How Germany failed to live up to its global health ambitions

BERLIN – Germany has spent the past decade positioning itself as a global health leader.

The health ministry released a 2013 global health policy that emphasized multilateralism and exporting German knowledge to tackle pressing health challenges. Chancellor Angela Merkel then set global health high on the agenda of her country’s 2015 G-7 and 2017 G-20 presidencies, with a particular focus on combating antimicrobial resistance and pandemic preparedness.

Ahead of the 2017 meeting of rich country leaders, Germany even invited their health ministers to Berlin to run through a pandemic simulation. When it was over, then-Health Minister Hermann Gröhe drafted an op-ed for The Lancet, explaining, “All of this support shows that in recent years global health policy has become a hallmark of German policy and an expression of our international responsibility.”

The COVID-19 pandemic seems to have muted that expression.

“Where has Germany’s leadership been in all of this?” asked Dr. Peter Tinnemann, who heads the global health science unit at Charité, a university hospital in Berlin. “Where has Germany worked with the World Health Organization constantly on this? Where are the German technical experts implementing stuff? Where are the hundreds of millions being given to kick-start economic development in most-affected countries?”

The problem, observers said, is that while Germany spent much of the past decade advancing its global health leadership, it did not coalesce around a cohesive, government-wide strategy. As a result, when the pandemic struck, individual arms were able to endorse specific efforts and the chancellory could preach multilateralism, but Germany was not prepared or positioned to help shape a comprehensive strategy for responding to the crisis.

But the country has a high-profile opportunity to change that when it takes over the presidency of the Council of the European Union in July — and positive signs are emerging.

‘A turf battle’ for global health

Global health had not historically featured high on the priorities of  German governments, who did not see it as a viable issue for attracting voters. That began to change under pressure from civil society, but was jump-started by the West African Ebola outbreak declared in 2014.

Tinnemann said the epidemic woke Germany — and particularly Merkel — to the global threat of pandemics. She put Ebola on the G-7 agenda the following year and pushed for WHO reforms that would speed up the global response to health emergencies.

Her early priorities set the tone for Germany’s growing involvement in global health, which centered on strengthening and improving multilateral institutions and on health security threats like pandemics or AMR, whose immediacy might resonate with German voters.

But, in part because of uncertainty about which of the relevant ministries — health, development, or education and research — would take on the global health portfolio, it never came together into a government-wide approach.

“There was a turf battle over which ministries [should be] involved and a hesitancy to communicate on behalf of the whole government,” said Katri Bertram, a global health consultant based in Berlin. That created a situation where “implementation is so fragmented, with so many stakeholders and no clear space to communicate what is done and financed.”

The result is that different arms of the German government have introduced or promised a number of initiatives — the Global Health Hub Germany or the Global AMR Research and Development Hub — but with no sense of what connects them and no central authority to consult when promised initiatives, like regular pandemic preparedness exercises, fail to materialize.

While the ministry of health appears to have ultimately emerged as principal keeper of the portfolio, it has not yet released a months-delayed revision to the country’s global health strategy that analysts were hoping would define what Germany aims to achieve in the field and how the country’s various ministries, institutions, and universities will support that vision. It will also be critical for maintaining the emphasis on global health once Merkel leaves office after next year's federal elections, they say.

But the situation appears to be growing even more fragmented. The ministry of economic cooperation and development, or BMZ, which controls most of the government’s official development assistance spending, announced a new strategy just ahead of the pandemic that would end bilateral health aid and channel it through multilateral institutions instead. And Green Party parliamentarians accused the research ministry of investing in studies on poverty-related diseases without ensuring the results were widely available.

A window of opportunity for change

This was the context when the COVID-19 pandemic began.

Germany did take some early actions. It co-chaired a European Council fundraiser for research and was quick to support calls for universal access to any vaccine or treatment that emerged, whether from Germany or elsewhere. Merkel has also defended WHO in the face of U.S. threats to withdraw from the global health body.

It is a response that has all of the hallmarks of Germany’s recent approach to global health: a focus on multilateralism and health security and some individual initiatives, like vaccine research, that play to Germany’s strengths. This is the approach Germany feels comfortable taking, Bertram said.

“[Germany] plays its part in some ways, but also has stated quite publicly as well that it thinks that everybody should pay their share and always expects others to fill that gap together with Germany,” she said. “We are going to help build a coalition, but need others to play along, as well.”

With Germans newly attuned to just how interlinked their health and welfare is with those around the world, Tinnemann said there is an opportunity to leverage this moment to center health more explicitly across all government efforts and to expand the vision of what Germany is trying to achieve.

"They need to be linking global health to German public health issues or it risks being forgotten about again,” he said — particularly with an economic downturn approaching

There are signals this might be happening. BMZ was quick to present a more holistic vision of a German response — both increasing its domestic resources to help lower-income countries weather the pandemic by reallocating €1 billion ($1.13 billion) of its own budget and calling for an additional €3 billion, and setting expectations for partner countries and international organizations. The ministry’s emergency response also drew links to related issues — globalization, climate change, urbanization — committing Germany to a more sweeping vision of pandemic preparedness that reckons with these broader concerns.

It remains unclear whether the ministry actually has the remit to guide this, but its early proposal has at least helped set the tone as additional strategies emerge ahead of Germany’s term as president of the Council of the European Union — the body where ministers from EU countries discuss and adopt legislative provisions — which it takes up in July.

In late May, parties from parliament’s global health sub-committee tabled a series of applications in front of the Bundestag calling for strengthened international cooperation in health policy. The proposal from members of the ruling coalition of Christian Democrats and Social Democrats called on the federal government to integrate health into all its policies and to improve inter-departmental cooperation. It was adopted by a majority in the Bundestag, though it does not have the force of law.

Even more ambitious proposals from the Left and Green parties, setting specific global health funding targets for the government, were also tabled and referred for further discussion. Despite some differences, Maike Voss, an associate in the global issues division of the German Institute for International and Security Affairs, said it was significant how closely aligned most of the party's documents were.

“That’s a good sign for coherent global health policymaking from the German side,” she said. “What’s good to see from the parties is that they [are using] their power to accelerate the government in regard to the development of a global health strategy.”

That was the goal, said Dorothee Friedrich, a research assistant for Heike Baehrens, chair of the sub-committee from the Social Democrat party. “We have … momentum right now because of the coronavirus situation,” she said. “There is a window of opportunity to raise a broader awareness.”