Is the G20 a short-term crisis arrangement focused narrowly on economic issues? Or does the increased prominence of the G20 indicate significant change in global governance beyond the crisis and beyond finance? We recently discussed these issues during a half-day workshop in Oxford with the Oxford-Princeton Global Leaders Fellows.
While it’s still too soon to tell, examining the G20’s relevance to other issue areas is a good place to start. In the case of global health governance, it is not clear whether the G20 holds real promise as an institution for resolving key issues. Rather than crystal-ball-gazing, however, we need to think carefully about how to evaluate this evolving institution. Why, and under what conditions, might the G20 help the governance of global health? What functions would the G20 in health provide that the existing health institutions are not filling? What are the gaps in global health governance which that specific governance arrangement could address? In other words, what can the G20 in health do that no other body can do? There has been rapid proliferation in the number of bodies- what would yet another institution add?
‘The G8 versus the G20’
The G8 is largely composed of ‘like-minded’ countries with similar strategies on how to improve health. It has played an important role in financing global health through formal commitments, creating new institutions, and prioritizing certain issues on the global stage. For example, the G8 was the driving force behind the creation of the Global Fund to Fight HIV/AIDS, TB and Malaria in which a large portion of funding continues to come from G8 countries. Similarly, Japan recently took advantage of its leadership of the G8 and used the 2008 Toyako summit to push for health systems strengthening. And in 2005, under UK leadership, the G8 committed to reaching universal access to antiretrovirals for those living with HIV/AIDS. Would the more inclusive G20, which contains a number of countries (ranging from the US, to South Africa to Indonesia, to Russia) with varying views on how to improve global health, be able to reach consensus and drive forward the agenda in a meaningful way?
Given the fundamental lack of trust between many of the countries within the G20, consensus among its many members may not be easily achieved. This is most evident in the WHO negotiations over virus-sharing, or as they are officially known the WHO Pandemic Influenza Preparedness Intergovernmental Meeting, where the U.S. and Indonesia have been unable to reach agreement.
‘Membership of a G20 for health’
Would the G20 become a larger forum for countries to discuss a wide range of issues from finance to security to health? What would drive country participation in a G20 discussing health? In other words, why would an institution that cuts across many issues help?
For health, one advantage of such a cross-cutting institution would be the facilitation of better coordination among domestic agencies (health, finance, trade) within each country. This is significant because so much of what impacts health lies outside the health sector. However this benefit would be negated if a G20 for health was realized as a G20 for health ministers.
‘Winners and Losers of the G20’
While a G20 gives increased visibility and voice to those powerful economies excluded from the G8, what will this mean for those weaker countries not at the table, such as Bolivia and Niger, and the inclusion of their interests? Who will represent their interests in the G20? We shouldn’t assume that it will be the regional hegemon. In fact, participating in the G20 might strengthen certain countries (e.g. South Africa) which can then use this power to strengthen their position within the region (e.g. AU).
It is not clear how this would be resolved in health governance: for example, India and Brazil have played a major role in representing the ‘views of the South’ in negotiations within the WHO on Public Health, Innovation and Intellectual Property, the Framework Convention on Tobacco Control as well as within the WTO in the Doha Declaration on TRIPs and Public Health. So far, there has largely been convergence in position, but what happens when interests diverge?
‘Regional Groups and the G20’
The past decade has seen an increasing number of groupings by ‘like-minded countries’. In health this is reflected in the growth of bodies such as ASEAN, ACMEC, UNASUL, CPLP, and IBSA. What would be the relationship between the G20 and these regional groupings? Would the G20 strengthen or detract from the operations of these groups?
To understand this, it is important to look at what gap the regional groupings are filling in health:
- Community of Portuguese Speaking Nations (CPLP): cooperation to strengthen health systems, primary health care policy, and Ministries of Health, as well as partner academic institutes such as the National Institutes of Health, the National Schools of Public Health, and the Schools of Health Technicians
- UNASUL (Union of South American Nations): cooperation to launch a South-American Commission on Social Determinants on Health and the South-American Council of Health consisting of Ministers of Health
- ACMEC (Cambodia, Lao PDR, Myanmar, Thailand and Vietnam): cooperation to strengthen surveillance and response systems as well as preparedness measures (e.g avian flu). ACMEC has also been involved in the discussions surrounding influenza virus, vaccines and other benefit-sharing to ensure countries reach a similar position before WHO negotiations.
These three bodies have been reasonably successful in achieving their goals among the countries involved, and it would be important for a G20 on health to identify shared objectives and then put in place appropriate coordination mechanisms such as regular consultations, systematic reviews of reports from regional meetings, and inclusion and participation of group representatives. A G20 might bolster existing collaborative mechanisms among ‘like-minded countries’ rather than detract by setting up parallel processes.
Discussing the rise of the G20 in sectors such as health is premature, but focusing on the G20 as a way into discussing the larger issues in global health governance would be one way to understand the vast chaos that characterizes the global health system.
December 1st, 2009 at 4:52 pm
I agree with your observation that much is still to be determined, and a fundamental question is “is this good for the world – including those not represented in the G20″.
If one looks at the share of GDP, trade, banking activities, CO2 emissions – it is clear that you need a G20-like organization to get anything substantive done. G8 is simply too small a share of these measures to affect a meaningful change in economic, financial, or climate change discussions.
Global Health is different in that G8 countries constitute 85% plus of health related ODA.
This raises a few issues:
- Why bother increasing members for ODA discussions unless G20 countries chip in additional resources?
- Is it meaningful to talk only about ODA? If we took health spending, G8 would constitute a much smaller share. Thus, issues of health system strengthening, pandemic preparedness, intellectual property, chronic disease management etc may make sense to discuss.
- Even if global health retains its focus on ODA, and G8 actually makes more sense as a grouping, is it realistic to assume that health carries such a weight within the overall global issues as to effect institutional shift from G8 to G20?