Solidarity for a Healthier World

The global COVID-19 pandemic is a clear demonstration that health emergencies know no borders and that strengthening health systems globally is the best defense against international public health crises, which can become international economic crises. COVID-19 should serve as a wake-up call that one of the best investments the US can make for achieving a healthier, more secure, and peaceful world is in strengthening health systems globally. The Sustainable Development Goals (SDGs), which the U.S. Government (USG) pledged to help achieve at the U.N. General Assembly in 2015, provide an existing framework for strategic investments in health systems strengthening. By leading global efforts to achieve the health-related SDGs, the USG can transform global health, build resilient, country-owned health systems, and help to prevent approximately 97 million premature deaths by 2030

To enable significant progress toward the health-related SDGs in order to prevent, mitigate and respond to health crises, the USG must:

1. Transform USG global health funding to improve efficiency, equity and sustainability

Reaching the end of this pandemic and containing future outbreaks demands strengthening health systems, especially in the most impoverished countries with the worst health outcomes. This requires transforming the way that the USG funds and supports global health. Currently, US global health funding is hugely inefficient, consistently ranking lowest among donor nations in terms of the aid quality. To improve the efficiency, equity and sustainability of global health funding the USG should:

• Deliver global health funding and programs through an overarching health system strengthening framework

  The SDGs clearly demonstrate global political consensus and commitment to transition from a disease-specific approach, an artifact of the Millennium Development Goals (MDGs), to a health system strengthening approach. The transition to health systems approaches is urgent; targeted vertical approaches to specific diseases/conditions are ill-suited to responding to pandemics or to strengthening public health. Lessons from the MDGs have shown that even disease-specific goals require strong cross-cutting health systems investments, yet USG funding remains largely disease-specific and delivered by international and private sector actors, often resulting in parallel systems and large inefficiencies.

• Support national health plans, public institutions, local priorities, and donor coordination

  For funding to be optimized it must support system improvements in line with the national health plans. Investments in strong systems harmonize resources, foster local ownership, and improve responsiveness to meeting all health needs and ensuring healthy and productive populations. However, USG funding commonly bypasses these plans and public institutions with parallel inputs, which lead to massive inefficiencies, fragmentation of care delivery, poor care in public facilities, and internal brain drain of health care workers from the public sector. In 2015, around two-thirds of US official development assistance (ODA) in 2015 bypassed recipient governments altogether. While the USG has committed to the Paris Declaration on Aid Effectiveness and the UHC 2030 principles for effective development cooperation, harmonization with other donors is still limited. Existing laws authorizing foreign aid expenditures should be amended to enable increased support of public institutions.

• Prioritize support for multilateral mechanisms

  Multilateral funding mechanisms are more efficient, equitable, and less fragmented than bilateral mechanisms and as such are preferred by recipient governments. Yet, only 14% of US ODA provides core funding for multilateral organizations, one of the lowest shares of all donor nations.

• Funding for global health should not be tied to spending on US goods and services

  “Tied aid”, i.e. the requirement that aid be used to procure donor country goods and services, significantly reduces effectiveness and increases the direct cost of goods and services by 15%-30% on average. As of FY2017, 67% of U.S. foreign assistance funds were obligated to U.S.-based entities. Untying aid increases effectiveness, reduces transaction costs, and improving recipient countries ownership.

• Introduce a new objective for reducing health inequities

  The US should promote the strengthening of systems to provide universal, high quality health services, rather than continuing to promote privatization and for-profit solutions. An emphasis on the private sector and promotion of privatized services undermines public system strengthening, access, equity, financial risk protection, and the right to health. Achieving health equity requires the strong public provision of care and strong regulation of privately provided care. Pro-poor financing, including the elimination of out-of-pocket expenditure, is required to achieve equity.

• Restore the USG’s membership and funding to the World Health Organization and the Pan American Health Organization.

  Effective international cooperation requires the US participating and collaborating in solidarity with other countries. Restoration should include all previously pledged assessed and voluntary contributions and also recognize that greater resources, technical cooperation and solidarity will be needed in the setting of a pandemic.

2. Increase USG investments in global health

Significantly improved international cooperation is needed to prevent, mitigate and respond to health crises, outbreaks and pandemics, which will only increase in frequency.  The drivers of these health crises are weak public health systems, poverty and inequity. Consequently, the most effective pandemic preparedness and response strategies are those prioritize equity and system improvements. It is critical that any approach to promote “global health security” understands this fundamental point. Achieving global health security requires individual health security, which requires high quality care for everyone, especially the most vulnerable. The only way to achieve this is through adequately funded and responsive health systems. The SDGs already provide the framework for driving this goal forward but the US must take decisive actions for achieving the SDGs and addressing structural factors that prevent their realization. With the achievable UN ODA target of 0.7% of GNI in mind, the USG should:

• Increase investments in global health to $50 billion annually

  There is currently a significant external funding gap that must be closed for the achievement of the health-related SDGs in low- and middle-income countries (LMICs). While domestic resource mobilization is an essential component, for many LMICs, there is simply not enough tax capacity to mobilize the resources required. It is commonly emphasized that governments need to make domestic investments in health equal to 5% of GDP or 15% of the total government budget, and this is a critical step. However, even with these considerable investments, a total financing gap in excess of $50 billion annually would remain for just for the 34 low-income countries.  The financing gap for LMICs is much greater than this amount, due to a combined population of around 3 billion people. In order to move toward closing this financing gap, OECD Development Assistance Committee members, including the US, must meet the UN target of 0.7% of gross national income (GNI) for official development assistance. This would represent about 4-fold increase in ODA; a 4-folding increase in ODA for health would represent about $50 billion annually. Currently US overall contributions to ODA are only 0.17% of GNI, and have flat-lined since 2011. Indeed, the USG should influence all nations on OECD’s Development Assistance Committee to meet this target as currently only five nations are doing so. This will go a long way to closing the gap between what LMICs can possibly mobilize and what is required for achieving SDG

3. Do no harm to the health of people around the world

Health is an acute reflection of broader inequalities. Achieving health equity requires international cooperation to address these inequalities through measures including but not limited to:

• Clamping down on multinational tax avoidance and illicit financial flows

  The US must not oppose financial taxation accords and other international measures that attempt to address multinational tax avoidance and illicit financial flows.

• Putting an end to onerous debt repayment and structural adjustment conditions

  The US must work with the international community to put an end to onerous debt repayment and structural adjustment conditions that continue to cripple the public sector and economies in the global South.

• Addressing tax, anti-trust, trade, and environmental policies to ensure adequate livelihoods, environmental sustainability and a healthy future for all

  The US must not support measures that limit access to medicines, vaccines and health commodities, including by supporting the use of public health flexibilities defined in the Doha Declaration on the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), and ensuring that future trade agreements do not include language that protects corporations over wellbeing and sovereignty. In addition, the US must exercise anti-trust policy to ensure competitive markets for health care commodities exist when companies are based in the US.  

A long-term goal of supporting countries to increase their taxation and regulatory capacity to domestically mobilize resources and be independent of ODA is critical; doing so in an inexorably interdependent world requires creating a fairer global economy. Decreasing ODA without making the global economy fairer and unshackling the ability of LMICs to raise revenues serves to further undermine the SDGs and human rights of people in the global South. Inadequate global health resources result in prioritizing interventions considered “sustainable” based on inadequate health budgets of impoverished countries, which maintains the unacceptable and staggeringly inequitable status quo. This status quo is a direct result of historical and ongoing exploitation. The economic order that was consolidated in the colonial period - founded on dispossession, slavery, and extraction - still exists. Further, in recent decades, it has been coupled with trade, intellectual property, investment and fiscal consolidation rules that systematically drive poverty in the global South. Contrary to complaints about “overly generous aid”, total annual net resource outflows from the global South to the North stand at approximately $2 trillion, a sum that dwarfs ODA and other assistance.