assuming that all the requests are complementary and synergistic and make sense.

So, you know, the question really is how Ministries of Finance think about the future? Do they think it’s going to ratchet back down, or do they think, “We have to sustain this level of effort, given the catastrophic nature of what has happened, the excess mortality, etc., and the need to prepare for the next time?” So, I guess, you know, maybe our ask as a global health community would be to sustain the 2020 level of global health aid, and in doing so, we would, sort of, meet all of the articulated needs that are out there so far, including preparedness.

On the question of the political economy of contributions to preparedness financing, I think, you know, one thing is that we’re still early in this process of setting up the fund, and determining its uses, so, there are certainly some countries that are wait-and-see. But, on the other hand, I think there is a lot of agreement on the kinds of things that need to be financed. No-one disputes that there should be better disease surveillance and rapid control of outbreaks when they’re detected. There’s – at least 75% of people would agree, that’s my not-scientific poll, that, you know, we probably need distributed manufacturing of medical countermeasures.

So, you know, those two things on their own seem to have a lot of impulse, and I think the question is, well, do countries want to finance that bilaterally, or would they finance via this multilateral channel? I think there are good reasons to finance via the multilateral channel, connecting to the multilateral development banks, you know, one of which is that they can take donations through, you know, funds like the IN, which is their concessional lending window. Donor governments donate, and then the bank takes that money and raises more money on the market, and is able to pass on on-lend in very concessional ways to low and middle-income countries. That seems to me a really important mechanism, and the idea of this fund, if it can blend its money with the MDBs, not just the World Bank, but the regional development banks, I think that’s a really good way of, sort of, making the most of limited donation monies, and I hope that donors will see that.

And, I mean, we should also think about, is that a path forward for the Global Fund to fight AIDS, TB and malaria as well, just given these are basic public health expenditures, there are lots of synergies with other areas of the health system, we, you know, we don’t want it off-budget, you know, that’s not the way to finance human resources, or things like that they know are needed. So, I think, you know, I hope that the government – you know, some of the G20 governments come to the table in that sense, and, you know, I’ll stop there, but there’s plenty to be said.

Creon Butler

If I could just ask you about that choice between, if you like, what countries should be financing domestically in the – in this health space, and that includes, if you’re talking about, sort of, really poor countries, doing so with support from aid or MDBs, or whatever, so – but it comes from, you know, it’s via their budget. And what should be done through, you know, vertical funds, big global facilities, particularly where it relates to something that works – that is critical to everybody, like, you know, preventing a future pandemic? What is your view about where the dividing line should come between those two approaches?

Amanda Glassman

Well, I definitely think that Emma raised some of these issues in her intervention as well and, you know, I think certainly research and development for medical countermeasures is something that’s a global public good, it needs to be financed, you know, it’s – it wouldn’t necessarily be financed very easily by any low and middle-income country, responding to the disease burden in their own countries. So, I think there’s a role obviously for domestic finance in that space, but there’s definitely a lot of value added that could be brought to the table from global sources.

You know, I think the question of – about the global procurement mechanisms is important. You know, the – they were created in the – when was it, 20 – in the – I can’t remember the year, 2000s, it seems like it should have been longer ago. But, you know, they were created when high prices of new and under-utilised vaccines, for example, or antiretrovirals, those prices were not obtainable by developing countries buying by themselves on the market. And, yeah, things have changed, ARV prices are down now. Any country can afford to buy antiretrovirals, first-line at least, so, the question is, well, you know, when is it that these global procurement mechanisms are best utilised? And I think it’s probably for new, highly cost-effective technologies, it’s probably for things that are not – you know, that wouldn’t be cost-effective, covered under a domestic budget, but would be right over the line, and we’d like to maximise health, so, things maybe like HPV vaccine, MDB – MDB – MDR TB treatment, for example, is very expensive.

But then we have to think about, well, what are the incentives that we’re creating if we finance these expensive things, that are, kind of, the last resort stuff, while governments, you know, may not, you know, invest in primary prevention in the way that they should? So, I think that these are all open questions that require a lot of consideration.

Creon Butler

Yeah, great, thanks very much. Steve, you talked earlier about, you know, that for any spending priority, the kind of basic requirements are analysis, information, and the issue of uncertainty. Now, you know, if I was to come to you and say, “Look, how can we cut through all of that to get support for, you know, a G7 Finance Ministry to fund a decent share of this, you know, the long-term preventive measures,” you know, is – well, what – you don’t know, but what is your guess as to what is the blockage at the moment, in an unnamed G7 country, let’s say?

Stephen Pickford

Well, my guess is that you’re starting from a position of a known short-term set of problems, which require financing, you know. You look at what goes on in Westminster; there is huge pressure to do something about the cost of living prices, do something about petrol prices, do something about cases to GPs. All of these are very immediate and very upfront political pressures, and the problem is that the temptation is always to respond to the people who are shouting loudest at the particular time.

I was struck by what Emma and Amanda were saying about, “Why don’t we, you know, why don’t we just set the level of support, you know, why shouldn’t global health funding be the same as, you know, on the same basis as funding the fire service or the police service?” And I think part of the problem is coming back to, there is a rather unco-ordinated set of asks, and every ask seems to be on top of one another.

A Finance Ministry will find it very difficult to, sort of, take this, the next ask and say, “Well, how is it – how does it relate to what you were last asking for?” The – I mean, the reality is that the UK became quite successful, and it’s now no longer so successful, on international development assistance, ‘cause it, kind of, just said, “There’s a baseload issue here, we’ll put in 0.7% of GNI, and we will decide every year what’s the best way of spending it, but we’re going to commit to that.” And that ultimately is, I would have thought, a more productive way forward, in terms of the global health ask. The problem then is thrown back onto people who are saying, “Well, you know, this one priority is – within global health is much more important than other priorities,” but it does force people to confront what the Finance Minister will be confronted with, which is, “How do I distinguish between these priorities?”

Creon Butler

Yeah, in a way, this is – this goes down the, sort of, assessment route essentially, to say, put a much bigger figure, but one figure, and Finance Ministers commit to that figure. There’s then a bunfight within the global health community to figure out, you know, how we’re going to spend that. The question, when you have something like COVID, do you need a, sort of, a special clause to say, “Okay?” But, yeah, that is certainly one approach.

So, we’ve got some great questions coming in, and what I want to do in our next 20 minutes is to try and get through as many as we can. And, Emma, you’ve spotted one that you want to come back to straightaway, I think, from [inaudible – 40:47], if that’s the correct pronunciation, on the, sort of, definition of global public goods. Do you want to kick off with responding to that, and then we’ll take as many of the questions as we can?

Emma Ross

Sure, so, this was a question about “which criteria could exclude an item from the list of global public goods?” You know, part of the issue here is that there is no agreed definition of what is a global public good, what is a good, but I think there are some things that, you know, the point is to zero in on what can be agreed, and that’s why there is a UN Secretary-General’s advisory group on this, because it’s – the answer is not obvious.

But I think for our purposes, I mean, I think what could be included, let alone, say, “Anything that’s not this may be excluded,” is health priorities that benefit everyone, in all countries, and that will be undersupplied if left to individual countries, or to the market, and therefore require collective action to produce it and to deliver it. So, if it’s something that can be done by an individual country or the market takes care of it, then I guess it’s not a global public good. It’s really similar to things that are neglected by normal business as usual. That there needs to be, on an international level, a stepping-in, so, I don’t know if that’s a helpful thing, or if – Amanda’s nodding her head – if you wanted to come in and correct me on that on a different…

Creon Butler

Yeah, lots of nodding. Maybe we’ll go through some of the questions, but if you want to come back to any of the things that have been said, please do. I mean, I – the next one I wanted to go to, which we’ve, to some extent, tackled already; Jeremy Ross was saying, “What are the health and social care funding models available?” So, you know, Steve talked about one of them, which is a, kind of, an assessment model for dealing with the international health priorities, which would be a sum of money that all countries provided, and that would deal with the burden sharing and so on.

I don’t know if any of you want to, sort of, flag other models, perhaps, possibly, Amanda, that’s something you’d want to just highlight, other things that should be looked at as an alternative way of approaching this.

Amanda Glassman

So, I think the assessed contribution model is a good one, and I mean, certainly been floated by Joep Lange Institute, it’s – and it really is, in a sense, the World Health Organization’s existing core financing formula, but for that same reason, I think we need to explain then why it hasn’t worked so well.

Creon Butler

Yeah.

Amanda Glassman

In the case of the WHO, why it hasn’t been easy to adjust assessed contributions over time, and we all are familiar with, you know, it’s a – they’re financing, like, $1 billion or something through that assessed contributions, and the – you know, to get a very small incremental change was as huge production. So, you know, I think we have to say, “Well, what is the issue here?” And I guess it has to do with the governance, the perceived efficiency, the voice and control that financiers have over what happens, all of those, sort of, realpolitik elements enter into the assessed contributions discussion.

But, that said, if we contrast it to the World Bank’s IDA, that has – it’s not exactly assessed contributions, but it’s a different model than what we see at the Global Fund or what we see at WHO, but we see countries coming – except for the UK last year, I’d love to hear why that happened from some of you, but, you know, it’s a way, a replenishment conference, and you look at reforms, at the same time, to the model of financing, the donors have some say, recipients also have some say on the priorities, and they, together, negotiate a plan for the following three years. And so, you know, I think if we do talk about assessed contributions, I hope that we think more about the World Bank’s IDA model rather than some of the other things that are out there, that have proven difficult to sustain.

I mean, the other thing just to say about, like, the Global Fund is a very successful fundraiser, and they’ve increased their amounts every time that they come to the market, let’s say. It is the same 14 governments, however, that finance 95% and up of every replenishment. So, I think the question is, do we need that huge fundraising stuff to create all those political goodies for the Politicians to be able to deliver? And that may be true, and in fact, that could be why IDA is going down over time, whereas Global Fund’s, sort of, on the up-and-up. So, I think all those things we have to consider about what model works.

Creon Butler

Right. So, another question we’ve got is around information, and it actually ties into one of the issues that’s come out through the – some of the work that we’ve been doing in Chatham House, which is, you know, that there is a very strong role for civil society in underpinning the meeting of critical global health needs. But then you find, as, you know, say, the difference between HIV/AIDS on the one hand and AMR on the other, there’s a big difference in how, you know, the threats are being communicated, this is partly the nature of the problem.

And one of the factors that’s been identified is around information; does the public have the right kind of information in this area in order to make the judgements to underpin civil society’s work, and so on? And so, I just want to throw this question to you, as to whether, you know – in climate change we have the IPCC model, you know, there’s a massive periodic effort to collect all the information together and say, “This is the problem, this is where we are,” and it’s incredibly powerful, particularly as the problem’s got worse. Is there a need for something like that in the global health space, and if so, what should it look like? Anybody want to have a go at that? Amanda, you’re nodding, so, I’ll come back to you, but I’ll go to the others as well.

Amanda Glassman

No, I love that idea, and actually, I was – there’s a colleague whose name is Ben Oppenheim, who published a piece in Nature proposing an IPCC-like mechanism in global health to detect pandemic risks early, and to discuss the science of it, and to build the science, to crowdsource the science and then be able to come up with these, kind of, consensus statements, judged on the basis of how strong the evidence is underpinning each statement.

I think that’s a very, very good idea. I think the, kind of, impressionistic committees that we have at WHO at this time are, you know, they’re too easy to question for that reason, and I think that’s been the power of the IPCC over time, so, could we – you know, it doesn’t mean – that doesn’t mean that it would be outside of WHO, it could be, you know, sort of, affiliated to WHO, but something like that might be important, going forward.

Creon Butler

Great. Yeah, Emma.

Emma Ross

Yeah, I think it’s really interesting, but I suddenly had a question for Stephen, that, you know, is – IPCC for global health would improve confidence in the evidence, you know, if there is a trusted WHO or, you know, IHME, or – there are lots of people producing evidence, and maybe that’s part of it, that it’s fragmented, but to create yet another institution, so, say we do, my question to Stephen would be, is that going to be good enough? Do – are these decisions made on evidence from what we’ve seen is, you know, the evidentiary case can be made and still it doesn’t happen? So, it – and how much in climate change of the action has been down to IPCC science versus civil society pressure, or threats?

I mean, in global health, some of the things that have moved, for instance, if we think about sample sharing, for vaccine making, when Indonesia just refused to share their samples anymore, it’s when a country with power, you know, held everyone to ransom and flexed their muscles, that something changed. So, I’m wondering whether evidence is going to cut it, is that the way forward for us, or what – does it have a role, and if so, how important a role?

Creon Butler

Steve.

Stephen Pickford

I mean, off – my initial reaction is, it would help, in the sense that having a – what – having a body that is recognised as authoritative to sift through all the mass of technical medical information that very few of us even understand, let alone can make judgments about, must be a good thing. Is it – does it replace civil society and campaigning? No, no. I mean, if you look at climate change, I mean, if you go back to the history – well, I suppose, one of the first authoritative ones was the Stone Review in the early 2000s, which was a very, very hefty tome looking at the science and the economics of climate change.

That – I think that predated the IPCC, I may stand – really stand – be stand corrected, but essentially, it’s that building-up of a corpus of knowledge and consensus about what a, you know, what the science is, what the priorities are that flow from that, I would have thought, would be a very good thing. The problem, as I was saying earlier, is – in health, is partly that you have different groups saying, “My priority is most important.” How do you judge those priorities? And I think it would help enormously if – but is it enough? Well, it can only help, is my answer.

Creon Butler

Great. So, I’m going to speed up now, if you’ll forgive me, because a lot of good questions that are coming here, and just if I put perhaps three of them to you, two of them initially. So, one is around, there’s a question around the biosecurity justification for global health spending. Does it help, in a sense, to emphasise this? Obviously, there’s links to terrorism, I mean, there’s all kinds of different angles that you can develop this, so, that’s one question.

There’s also a question around, sort of, institutional, architectural change, so, I think all of you mentioned at some point that, you know, it’s not, kind of, fit for purpose, the global health architecture, all the different elements centred around the WHO, but with the World Bank as – now, if we’re going to make an effort at this, you know, what should the approach be, is it, kind of, an incremental approach, setting the direction of travel? Thoughts on that would be really helpful as well, so, perhaps one could take those two. Steve, if I could come to you on the biosecurity, is that going to help, in terms of Finance Ministries? Maybe then to Amanda on the global architecture, what’s the best way of approaching that?

Stephen Pickford

Well, I mean, I think, I’m not sure if it’s Finance Ministry or Finance Minister.

Creon Butler

Sorry, we’ve lost you, Stephen.

Stephen Pickford

I’m not sure if it’s Finance Ministry or Finance Minister, but having evidence that you are protecting your own citizens from a health problem is – it must help, it must help in terms of the domestic politics. If you can say, “I am protecting my own citizens,” it is easier, it makes life easier to do. But I just wanted to come back, because I think not only would an authoritative, sort of, assessment institution be a good thing, I think also you need to have an implementing agency, which everybody trusts. And the problem is that you’re getting quite a lot of competing institutions: the World Bank, the Regional Development Banks, the WHO, you need, in my expe…

One of the reasons that things happened more effectively in the global financial crisis is ‘cause you had one agency, one institution that everybody trusted. Getting to that point would be a big plus.

Creon Butler

Yeah, yes, indeed, thank you, and, Amanda, on the architecture point.

Amanda Glassman

Yeah, I think this is a hard to answer question, and it’s related to what Stephen was just pointing out. So, you know, I mean, you know, when we look at the climate sector, if we look at the security sector, of course there are eight to 22 hundreds of different organisations engaged in the provision of different aspects of the service. So I think of course there’s – you know, competition is a thing, but we should also say that each of the global health entities that are involved in the architecture really have quite different roles that are complementary, and if they’re not complementary, we should sort that out and make reforms such that they are complementary.

You know, notionally, it’s fairly easy to set out what each of them does or specialises in, and why they’re different and add value. I think, you know, the place where you see obvious overlaps are things like the procurement mechanisms, you know, do we need a separate global procurement mechanism for family planning products and for vaccines, and for ARVs, tuberculosis medicines? There are particularities of each of those markets, but I, you know, would question whether we need so many of those, and then of course, what’s their role vis-à-vis domestic spending and prioritisation, that we’ve already talked about. So, that’s an opportunity for reform.

But otherwise, you know, they do have quite clear areas of comparative advantage, like, you know, “I finance R&D of medicines.” “I do R&D of vaccines,” like, you know, etc. So, I think maybe thinking that through and laying out where there are these duplications, where there could be efficiencies, and that would, I think, be very convincing to Finance Ministers that would like to see that broad sector approach. That said, I think it’s more likely that Chatham House or CGD would do that analysis than they’re going to come together and work it out themselves.

I mean, ACT-A, in a way, was an effort to do that, and I – you know, should be recognised, but was hard to fundraise for, and co-existed with the institution’s own fundraising, so, that’s the challenge.

Creon Butler

Great, thanks very much. Emma, I was going to come to you on that, but I also had another question, if I could just throw in for you as well, which is, so, somebody responded to your comment about antimicrobial resistance, and asked, you know, “So, what are the really big global health threats?” And there is an issue clearly around, that there’s enormous focus on COVID, and yet quite a few countries are saying, “Hang on a second, you know, that isn’t the really big issue for us,” or at least there are others that are – and this then creates a, sort of, confusion among Finance Ministries, in terms of, “Where do we go?”

So, perhaps, if you’d like to comment first on the architecture point, but then just on this question of, you know, a) the question, what are the really big health threats, and b), you know, how do we prioritise between them?

Emma Ross

Okay, yeah, thanks, Creon. On the architecture thing, yeah, I agree that there’s probably duplication of – and lack of confidence in where to put the money, but this has come up before, but who really has the authority to rationalise the architecture and reform it? Yes, it needs reform and, you know, if you’re putting, you know, the Stop TB Partnership and you’ve got, you know, Malaria Ventures. Who’s in charge of saying, “Okay, you don’t exist anymore, we’re plucking this out of here and we’re going to put it together with that,” who gets to make those – how are those decisions going to be made? But I think this is part of the issue of who has control of this, or are we superimposing something that just wipes all of that out, that will have the authority to pluck from everyone?

Because to me, it looks like that will be years and years of wrangling and power struggles of – and more embarrassment for the global health community, about getting its act together and rationalising its architecture. That, I mean, theoretically, sounds great and lovely, but I worry and I start, you know, perspiring about taking that on, and what that would do to the reputation and the way the community is viewed. I mean, you know, and that would be in the glare of the spotlight, so, that was really my question about that.

And as far as what are the big threats, again, part of this depends on who you’re talking about and what you’re – if we’re talking about, for the international community to get involved in, we’re talking about the big threats, you know, we’re talking about heart disease and diabetes, they’re massive, huge, much – you know, in some countries, double burden, in some countries bigger than infectious diseases. But if we’re talking about what the international community should be getting involved in and sorting out, antimicrobial resistance has, you know, for a while been, you know, flashing the beacon but it’s coming, it’s very hard to grapple with that and to understand it, because it’s not as visible, and they haven’t really quantified it, or the predictive stuff of where it’s going. So, it’s hard to gain traction for it, or recognition.

But already during the pandemic and as it’s, kind of, stabilising, antimicrobial resistance is rising up the agenda and getting louder and louder. But even beyond that, as far as what are the big threats globally? You could argue that we got off – as horrible as COVID was, we got off quite lightly, considering, you know, a respiratory pathogen that could go – it could have been much more deadly. It was pretty widespread, I’m not sure about any more widespread, but pretty deadly and devastating, if this was moderate, so, that is always a looming threat…

Creon Butler

Yeah.

Emma Ross

…and avian influenza has always been the target of that, so, you know, there are…

Creon Butler

Great, thank you very much. Unfortunately, we’re almost out of time, but there was one question – I didn’t do terribly well at getting through them all, but there was one point that I just wanted to flag and see who would like to come back on, which is this, it’s a question about interdisciplinary approach. So, one thing that has really struck me, working on climate change, is, you know, Economists and Climate Scientists for a long time thought about climate change completely differently.

I mean, if you look at the, sort of, Economist models of climate change, it was nothing to do with, you know, quite what the climate science was saying. Now, is there an issue in health and finance and economics, a similar issue where we need more interdisciplinary, kind of, thinking, maybe study, or is actually that not such a big issue in the health world as it is – as it seemed to be, at least for a time, in the climate world?

So, I mean, I know various – I think there are various people with qualifications in this, exactly in this area, but I just wonder if there’s a – if anybody has a perspective, if that is part of our challenge. Amanda, maybe I could ask you, and then Steve or Emma, you may have views.

Amanda Glassman

Can you just repeat the question to me?

Creon Butler

So, it’s really about, is there a need for more interdisciplinary thinking, so, which combines economics, finance, health, development, and part of our problem is different buckets of analysis which, as I said, I found in the climate space, the groups didn’t really connect with each other until very recently?

Amanda Glassman

Yeah, and I think that was the – I agree with that statement, and that was one of the reasons why the G20 called for a health and finance working group.

Creon Butler

Exactly, yeah.

Amanda Glassman

So there would be a space where the two – at least those two disciplines could be working more closely together. Of course, as a Health Economist, that also sounds really good to me, and I think that’s what should be done. And I, you know, I have always idolised the UK health system for its huge integration of Health Economists, but perhaps the Clinicians feel differently, who are on this call.

So, I think it’s really important and, you know, of course, the other piece of it is, you know, just the equity issues that are – that have been surrounding this crisis, the importance of safety nets and social protection in dealing with the effects both of, you know, the lockdown, but also how that affects people’s nutrition and access to other kinds of services is hugely important. And one of the reasons why the MDB models are very interesting in this space, and even the verticals are starting to think in that way, the vertical health programmes have been starting to think about, you know, ways that, like, cash transfer programmes support people on AIDS treatment or TB treatment, and things like that. So, I definitely think an interdisciplinary approach is needed.

Creon Butler

Great. Okay, well, thank you, everyone. I’m afraid I’m really out of time now. Sorry for not getting to everybody’s questions, but it was a really, for me, certainly a really interesting discussion. Thank you for – thank you first to our panellists for their excellent comments, and also to our audience for spending their time with us, and also for putting some great questions. This will really be helpful in our ongoing project in Chatham House, and we look forward to seeing you all again for the next event in the series. But with that, thanks to everybody, and until next time. Cheers.

Amanda Glassman

Thank you.