Can the G20 actually deliver on global health?

India has big health goals for its presidency of the Group of 20 leading economies. The government has set three broad priorities — improving health emergency prevention, preparedness, and response, or PPR; strengthening pharmaceutical sector cooperation; and improving universal access to digital health innovations. Following three health working group meetings, health ministers from the G20 countries are set to convene later this month in Gandhinagar, in western India, to discuss how those priorities could translate into actual commitments in the leaders’ declaration in September. There are questions, though, about the effectiveness of the G20 as a forum for delivering global health outcomes that extend beyond funding initiatives — particularly since much of the global south is excluded from the body. There are also concerns around the effectiveness of any commitments if they are not linked to pledges emerging from other multilateral bodies and agencies and if they do not translate into measurable responses at the national level. “The question at the end of the day is accountability,” Sandhya Venkateswaran, a senior fellow at the Centre for Social and Economic Progress, told Devex. “My sense is there hasn’t been enough discussion on accountability in the conversations they are having.” It wasn’t so long ago that health was hardly on the G20’s agenda. During its 2017 presidency, Germany hosted the first meeting of the members’ health ministers and spurred a commitment in the final declaration to strengthen health systems and combat antimicrobial resistance, or AMR. The COVID-19 pandemic ensured discussions around global health would continue, even as the G20 has had to figure out which issues to actually weigh in on. Pandemic preparedness was an obvious discussion point and Italy’s G20 presidency in 2021 saw the creation of a G20 Joint Finance-Health Task Force, which is working to help bridge the two groups of ministers to ease coordination of pandemic PPR. Though the task force has had few public successes, it is working to build momentum around the Indian presidency’s goals. Under the Italian presidency, the G20 also developed the Pandemic Fund, dedicated to investing money in PPR. Ultimately launched under Indonesia’s presidency last year, the fund recently allocated its first round of grants. Other issues have largely emerged at the discretion of the country holding the presidency. The Indonesian presidency added an emphasis on improving access to vaccines, therapeutics, and diagnostics, including through improved regional and local manufacturing. India maintained both of those priorities, while introducing its own “centerpiece action, focusing on digital health solutions to achieve universal health coverage,” according to Neeraj Jain, India country director for PATH. The public health nonprofit is working closely with the Indian presidency to support its health goals, including setting up discussion groups around the meetings. The idea underlying India’s digital health focus is creating a connected digital health ecosystem that draws innovators and investors to work toward a common goal of creating “digital public goods, with a focus on low- and middle-income countries,” Jain told Devex. It could also prompt resolutions on issues such as common standards and interoperability for digital health products, which would make it easier for technology to transfer between locations. Though the priorities are set and being debated, questions hang over the discussions, including whether they will translate into actionable items. To some degree, that will depend on health ministers and leaders of the G20 countries. Within the broader effort to strengthen pharmaceutical sector cooperation, Jain is looking for an increased focus on research collaboration, in the vein of ongoing efforts to build a vaccine library or commitments to build regional collaboratives. Alan Donnelly, the convenor of the G20 and G7 Health and Development Partnership, told Devex that he is eager to see commitments around sustainable health financing that reward countries for investing in their health systems by rescheduling or even writing off debt. Ultimately, though, most specifics should be filled in at the country level after the heads of state convene in September and release their leaders’ declaration. In many cases that will require a level of coordination between those leaders and legislators and bureaucrats in their countries that has not always come to pass. Donnelly pointed to G20 commitments around AMR, including a pledge to have national action plans “well under way” by the end of 2018. “A vast majority of countries have action plans on AMR, but in most countries it’s ink on paper,” he said. “This is where we’ve got to move from solemn declarations into measuring results.” And though the Pandemic Fund has launched, it has so far raised only $2 billion out of the $10 billion needed annually to fill financing gaps in pandemic preparedness. Donnelly suggested more direct engagement from legislative bodies, which can hold the executives accountable for their commitments. “There’s this democratic deficit that exists between the things that are agreed at heads of government and ministerial meetings and then activation and implementation,” he said. “The aim is to look at how do we get parliaments to hold their governments to account.” He said the partnership plans to begin outreach to legislators as soon as a leaders’ declaration is signed to encourage them to approach their government and find out how those commitments can be practically implemented. Another way to facilitate results, Donnelly said, is to ensure that the G20 is working in tandem with other multilateral efforts, such as the Group of Seven leading industrial nations. Donnelly said there has been some communication between India and the G7 president, Japan, and his organization’s partnership will push for continued dialogue between next year’s G20 chair, Brazil, and G7 president, Italy. The G20 is also forging additional connections, including looking to the World Health Organization to oversee a mechanism for sharing best digital health practices. Those connections — particularly with WHO, which has a truly international membership — can go some way toward convincing countries that are excluded from the G20 that the body is working to improve global health. But there are still broad concerns, Venkateswaran said, that the G20 is setting priorities and delivering outcomes that will primarily benefit its members. There is little to show for the focus on improved access to vaccines and diagnostics under Indonesia’s G20 presidency, for instance. India has maintained that it is serving as the voice of the global south during its presidency, including through the push to democratize access to digital health tools. But the rest of the world is still waiting to see the practical outcomes of those efforts. “There are only a few countries from the global south that are part of the G20,” Venkateswaran said. “There are processes in place to be inclusive, but it’s not enough. Much more needs to be done.”