Indoor air pollution
Indoor air quality experts gathered in Bern, Switzerland, to discuss how to improve air quality in European schools, homes, offices, and healthcare facilities.

After the COVID-19 pandemic and social distancing in indoor spaces raised awareness of the risks of infection in closed spaces and super-spreader events, scientists concerned about human exposure to other indoor contaminants and strategies to reduce risks are hopeful that the time has come for more action.

BERN, Switzerland – A dearth of data and low public awareness of the presence of pollutants in the indoor air we breathe are the greatest impediments towards making spaces more healthy, experts said at the first World Health Organization/Europe Indoor Air Conference.

The conference on Wednesday 20 September, was the first-ever WHO event focusing on the wide range of indoor air pollutants that can affect the health of people in modern homes and buildings. It was co-hosted by WHO’s European Region, the Swiss government and the Geneva Health Forum. 

The conference went beyond long-discussed issues of indoor air pollution from coal and biomass heating and cooking systems, which are a major issue in many low and middle-income countries, including parts of WHO’s 53-country European Region.

Overlooked for too long

“This is not a new issue or a new concern. But the pandemic, with its devastating toll, has raised the issue of indoor air quality higher on health and environmental agendas than ever before,” Kluge told the conference.

“Indoor air quality has been overlooked for far too long,” said Hans Kluge, WHO’s regional director, speaking at the conference via video link from Copenhagen.

WHO’s European Region was the first to issue a number of guidelines relating to indoor air pollutants other than cooking smoke. More recently, WHO issued global guidelines for ventilation to reduce virus transmission, including the COVID virus, SARS-CoV2.

Some 150,000 people die in the World Health Organization’s European region each year from exposure to smoky coal and biomass fuels used for cooking and heating, a “shocking” number in and of itself, Kluge said.

But that is only part of the picture, with the health impacts of other indoor air pollutants still unquantified, Kluge added.

“Often there are more pollutants inside than outside,” said David Vernez, professor and head of department at the Center for Primary Care and Public Health at the University of Lausanne in Switzerland, at the conference opening. “We are probably only seeing the tip of the iceberg.”

With Europeans estimated to spend up to 90% of their time indoors, the quality of the air that they breathe within those spaces is vital to their health, Vernez said.

Sources of Indoor Air Pollution

Indoor air pollutants come from a variety of sources, including the buildings themselves, outdoor air and human activities. Radon, asbestos, formaldehyde, and other toxic products are commonly found in homes, offices, and public spaces and can pose a serious risk to human health.

Radon, a radioactive gas found in some soils and rocks, can seep into buildings and cause lung cancer. Asbestos fibers, which can become airborne during building renovations, can also cause lung cancer and other respiratory diseases. Formaldehyde, a chemical used in particleboard and other building materials, can irritate the eyes, nose, and throat, and may also increase the risk of cancer.

Indoor moisture from condensation and humidity in poorly insulated and ventilated bathrooms and kitchens can promote the growth of mould and pathogens that contribute to asthma and other respiratory diseases.

Inadequate air exchanges in crowded spaces or poorly ventilated rooms can also increase carbon dioxide (CO2) levels – with elevated levels potentially reducing cognitive performance, according to recent research. 

Breathing Clean: How Improving Indoor Air Quality Can Save Lives and Boost Productivity

Two million healthy life years lost

The two million healthy life-years lost in EU countries to polluted indoor air every year are comparable to those lost to road traffic accidents.

Pawel Wargocki, associate professor at the International Centre for Indoor Environment and Energy at the Technical University of Denmark, explained that an estimated 2 million healthy life years – a measure of the number of years a person at birth is expected to live in a healthy condition – are lost in the European Union due to indoor air pollution. That is equivalent to annual road traffic injuries.

The economic costs of indoor air pollution are also staggering, totalling about $200 billion every year.

“We need to integrate our activities to improve indoor air with the activities that lead to the improvement of outdoor air quality so that it will have a positive impact on the indoor air quality,” Wargocki said.

Energy efficiency standards can also harm air quality

Sealed windows and an ageing HVAC system in a Stockholm apartment building – a combination that experts now say can lead to health risks from indoor air pollution.

Despite existing guidelines to improve indoor air quality, many buildings lack adequate ventilation. This is especially true of energy-efficient buildings built since the oil crisis in the 1970s, which often have reduced air intake and ventilation systems that remove pollutants and reduce moisture. 

In Switzerland,  Minergie energy efficiency standards require the installation of air exchange systems in new buildings to remove pollutants and reduce moisture. Under these standards, opening windows is optional. 

Roger Waeber, head of the indoor pollutants unit at the Swiss government’s Health Protection Directorate, told Health Policy Watch that corners may be cut when old buildings are renovated.  “Most often the air quality in schools in Switzerland is unacceptable,” he said.

Waeber Authorities granting building permits for renovations in public buildings may often not press for a ventilation plan, Waeber said.

“This is an awareness problem. They shouldn’t provide a permit for a school that doesn’t comply with those standards.” 

Waeber added that other people involved in the construction may forget about ventilation systems as they focus on other design issues. Finally, the municipalities themselves may decide that ventilation systems may be too costly to include in a project, without realising their value for human health.

Certification of indoor air quality needed

Belgian Deputy Prime Minister and Minister of Health and Social Affairs Frank Vandenbrouke addressed the conference via video link.

“It is remarkable to think that this is the first WHO conference (on indoor air pollution)”, WHO Chief Scientist Jeremy Farrar commented at the conference, speaking by video recording from the UN General Assembly in New York. 

“If after the last three years, we do not appreciate the importance of the air we breathe on every part of our lives, then we have really missed an opportunity to move the world forward.”

Farrar emphasised the importance of ethical and social justice considerations in addressing indoor air pollution.  “Whose air is it?” he asked. “What I breathe out will affect you, what I breathe in has come from you.”

In Belgium, Frank Vandenbroucke, deputy prime minister and minister of social affairs and public health, said that recently approved national legislation on indoor air quality has set an agenda for better monitoring, communicating and consulting with stakeholders. 

Vandenbroucke emphasised the need to support scientific research to better understand outdoor and indoor air pollutants. “We need such a knowledge base to define the most efficient regulatory approaches and to use the best existing technologies to reduce the effects of airborne pollutants on our health.”

The minister said that certification of indoor spaces would allow the public to gain confidence in monitoring of pollutants in those areas, and to ensure “transparent, reliable and comprehensive communication” about the air quality.

The pace of change is slow 

Particleboard found on buildings often contains formaldehyde, a carcinogen that can contribute to unhealthy indoor air exposure.

Jelle Laverge, an associate professor at Ghent University in Belgium, explained that the current pace of improvements in Europe is projected to be slow.

Projections by the International Network for Information on Ventilation and Energy Performance (INIVE) for the European Commission, forecast that only 20% of existing buildings will have adequate ventilation strategies by 2050.  

Working within the context of Belgium’s new legislation, Laverge set out with scientists to implement a strategy to provide data to occupants of public buildings through informed consent, by installing air monitors in the buildings, which was “a cheap and quick way” for people to check on indoor air quality.

However, the programme underscored certain challenges, such as building managers not being fully qualified to implement the monitoring strategy and even knowing which type of monitors to order for measuring key pollutants in real-time.

“Giving the right people (involved in implementing monitoring) the right kind of information is really challenging. As experts, we typically talk amongst ourselves and expect that everybody understands what we are talking about,” he said.

Indoor air quality should be evaluated in every public building 

CO2 monitors measure indoor levels of carbon dioxide; high levels have been associated with reduced cognitive performance.

For such a programme to be effective, Laverge said, “every owner of a public building needs to make or have someone make a risk assessment regarding indoor air quality of every public space in the building that then needs to go through a certification process. The outcome of that is a label that needs to be shown in every public space.” He said this could include levels of healthy and polluted air in indoor spaces, in terms of the calculated impact of the combined pollutants on health.

Catherine Noakes, professor of environmental engineering for buildings at the University of Leeds in the United Kingdom told Health Policy Watch that indoor air quality isn’t getting the attention it deserves,  even amongst engineers and architects. She said their focus is often more on sustainability and climate impact. 

“I don’t think we have health included in the same way,” Noakes said. “It’s important that air quality, water and all the ways in which our built environment affects our health be part of training.”

Cost vs benefits 

Catherine Noakes, professor of Environmental Engineering for Buildings at the University of Leeds, moderated the event.

Noakes lamented the “massive gaps” in guidance and regulations, pointing out that the latest European air quality directives will probably be pushed back due to conservative political opposition. ”We don’t have standards on our air quality and we have nothing to benchmark it against. Then we have this lack of awareness and enforcement, as air is invisible. It’s much more tangible to see your energy bills than it is to see the health consequences of the air quality.”

For Wargocki, improving indoor air quality, even marginally, through better ventilation and source control including particle filtration and elimination of other pollutants, could reap huge economic benefits due to superior work performance and better sleep.

“Every action has a cost, but the benefits here are significant, and they are measurable. We really need to have some economic calculations and involve the experts from the economy to take this into account,” he said. 

But for now, most people continue to be unaware of the health benefits. “We spend a lot of money in our houses, buying expensive beds, and invest more money in fitness and healthy food,” he told Health Policy Watch, “I think we should be educating people that clean aid will bring you similar benefits, but it is difficult for them to visualise.”

A panel combining Swiss parliamentarians and scientific experts at the Bern conference agreed that awareness of the health impacts of indoor air pollutants was key to driving concerted action.

Farrar, the WHO’s scientific lead, meanwhile, called for more cooperation. 

“It is crucial that we bring communities together: engineers, architects, urban planners, urban designers, people who work on infection and non-communicable diseases and in many other social sciences, behavioural sciences, as well as people who think about how our schools and transport is designed”, Farrar said.

“That is tough because we are all in our own individual silos. We need to come together and agree on some common language and a culture in the way we work together.” 

Image Credits: Pelle Sten/Flickr, Edna Winti/Flickr, Geneva Health Forum .

Cameroonian midwife Ashu Martha Agbornyenty speaks on stage at Goalkeepers 2023.

NEW YORK – While the world’s leaders set new global health goals and appraised existing ones at the United Nations (UN) last week, implementing these noble goals falls on the shoulders of people like midwife Ashu Martha Agbornyenty.

Agbornyenty works in poor communities in Cameroon, where the deaths of women and newborn babies are relatively common due to a lethal combination of poor resources, a shortage of health workers and a preference for traditional birth attendants.

The 24-year-old’s passion for uplifting both Cameroonian midwives and their pregnant patients won her the  Changemaker Award presented at a Goalkeepers event hosted by the Bill & Melinda Gates Foundation (BMGF) in New York last week.

Agbornyenty’s For Mom & Baby Foundation, that distributes kits containing essential birth supplies to pregnant women in crisis-stricken areas, runs workshops to prepare women for labour, and writes about the work of midwives and  pregnancy through a blog, Marthie’s Midwifery Diary.

“In the area where I work in Cameroon, there is a political crisis and a lot of the women deliver in bushes,” Agbornyenty told a media briefing last week.

“We partner with hospitals to provide medication to prevent postpartum haemorrhage, which is the leading cause of maternal mortality.

“I am also a young midwife leader working to curb the dropout rate of midwives. When I started as a midwife there was no one to guide me and I wanted to drop out. So far, I have personally guided 185 student midwives to stay in the profession and 40 of these are under my direct mentorship.”

Best practice to save lives

The UN held a summit last week to assess progress to achieve the Sustainable Development Goals(SDG) – 17 global goals adopted in 2015 to address poverty, development and climate by 2030.

The SDG targets were set in 2015, and the halfway assessment is depressing: just 15% of the 17 targets are on track to be achieved by 2030, and eight are going backwards. The target was to end all preventable child deaths by 2030, and cut the maternal mortality rate to less than 70 out of every 100,000 births – but the world is far off track to achieve these.

However, a series of relatively simple interventions could save the lives of millions of mothers and babies and put the world on course to achieve the SDGs related to child deaths and maternal mortality, according to the Gates Foundation’s Goalkeepers 2023 report.

The BMGF has funded research into the biggest killers of mothers and newborns – notably postpartum haemorrhage, the number-one cause of maternal death; anaemia and sepsis – and proposed a package of cost-effective measures to address these.

The key solutions involve: providing a V-shaped drape to health workers to enable them to easily measure a mother’s blood loss during and after labour; giving women in danger of haemorrhaging all five recommended treatments at once instead of sequentially; and replenishing an anaemic pregnant woman’s iron reserves via a five-minute intravenous infusion of iron.

BMGF CEO Mark Suzman said that the interventions had not been invented by his foundation, but that “somebody needed to sponsor the research to see whether, by implementing the various interventions together, you get a statistically significant outcome.”

The Foundation is currently working with the World Health Organization (WHO) to get these interventions introduced as best practices and rolled out as policy at global, regional and national levels – with the potential to save the lives of two million mothers and babies by 2030, added Suzman at a media briefing last week.

Mark Suzman, Gates CEO

PEPFAR re-authorisation

Suzman also said that his foundation was confident that the US Congress would reauthorise the President’s Emergency Plan for AIDS Relief (PEPFAR), which has been being stalled by allegations that some PEPFAR grantees have used grants to provide and support abortion. 

“While we are concerned, we are confident and cautiously confident that the US will be providing the necessary determination,” said Suzman, who described the abortion allegations as “factually untrue”.

PEPFAR was launched in 2003 by President George W. Bush and reauthorized three times so far. According to its most recent report,  PEPFAR has saved 25 million lives primarily through its sponsorship of antiretroviral (ARV) medicine for people with HIV. Millions of people, particularly in Africa, are entirely dependent on PEPFAR for their ARVs.

The Gates Foundation has invested heavily in preventing HIV, and Suzman described PEPFAR as one of the most successful global health collaborations in recent history.

Image Credits: BMGF.

NCD
Group photo of the second annual gathering of the Global Group of Heads of State and Government for the prevention and control of NCDs at UNGA 78.

NEW YORK – With lifestyle and diet risk factors for noncommunicable diseases (NCDs) exacerbated by climate change and air pollution, a group of national and global health leaders called for more intensive action on  NCD prevention and control on the sidelines of the 78th UN General Assembly. 

“NCDs continue to be a public health threat that requires concerted efforts, great investments and prioritization to put countries back on course towards achieving global targets as we inch towards 2030,” said Kwaku Agyemang-Manu, Minister of Health of Ghana, who co-chaired the second annual gathering of the Global Group of Heads of State and Government for the prevention and control of NCDs. 

The gathering on September 21, coinciding with the UN High-Level Meeting on Universal Health Coverage, builds on the first such meeting in Accra, Ghana in 2022, which coincided with the launch of the Global NCD Compact 2020–2030.  The Compact aims to align countries around scaled-up commitments and action on the prevention and control of NCDs essential to achieving both UHC and other health-related Sustainable Development Goals (SDGs).

The meeting was convened and led by the Global Group of Heads of State and Government for the Prevention and Control of NCDs – an informal, voluntary collaboration of countries that signed onto the Global NCD Compact, and committed to developing specific national responses on NCDs, with the aim of reducing related mortality one-third by 2030 in line with SDG target 3.4. 

“You [The Global Group] are on the front line to accelerate and scale up efforts to prevent and control NCDs and mental health conditions and achieve universal health coverage in your countries. Your leadership and the public health effort taken by your countries can save tens of millions of lives in years to come,” said WHO Director-General Tedros Adhnanom Ghebreyesus in opening remarks at Thursday’s gathering. 

Speakers highlighted the progress seen and barriers faced in low- and middle-income countries and regions, with countries such as Barbados, Timor Leste, and Ghana relating stories of the national experiences in the fight against NCDs. 

Alarming Levels of NCD Risk Factors 

Unhealthy, unregulated food is one risk factor for NCDs

The latest edition of the World Health Statistics reflects alarmingly high levels of risks related to many of the key factors that contribute to NCDs, such as heart disease, hypertension, chronic respiratory disease, cancer and diabetes – which together represent some 74% of premature mortality worldwide. Those risks include tobacco and alcohol use, physical inactivity, unhealthy diets laden with sugar, salt and fats, as well as air pollution.

Nearly one in four people (22.3%) globally still use tobacco. Obesity, driven by unhealthy diets and lifestyles, has been on the rise since the 1970s, with the greatest increases in obesity levels now being seen in WHO’s Southeast Asia Region, up from 1.9% to 4.7% (an almost 150% increase) and the Western Pacific Region, up from 2.7% to 6.4% (an almost 140% increase). Hypertension is also on the rise globally, and one of the biggest drivers of deaths from cardiovascular disease. 

Every year, NCDs cause 41 million deaths worldwide, which corresponds to 74% of total deaths, including 17 million ‘premature deaths’ before the age of 70 years.  Of the premature deaths, 86% occur in low- and middle-income countries (LMICs). 

This burden is notably felt in the African region, where between 50% and 88% of deaths in at least seven African countries are due to NCDs, according to the 2022 World Health Organization (WHO) Noncommunicable Disease Progress Monitor. Around two-thirds of Africans with non-communicable diseases (NCDs) die prematurely – before the age of 70. And yet, despite this burden, there remains a large research gap on the continent. 

Climate and Air Linkage 

Prime Minister of Barbados Mia Mottley (on left) speaking at the second gathering of states aligned with the Global NCD Compact.

Additionally, climate change and air pollution add to NCD risks and burden and may worsen mental health conditions. People living with NCDs are especially vulnerable to climate- and pollution-related risks.

In their comments at the meeting, Both Norway and Barbados highlighted the need to bring the linkage between climate and health to the forefront of NCD policies. 

“The question of the effects of climate change in this context is very timely, we have to raise awareness to the threat of climate change on health, not at least on NCDs. Climate change and NCDs are interlinked in many ways,” said Ingvild Kjerkol, Minister of Health of Norway. 

She used the example of extreme heat exposure, extreme weather events, and related to that, the physical and mental stress of displacement and trauma as events that worsen NCDs. 

“The weakest are, as always, at most risk. Climate change will also produce shocks to the health system and to deal with that you need the resilience that comes from universal health coverage.”

In 98% of African countries, the future health, development and safety of children are severely threatened by the effects of climate change, said Mia Mottley, Prime Minister of Barbados, in remarks to the group. 

Mottley’s  “Bridgetown Initiative” has been advocating for creative forms of debt relief to heavily indebted developing nations in Africa and elsewhere, so as to free up funds for more investments in both health and climate.   

“Africa spends more money on debt service than it is now spending on health care. That is a completely unacceptable set of circumstances,” Mottley told the group.    

“In the context of the consequences that we expect to flow from the climate crisis, it becomes even more acute, because there has to be the capacity to respond in ways that we might not otherwise have had to do in the past because of the extreme heat, the extreme cold, extreme droughts, etc. and its impact on households and individuals.”  

Milestones of progress 

Mottley and other national leaders at the meeting provided snapshots of the recent initiatives their countries had undertaken in the fight against NCDs. 

Barbados, for instance, has committed to eliminating trans fats and partially hydrogenated oils by December 2024. They’ve also been working with the Caribbean Community (CARICOM) and the NCD Commission to address front-of-package labelling, which has challenges that Mottley acknowledges.

“[Front-of-package labelling] is one of the areas for small states that is going to be very difficult because we are not producers of goods. We are takers of goods and we therefore would wish to see a hemispheric approach or global approach to this to ensure that those goods which we import, comply with [regulations] and not simply to put regulations in place that cannot be met,” Mottley said.  

Tobacco control and physical activity in Timor Leste

Tobacco products increase the risk of coronary heart disease

In regards to tobacco control, Timor Leste’s first tobacco cessation center, opened last year, has now expanded to six more municipalities. Warning size labels on cigarette packaging have increased, as well as the tax on tobacco, which has increased five-fold, from $19/kg to $100/kg in January 2023. 

In recognition of these achievements, the Minister of Health, Dr. Odete Maria Freitas Belo, was awarded the WHO Director General’s World No Tobacco Day award back in May. 

“If we are sincere about improving the health of our people, the prevention and control of NCDs must remain a top priority,” said President of Timor Leste, José Ramos-Horta. 

He also pointed to Timor Leste’s efforts to promote more physical activity. WHO has supported the Ministry of Health in establishing open-air gymnasiums in various communities, encouraging citizens to embrace an active lifestyle. 

“Our health is decided outside the health sector on where we are born, live, work and play. The cost effective way to battle the scourge of NCDs is to move upstream on the prevention agenda. It is easier to close the tap than to mop the floor,” said Ramos-Horta.  

Vice President of Tanzania Philip Mpango pointed to rapid urbanization and changing lifestyles in Tanzania as among the reasons for the rise in NCDs in the country. While awareness-raising initiatives and early detection programs can make a difference, the fight against NCDs must be a systemic, global effort, he emphasized. 

“As we navigate these challenges, we must acknowledge that the battle against NCDs is not one that Tanzania can fight alone. It is a global issue that requires global solidarity and cooperation,” said Mpango.

“As leaders, we are duty-bound to confront this crisis head-on. Through the measures we have implemented and the support of our international community, we can turn the tide on NCDs in Tanzania and ensure a healthier future for people.”

Image Credits: Sven Petersen/Flickr, Chris Vaughan.

UN Deputy Secretary-General Amina Mohammed holds back tears after revealing that her father died from tuberculosis.

An emotional Amina Mohammed, Deputy Secretary-General of the United Nations (UN), revealed that her father had died of tuberculosis (TB) as she thanked advocates for their work to secure the adoption of the UN political declaration on TB at the high-level meeting (HLM) on Friday.

Urging UN member states to devote the necessary resources to ending one of the world’s oldest and deadliest infectious diseases, Mohammed said that her commitment to ending TB was personal.

“My commitment is my personal story: losing my father to TB at 50, 37 years ago this week,” said Mohammed, blinking away tears. 

“Today we have the tools to diagnose and treat TB, and what we need right now is a vaccine. Let’s end TB now. It is possible.”

Earlier, she described TB as “a major cause of global antibiotic resistance” and “a global health security threat” aggravated by” armed conflicts, economic upheavals and climate disasters”. 

“We must work to address the main drivers of TB: poverty, undernutrition, a lack of access to health services, the prevalence of HIV infections, diabetes, mental health and smoking,” said Mohammed.

Dr Tedros Adhanom Ghebreyesus, World Health Organization (WHO) Director General, joined TB activists chanting “Stop TB” before addressing the HLM.

None of the targets set by the previous HLM on TB in 2018 have been met, largely due to the COVID-19 pandemic, said Tedros.

Member states committed to treating 40 million people for TB between 2018 and 2022, but only 34 million people were reached (84% of target), said Tedros.

However, the biggest failure involves the target of treating 1.5 million people for multidrug or rifampicin-resistant TB  – with slightly over half this target reached (55%). 

While we have new and powerful tools we didn’t have five years ago including a rapid TB test that gives results in two hours and effective treatment “one important thing that we do not have is a new vaccine”, said Tedros.

The BCG vaccine given to infants was developed over 100 years ago and is inadequate for protecting adults and teens.

“That is why the WHO has established the TB Vaccine Accelerator Council to develop, licence and ensure equitable use of a vaccine,” said Tedros, adding that the council had met for the first time this week.

Tedros addressing the UN HLM on TB on Friday

Some new wins for TB

“This declaration contains clear targets for the fight against TB. The TB community should be proud of their amazing work done to secure these targets. However, we know commitments alone aren’t enough and declarations will gather dust without further action,” said Lucica Ditiu, executive director of the Stop TB Partnership.

“In 2018 member states promised to provide $13 billion a year in annual TB funding by 2022, yet they’re providing less than half that amount – who is accountable for the failure to follow through on this promise?”,

The declaration offers a number of new wins for patients, notably “specific, measurable and time-bound targets to find, diagnose, and treat people with TB with the latest WHO recommended tools, as well as time-bound and specific targets for funding the TB response and R&D,” according to a civil society analysis of the TB declaration,

Another big win for the TB community is stronger language around a commitment “to strengthen financial and social protections for people affected by TB and alleviate the health and non-health related financial burden of TB experienced by affected people and their families” and to ensure that by 2027 100% of people with TB “have access to a health and social benefits package so they do not have to endure financial hardship because of their illness”.

There is also the explicit recognition that it is a human right to enjoy the benefits of scientific progress.

But some key targets have also been watered down, such as the erosion of language around gender and human rights with  none of the key asks related to ensuring that all national TB responses are “equitable, inclusive, gender-sensitive, rights-based and people-centred” being secured.

The Stop TB Partnership said that it was working on translating the global targets and commitments to national level commitments,  and ensuring that civil society and TB communities have the resources and tools to ensure leaders follow through on their commitments.”

Future disruptions?

The three political declarations on health adopted this week – on pandemics, universal health coverage and tuberculosis – will be referred to the UN General Assembly for formal ratification, said UNGA president Dennis Francis. It is possible that the 11 member states including Russia, Syria and Venezuela that disputed consensus had been reached on these declarations in a letter sent to the UN Secretary General earlier this week will object then.

“Our delegations oppose any attempt to pretend to formally adopt any of the draft outcome documents in question, during the meetings scheduled for 18, 20, 21 and 22 September 2023, respectively,” the 11 warned.

“In addition, we reserve the right to take appropriate action upon the formal consideration of these four draft outcome documents in the coming weeks, after the conclusion of the High-Level Segment of the 78th Session of the General Assembly, when they must all be considered by the General Assembly in accordance with its rules of procedures.”

However, none of the 11 contested the adoption of the declarations in the HLMs despite some of them speaking during the proceedings.

Activists rally outside the European Union Mission in New York shortly before the HLM, calling on the EU to stop aiding Uganda after it passed its Anti-Homosexuality Act outlawing LGBTQ people.

NEW YORK – While the United Nations (UN) high-level meeting (HLM) on universal health coverage (UHC) adopted a political declaration on Thursday committing member states to accelerate health for all, this will remain a paper promise unless governments invest in primary healthcare.

This was the challenge issued to member states by World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus at the start of the HLM.

“Ultimately, UHC is a political choice. The political declaration you have approved today is a strong signal that you are making that choice, but the choice is not just made on paper,” said Tedros.

“Most of all, it’s made by investing in primary health care, which is the most inclusive, equitable, cost-effective and efficient path to universal health coverage. In particular, investing in primary health care means investing in the people who deliver it: the healthcare workers who are the backbone of every health system.”

Tedros then made three requests of member states: make UHC “the central policy priority for your government”; increase domestic investments in primary health care, health workers and financial protection starting with the most vulnerable; and address the drivers of poor health in “the food people eat, the air they breathe and the conditions in which they live and work”.

Dr Tedros challenges to UN member states to invest in primary healthcare.

Going backwards?

In 2019, the UN adopted a similar political declaration on UHC aimed at ensuring all people have access to health services when and where they need it, irrespective of their financial position. 

But progress towards UHC has stalled since then, primarily due to the COVID-19 pandemic. By 2021 over half the world’s population – at least 4.5 billion people – were not fully covered by essential health services. About a billion spent over 10% of their income on health expenses.

Rebecca Akufo-Addo, Ghana’s First Lady and a UHC champion, told the HLM that “geography, income, education, gender and age continue to exclude many from basic health services” while “a further threat is the rise of non-communicable diseases.”

“We cannot continue to push people into poverty because of illness. We must develop insurance schemes that cover our people,” urged Akufo-Addo.

US activists protesting outside the EU Mission in New York on Thursday against what they describe as EU collusion with the anti-LGBTQ Uganda.

Expanding access to healthcare is also constrained by religious and cultural bias. The EU has not halted aid to Uganda despite that country passing an Anti-Homosexuality Act in May that criminalises LGBTQ people, even compelling health workers to report “suspected” LGBTQ people to the police. Kenya, Tanzania and Ghana are considering similar legislation.

Shortly before the HLM began, activists held a protest outside the EU Mission in New York to protest its ongoing aid to Uganda, holding posters calling for UHC to apply to everyone.

Addressing the HLM, the US and Norway explicitly called for UHC to be inclusive of all marginalised people.

“We must take bold action to include historically marginalised populations and ensure sexual and reproductive health and rights for all,” said Xavier Becerra, US Secretary of Health and Human Services.

“We must include the voices of women, the underrepresented, and LGBTQIA+ populations in our decision-making, and we must meaningfully include all people in all their diversity and reject policies that hinder their access to care because of bias, discrimination, or stigma.”

EU Commissioner Ylva Johansson

EU Commissioner Ylva Johansson said that governments “need to address the determinants of health as well as inequality and gender equality, including sexual and reproductive health, as a prerequisite for equitable, sustainable health systems and UHC”. 

Sexual and reproductive health services are dismal in many parts of the world. At an event earlier in the week, philanthropist Melinda French Gates said that almost half of women in sub-Saharan Africa who wanted contraception could not get it. Meanwhile, access to abortion – even when a woman’s health is in danger – is getting far more difficult in many parts of the world, including the US.

Africa’s ask, EU and Japan’s response

Tunisia’s foreign affairs minister, Nabil Ammar

Tunisia’s foreign minister, Nabil Ammar, speaking for the Africa group, called for “sufficient, predictable and sustainable financing to support national efforts by developing countries [to achieve UHC] through bilateral and multilateral financing, including innovative financing mechanisms and concessional financing”. 

He also called for international financing to support the local and regional manufacturing of medical countermeasures to ensure Africans are protected during health emergencies and pandemics.”

Both Japan and the European Union have invested heavily in UHC. Japanese Prime Minister Fumio Kishida said that his country had made contributions totalling more than $7.5 billion dollars to assist with this.

He also said that G7 leaders had also endorsed the Impact Investment Initiative for global health to pursue expansion of private investment in UHC.

EU Commissioner Johansson said that between 2021 and 2027, EU institutions alone will contribute over €4.4 billion to health system strengthening in countries that most need UHC.

She emphasized strengthening primary health care “as the first line to protect people’s health and defend against infectious disease outbreaks”. 

“We must foster digitalization as a fundamental enabler and exploit the potential of voluntary technology transfers based on mutually agreed terms fully in line with international intellectual property rules,” she said

Image Credits: Kerry Cullinan.

United Nations Secretary-General António Guterres sent a clear message to the world’s largest polluters when he excluded them from his Climate Ambition Summit. But will they listen?

The United Nations Secretary-General, António Guterres, explicitly excluded the world’s five largest emitters of greenhouse gasses – China, the United States, Russia, India and Japan – from his Climate Ambition Summit, held Wednesday on the sidelines of the UN General Assembly.

The United Kingdom, another major polluter, was notably absent from the summit, amid reports that Prime Minister Rishi Sunak had avoided the UN General Assembly after being warned he would be excluded from the climate discussions.

The summit, announced by Guterres in December 2022, was intended to be a “no-nonsense” showcase of the “first movers and doers” fighting to keep alive the increasingly unrealistic goal of limiting global warming to 1.5°C.

By excluding the world’s largest emitters, Guterres sent a clear message to their leaders: you are not taking the climate threat seriously.

“Humanity has opened the gates of hell,” Guterres said. “We must make up time lost to foot-dragging, arm-twisting, and the naked greed of entrenched interests raking in billions from fossil fuels.”

The United Nations kept the final list of world leaders invited to speak at the climate summit under wraps until the eve of the meeting on Tuesday.

In the months leading up to the summit, Secretary-General António Guterres made clear that only countries that had taken significant steps to address climate change would be invited. Invited countries were also required to send a high-level leader to the summit.

Several G20 countries made the final cut, including Brazil, Canada, South Africa, and nine European Union countries, among them Germany, France, and Spain.

“To all those working, marching and championing real climate action, I want you to know that you are on the right side of history and that I am with you,” Guterres told the General Assembly on Tuesday. 

“One summit will not change the world, but today can be a powerful moment to generate momentum,” Guterres said. “We can and we must turn up the tempo.” 

Excluded leaders show few signs of caring 

Rishi Sunak announced a U-turn on net zero targets from London during the Climate Ambition Summit on Wednesday.

The lineup at the climate summit on Wednesday stood in sharp contrast to the two previous UN climate action summits in 2014 and 2019.

In 2014, then-UN Secretary-General Ban Ki-Moon hailed the gathering of a record number of heads of state, business leaders and civil society as “a great day for climate action”.  In 2019, 65 countries made pledges to cut carbon emissions, and heads of state from every major nation attended, including Indian Prime Minister Narendra Modi and former US President Donald Trump.

But this year, the climate summit convened by the UN Secretary-General had not even concluded by the time Guterres received a stark sign that major polluters were not listening.

As the Climate Ambition Summit got underway at UN headquarters in New York, British Prime Minister Rishi Sunak — the first prime minister to skip the U.N. General Assembly in a decade — announced plans to renege on many of the UK’s existing climate commitments, including ones made by his Conservative predecessors, such as former Prime Minister Boris Johnson, who hosted the COP26 Conference in Glasgow in 2021.

The move follows Sunak’s vow to “max out” U.K. fossil fuel reserves in the North Sea in August. Infosys, a six-trillion-dollar company founded by Sunak’s father-in-law, signed a $1.5 billion deal with British Petroleum just two months before Sunak announced the new oil and gas drilling licenses.

Shell CEO Wael Sawan, who called the phase-out of fossil fuels “dangerous and irresponsible” on July 6, 2023, the hottest day ever recorded in human history at the time, is a member of British Prime Minister Rishi Sunak’s business council.

Guterres’s message to the world’s largest polluters at the Climate Ambition Summit was further undermined by the fact that most of the key leaders he barred from the summit — Chinese President Xi Jinping, Russian President Vladimir Putin, and Indian Prime Minister Narendra Modi — chose not to attend the UN General Assembly in the first place.

Brazil makes ambitious commitment to halve emissions by 2030

Brazilian minister for the environment, Marina Silva, announced at the climate summit that her country aims to cut its carbon emissions by 48% by 2025, and 53% by 2030. Silva made the announcement in place of President Luiz Ignacio Lula da Silva, who missed the summit due to illness.

The ambitious goals mark a significant shift in Brazil’s climate policy under Lula, who has vowed to reverse the environmental damage done by his predecessor Jair Bolsonaro.

Bolsonaro presided over a period of mass deforestation in the Amazon and denied the existence of climate change.

European Union on track to surpass its 55% reduction goal

European Commission President Ursula von der Leyen told the summit the EU is on track to surpass its goal to reduce greenhouse gas emissions by 55% by 2030. The EU will also continue to contribute its “fair share” of $27 billion to the global climate finance fund, she said. 

Her counterpart, European Council President Charles Michel, told the General Assembly on Tuesday that the EU is committed to ensuring that concessional finance is available to countries that need it.

Michel compared the current global financial architecture to “an old house, built in another time, for another time”. 

“We need to make sure everyone has fair access to financing,” Michel said. “It costs eight times more for African economies to borrow than it does the rest of the world.”

“That is simply unfair,” he said.

Only 17 Countries call for a global “phase-out” of fossil fuels 

Carbon capture and storage technologies will play a minimal role in mitigating global emissions, according to Climate Action Tracker.

The heads-of-state of 17 countries, including Kenya, Colombia, a group of small island states, and EU countries such as France, Belgium, Denmark, and Spain, published a letter ahead of the Climate Ambition Summit calling for a global phase-out of fossil fuels.

“There can be no more pretence that anything other than staying within 1.5 degrees is an acceptable limit to pursue,” the letter warned.

The statement by the 17 countries explicitly denounced the idea that carbon capture technologies can be a solution to the climate crisis.

“[Carbon] abatement technologies have a role to play in reducing emissions, but that role in the decarbonization of energy systems is minimal,” the letter said. “Systemic transformations are needed across all economic sectors, driven by a global phase-out of fossil fuels.”

The statement by the 17 countries directly contradicted the position of the United Arab Emirates, host of this year’s upcoming UN Climate Conference COP28, which aims to focus on reducing emissions rather than phasing out fossil fuels.

Critics say that the UAE’s stance, shared by other petrostates such as Saudi Arabia, would place untested carbon capture technologies at the center of global mitigation efforts and disincentivize critical investments in renewable alternatives to fossil fuels.

Fossil fuels are currently currently subsidized at a rate of $7 trillion every year, according to the International Monetary Fund.

Most climate scientists agree that carbon capture and storage technologies can play only a minimal role in decarbonising the economy. A recent report by Carbon Action Tracker found that such technologies will play, “at best, a minor role” in helping the world reach the 1.5°C target set in the 2015 Paris Agreement. 

“The direction for all fossil gas, whether equipped with carbon capture and storage or without, is the same: It’s one of swift decline,” Neil Grant, one of the Carbon Action Tracker report’s authors, told Semafor.

The high-ambition position statement also called for trillions of dollars in climate financing and financial system reforms to address the climate crisis.

“The mobilization of finance for climate action must reach the trillions, and we must put in place financial system reforms to be responsive to the multitude of crises the world faces today,” the statement said.

“No country should have to choose between fighting poverty and fighting for our planet.”

Money, justice, and global finance reform 

Mia Mottley, Prime Minsiter of Barbados, began campaigning for the Bridgetown Initiative at climate talks in Glasgow in 2021.

Guterres has made climate change the cornerstone of his tenure, and the agenda of the Climate Ambition Summit reflected his flagship issues.

Top of the list is a call for reforms to the global financial system and multilateral banks – which Guterres calls a “new Bretton Woods moment” – and securing climate justice through a surge in climate finance.

Mia Mottley, the prime minister of Barbados and a leader of the movement to reshape the global financial architecture to help countries such as her own adapt to climate change, described the lack of climate finance as “almost a crime of humanity” at the Climate Ambition Summit.

UN Secretary-General António Guterres also called on world leaders to fully operationalize the Climate Loss and Damage Fund, which was agreed to at COP27 in Sharm el-Sheikh in December 2022 after years of resistance by major polluters.

The fund is supposed to support climate adaptation and mitigation in poor nations, which emit a tiny fraction of the world’s greenhouse gases but are suffering a large brunt of climate impacts. However, the mechanisms for financing the fund, prioritising countries’ needs, and delivering money remain poorly defined.

“Make no mistake, the storm is gaining strength,” Samoan Prime Minister Fiame Mata’afa told the summit in a statement on behalf of the Alliance of Small Island States, which face an imminent and existential threat from climate change. 

“The pursuit of profit over the well-being is not right – it is unjust,” Mata’afa said. “Our contribution to greenhouse gas emissions is less than 1%. The G20 is responsible for 80% of the emissions.”

Civil society’s hopes for climate justice now rest on the outcome of the UN Climate Summit set to take place in Dubai in November.

“We the people of the global south are not asking for aid or assistance,” said Lidy Nacpil, coordinator of the Asian People’s Movement on Debt and Development. “Climate finance is an obligation, and part of reparations for the historical and continuing harms and injustice.” 

“We have a right not just to survive, but to build a better home and future for our children,” Nacpil said. 

Image Credits: UK Foreign Office, Climate Action Tracker, UNCTAD.

Plenary panel of the High Level Meeting on Pandemic Prevention, Preparedness and Response, Wednesday 20 September.

NEW YORK – A long-awaited political declaration by United Nations (UN) member states on more effective pandemic preparedness and response was approved at a High-Level Meeting (HLM) on Wednesday – without the anticipated political objections raised by 11 member states including Russia in a letter to the global body earlier in the week.

The declaration is a milestone insofar as it signals recognition by the world’s heads of state that pandemic threats are existential threats, much more than simply health emergencies, said Carolyn Reynolds, co-founder of the Pandemic Action Network, which has pushed for a broader approach to pandemic preparedness and response since the onset of the COVID pandemic: 

“Pandemic prevention, preparedness and response is so much more than a national health issue; it is a national and global security and economic issue. Like climate change, pandemics are a global systemic risk and existential threat to humanity, and we need to treat them as such.”

No real commitments

At the same time, the declaration has been bitterly criticised as a text that is largely rhetorical and devoid of real commitments, beyond the pledge to convene another high-level meeting in 2026. During the member state comments following the plenary, heads of state from the world’s leading countries were noticeably absent, with most of the interventions led by ministers of health. 

At least for the upcoming year, the ball is now back in the court of World Health Organization (WHO) member states, which must come to agreement on an effective pandemic accord that places equity at the center of the global response, said former New Zealand Prime Minister Helen Clark, co-chair of the Independent Panel, the WHO-appointed body that issued a scathing report on shortcomings in global pandemic response in 2021.  

WHO member states also must agree to revisions in WHO’s International Health Regulations (IHR) that empower the Organization to “sound the alarm rapidly with evidence and without bureaucracy,” Clark said.

“The Geneva processes, they must be ambitious,” Clark told the HLM. “A new pandemic accord can commit countries to strengthen national health systems surveillance, solidarity and equity. This is the world’s next opportunity. Please don’t miss it in Geneva.”

Helen Clark, former prime minister of New Zealand and former co-chair of The Independent Panel on Pandemic Prevention, Preparedness and Response

Governance: who leads?

Critics have also expressed misgivings about the ability of WHO, representing politically weak health ministries, to oversee and enforce the kinds of tough, binding commitments that would be needed for effective pandemic response.  Those concerns have been behind the push to make UN fora platforms for pandemic debate and decisions.

Advocates for more UN-centred action have proposed the creation of an independent pandemic governance mechanism in the office of the UN Secretary-General, and/or a UN Global Threats Council, to oversee the implementation of any pandemic accord approved by WHO member states.

“I continue to believe that action at the head of state and government level is so needed to help break the cycle of panic and neglect, which sets in around pandemics and to sustain political momentum around preparedness and response,” said Clark, who has called for the creation of a UN-hosted Global Threats Council. 

“And then on accountability. independent monitoring of country preparedness is needed to guarantee our mutual assurance, compliance and accountability with international agreements.” See related story.

Leaders Suggest UN May Be More Appropriate to Lead Pandemic Response Than WHO

R&D and tech transfer 

And a pandemic accord is only the beginning. There need to be much broader reforms in mechanisms to finance improvements in developing country health systems, as well as ensure R&D and technology transfer, HLM speakers  emphasized.  

“There has to be a pre-negotiated and financed end-to-end ecosystem for medical countermeasures,” Clark said.”Every region on earth needs the technology, the knowledge and the local capacity to stop outbreaks when and where they occur, and essential supplies to safeguard human life must be accessible. No country should be at the mercy of global markets to protect their citizens. 

Drowning in debt

Amina Mohammed, deputy UN Secretary-General

As for finance, while some $2 billion has been gathered for a new World Bank managed Pandemic Fund, that is woefully inadequate in comparison to the sums required for debt-burdened countries to improve their health systems and prepare hospitals, data systems and laboratory facilities to meet future threats, critics have said.  

An SDG “stimulus” package including “deep” reforms to the international financial architecture is needed to empower countries, UN Deputy Secretary-General Amina Mohammed stressed. 

“Many developing countries are drowning in debt,” Mohammed told the high level meeting, echoing remarks at a SDG Summit on Monday. 

“Today Africa spends more on debt service costs than on health care and education. We need a finance boost so that countries can invest in universal, resilient health care; their populations have a right to [access]. 

“We’re calling on countries to support the stimulus to scale up affordable long-term financing by at least $500 billion per year, and to support the development of an effective debt-relief mechanism that supports payments, suspensions, longer lending terms and lower rates for developing countries that are drowning in debt – and create the fiscal space to spend on the health that people have a right to [enjoy].”

Strong signal, but not binding 

WHO Director General Dr Tedros Adhanom Ghebreyesus at a press briefing on the High Level declaration on pandemics.

The declaration is a strong signal that countries are committed to learning the lesson of the COVID pandemic.and strengthening the world’s defenses against pandemics, said WHO Director General Dr Tedros Adhanom Ghebreyesus.  

“For too long, the world has operated on a cycle of panic and neglect. When an epidemic or pandemic strikes, response is in crisis mode and when it passes, they move onto the next crisis and fail to learn the lessons that could prevent or mitigate the next epidemic or pandemic,”  said Tedros, speaking at a press briefing shortly after the declaration’s approval. 

The WHO Intergovernmental Negotiating Body (INB) will resume meetings on the Geneva pandemic accord text and discussions on the text in November, with further meetings scheduled for December and January, said Dr Jaouad Mahjour, head of the WHO Secretariat supporting member state negotiations in the INB and in a parallel body for revisions to the IHR. 

Key divisions have emerged between developing and developed countries over Pandemic Accord language around equity and access to the diagnostics, treatments and vaccines that would be needed to counter any future pandemic. 

At the same time, there are geopolitical divides over the process by which new pathogen threats might be reported more rapidly and effective action taken, with fears that such commitments could somehow erode national sovereignty.  

“The process is a bit slow and there are contentious issues that have to be addressed,” said Tedros of the Geneva negotiations. “But the good news is that the areas are now identified and member states are going to get into real negotiations on the issues that are dividing them, and I hope that they will have a way to address these differences and find common ground.”

“Today’s agreement is very historic and we hope it will give energy, it will give negotiation energy and push it forward.”  

NEW YORK – Despite the weaknesses of the political declaration on Pandemic Prevention, Preparedness, and Response (PPPR) expected to be adopted by the United Nations (UN) High-Level Meeting (HLM) on Wednesday, some world leaders believe that the UN is a more appropriate forum to thrash out the global pandemic response than the World Health Organization (WHO).

Juan Manuel Santos, former President of Colombia and a member of The Elders, believes that the UN may be the better forum as “pandemic preparedness encompasses far more than health”.

Santos told a UN side meeting on Tuesday hosted by the Pandemic Action Network (PAN) that if the pandemic accord negotiations are still “mired in confusion” by the time the WHO Intergovernmental Negotiating Body (INB) meets for the seventh time later this year,  “someone has to say, enough, we need to shift it back to New York.”

Mary Robinson, former Irish President and Chair of The Elders, supported Santos’s view that pandemic negotiations should be at the UN. 

“We do need to strengthen the WHO, but we need to realise pandemics affect the whole economy. It has an incredibly devastating impact that drives countries into debt,” said Robinson.

“The world is dismally prepared for the next pandemic, which is definitely coming,” warned Joy Phumaphi, chair of the Global Preparedness Monitoring Board, adding that her body’s report on global readiness would be released in six week’s time.

Next steps?

Alejandro Solano Ortiz, Costa Rica’s Vice Minister for Multilateral Affairs, said that while he was optimistic that the declaration would be passed, “what are the next steps?

“This is a non-binding declaration. It’s just a political declaration, and we need concrete steps in this process to complement the Geneva [WHO] process.”

WHO member states are currently involved in two pandemic negotiations: strengthening the International Health Regulations (IHR), the only legally binding global rules governing health emergencies, and negotiating a pandemic accord to address gaps that emerged during COVID-19, particularly equitable access to vaccines and medicines.

Winnie Byanyima, Executive Director of UNAIDS, said that any future pandemic response needed to be based on technology-sharing to enable more equitable access to medical products.

Byanyima also said that many countries were unable to invest properly in health and pandemic preparedness as they were servicing debts that were bigger than their health budgets.

But Dr Magda Robalo, president of The Institute for Global Health and Development, said that “there is no way we are going to prevent, prepare and respond to pandemics if we don’t address the critical issue of the healthcare workforce.”

However, she too stressed that countries with massive debt repayments were unable to invest in their health systems and health workforce.

Global Threats Council

Helen Clark

Meanwhile, Helen Clark, former Prime Minister of New Zealand and former co-chair of The Independent Panel on PPPR, repeated the panel’s call for the establishment of a “high-level Global Threats Council” as a UN standing committee. 

It would be tasked with “really keeping everyone on their toes about the need for preparedness, and also support the mobilisation of finance to support […] the capacity of low and middle-income countries,” she said.

The Independent Panel had uncovered 16 previous reports about how unprepared the world was to address pandemics, as well as a previous call for a Global Threats Council to be set up following the Ebola outbreak.

“We have to break the cycle of panic and neglect. As we’ve seen with the COVID pandemic, which really isn’t over, we’ve been through the panic phase, and we’re well into the neglect phase. To break that, you need sustained political attention on the importance of preparedness and response because otherwise we will be doomed to repeat the painful lessons of history,” said Clark, reminding the audience that excess mortality during the COVID-19 pandemic was in excess of 24 million people.

Climate and health

Robinson also called for closer collaboration between the climate and health sectors, and for health to follow the lead of the climate sector, which is “trying to have the broadest climate justice movement possible”.

In the face of a massive fossil fuel lobby, climate activists are “trying to gather all the forces” and “the health space needs to widen the circle as much as possible. Health is everybody’s business [and we need] the same kind of connected movements.”

Mary Robinson, chairperson of The Elders

Most of the speakers at the PAN event expressed frustration that the declaration did not commit member states to any action. 

Zeid Ra’ad Al Hussein, former UN High Commissioner for Human Rights and also a member of The Elders, said that weaknesses in the UN system itself needed to be addressed.

“Some parts are highly developed and mature, where the mechanisms are layered and there’s a measure of surrender of sovereignty, which is acceptable. Then parts of the UN system are highly underdeveloped, almost primitive, and it’s staggeringly slow getting anything done. Health is one such sector. The other is climate,” said Hussein.

“In human rights, you have an interesting array of different incentives and disincentives to get governments to do things. That doesn’t exist where you have only a voluntary system and that is where we are with health.”

Glimpse of Bharat Mandapam in Pragati Maidan ahead of the G20 Summit, in New Delhi on September 06, 2023.

Health systems in Africa are under considerable strain: rapid demographic change, rising non-communicable diseases, and emerging and re-emerging threats such as COVID-19 and Ebola are increasing demands on limited health services.

Africa, however, faces a challenging period in health financing to meet these increasing needs. Health spending in most countries remains far short of what is needed to achieve universal health coverage, and in several countries, high debt service has outpaced domestic spending on health and education.

There is no indication from donors that development assistance for health will increase to meet these needs, which means that domestic financing will have to close these critical gaps.

These challenges need an integrated national, regional, and global response. Yet, the global development and health financing architecture has, historically, excluded Africa’s voice from important decisions. 

G20 countries have begun to collectively shape the post-COVID health financing agenda. The group has created a Joint Health and Finance Task Force, and launched the G20 High-Level Independent Panel on the best way to finance pandemic preparedness going forward. 

The African Union’s (AU) admission to the G20 therefore provides an opportunity for Africa to be recognized as a true strategic partner in development; for the continent to make critical inputs to decisions on its development, including health financing reforms; and has the potential to reinvigorate Africa’s resolve to reform domestic issues that hold back the potential for sustainable domestic financing of health. 

But questions remain about what kind of opportunity this presents: would the G20 membership provide true co-ownership? Would it present equal partnership to engage in meaningful and respectful partnership that would bring true and lasting change to Africa’s development? 

An opportunity for Africa’s voice to be heard and acted upon

A COVAX vaccine delivery to Africa in April 2021.

Historically, Africa has often been excluded from discussions and decisions that impact development and health on the continent. Two recent initiatives with little room for Africa’s voice and participation include the design of COVAX and the design and operation of the Pandemic Fund. 

A recent evaluation of the COVAX facility showed that the design of this important initiative had insufficient inputs from beneficiary countries, including those in Africa. Yet, this facility was intended to make substantial inputs into how the COVID-19 financing and response was implemented in Africa. 

“The original design process was driven by a small subset of stakeholders, notably donors and industry of the Global North, without the meaningful engagement of beneficiary countries,” the evaluation noted.

Similarly, the Pandemic Fund—a creation of the G20, sought to have game-changing impacts on the financing of pandemic preparedness and response globally. Yet, the Africa Centers for Disease Control and Prevention (Africa CDC), Africa’s foremost continental health agency with the mandate to lead public health policy and action in Africa, has yet to be accredited as an implementing partner of the Fund. 

Instead, the Africa CDC is represented as an Observer on the Pandemic Fund’s Governing board, denying it a full seat at the table where crucial decisions are made and preventing it from designing a coordinated regional response.

This limits the meaningful participation of the continent in the activities that seek to impact the pandemic preparedness and response landscape in Africa. As a result, in the first allocation of funds by the Pandemic Fund, Africa is the only continent without a funded regional proposal. 

Going forward, the AU can use its voice within the G20 to ensure that this doesn’t happen again and that it has a seat at the table on all future global health decisions that affect its development: this might include international trade practices, the impacts of climate change, and the growing threat of antimicrobial resistance. 

Africa can now contribute its voice on these issues at the G20 in unison.

Two key health financing concerns for the G20 to consider: debt relief and reforming global health aid

Interest payments in Africa have increased by 132% over the past decade, according to the UN Conference on Trade and Development (UNCTAD).

The G20 membership presents an opportunity for Africa to boldly confront two key global issues that hold it back from achieving its health financing goals. 

Firstly, about 23 African countries are in or at high risk of debt distress. Debt service has clearly outpaced spending on health and education, with consequences on other sectors of the economy. With many of Africa’s creditors in the G20, Africa has an opportunity to make the case for debt relief to assist it with rebuilding its health systems. The G20 has done this before—at the height of the COVID-19 pandemic, it suspended  $12.9 billion in debt service payments. 

Secondly, the AU could press the G20 to revisit prior agreements on aid effectiveness to ensure that foreign aid is properly monitored and aligned with national and regional priorities.

This is timely as many stakeholders are now calling for substantial reforms of the global health architecture, including major institutions such as the Global Fund and Gavi, to increase country ownership and strengthen country capacity in a sustainable manner, while charting a clear path to ending dependence on these institutions. 

Africa can therefore use the G20 as a means through which to establish a new compact for donor and domestic financing of health services that puts African governments back in charge of setting health priorities and funding core services, with aid restored to its place as a supplementary health financing stream.

An opportunity for a coordinated African domestic policy response

The G20 membership also has the potential to spur African countries to act on areas where there has been little progress in the past. Despite skepticism about the potential for domestic resource mobilization for health in Africa given the ongoing economic challenges, there are opportunities to boost domestic financing by introducing non-traditional or innovative financing mechanisms. 

Taxes on alcohol, tobacco, and sugar-sweetened beverages are lower in Africa than in all other regions. By “soft-earmarking” these funds for health, they can mobilize popular support, raise finance, and combat the growing burden of non-communicable diseases.

In addition, to mitigate the devastation of the COVID-19 pandemic on economies in Africa, countries should explore other forms of raising (for example through airline levies, import and other duties) and channel domestic resources to strengthen national and regional health systems and public health functions. 

Furthermore, the time is right for African countries to strengthen their public financial management systems and introduce the use of evidence-informed priority-setting mechanisms to improve efficiency in health system decision-making to ensure that resources are channeled to the most effective and cost-effective health interventions.

Concluding Reflections

The admission of AU into the G20 is timely and welcome.

It presents an opportunity to reflect on Africa’s role in ongoing global development and health financing conversations. It gives Africa a voice and a long-overdue seat at the table of global health financing reforms. 

It enables Africa to renegotiate debts to spur investment in health systems, to input into reforms of the global health architecture, and to establish a new compact for donor and domestic financing of health services that puts African governments back in charge of setting health priorities.

Finally, it gives Africa an opportunity to overhaul its financing systems to appropriately prioritize health in its spending through national budgets. 

Now is the time to move from agenda to action.

Authors

Justice Nonvignon is Acting Head, Health Economics and Financing Programme, Africa CDC. He is also a Professor of Health Economics at the University of Ghana, and Non-Resident Fellow of CGD.

Boima S. Kamara is the Health Financing Advisor at the Health Economics and Financing Programme, Africa CDC. He is a former Minister of Finance and Economic Planning, Republic of Liberia and former Deputy Governor (Research and Monetary Policy) of the Central Bank of Liberia.

Pete Baker is a Policy Fellow and Deputy Director of Global Health Policy, Center for Global Development.

Javier Guzman is a Senior Policy Fellow and Director of Global Health Policy, Center for Global Development.

Jean Kaseya is Director General of the Africa Centres for Disease Control and Prevention, African Union.

Image Credits: India Ministry of Culture, WHO.

NEW YORK CITY – World leaders issued a political declaration Monday warning that the world is nowhere close to achieving the Sustainable Development Goals (SDGs) it set in 2015. The declaration, adopted at the first UN high-level political forum on the SDGs since 2019, comes at a time when progress on the goals has been slowed by the COVID-19 pandemic, the war in Ukraine, and other crises.

UN Secretary-General Antonio Guterres billed the Sustainable Development Goals summit as a chance to agree on a “global rescue plan” to save the SDGs. Failure to achieve the SDG targets will leave millions of people around the world without access to education, quality healthcare, food, and routes out of poverty, Guterres told world leaders gathered at UN headquarters in New York City. 

“You made a solemn promise, a promise to build a world of health, progress and opportunity for all, a promise to leave no one behind, and the promise to pay for it,” Guterres told world leaders at the summit’s opening ceremony. “This was not a promise made to one another, as diplomats, from the comfort of these chambers. It was always a promise to people.

“Instead of leaving no one behind, we risk leaving the SDGs behind,” said Guterres. “The SDGs need a global rescue plan.”

Politics over people

Since the start of his invasion of Ukraine, Russian President Vladimir Putin has leveraged the importance of the Black Sea corridor to global food security to obtain concessions from the international community.

The political declaration was approved by world leaders without objection on Monday morning. However, a coalition of 11 authoritarian countries, led by North Korea, Russia, Iran, Venezuela, Syria and Belarus, also published a 17 September letter to UN General Assembly President Dennis Francis in which they stated that they did not consider today’s decision binding. 

The countries said that their objections to language in the declaration had been ignored and they “reserve the right to take appropriate action upon the formal consideration” of the documents in the UN General Assembly later in this autumn’s session.

The countries are reportedly upset over the deletion of a clause in the declarations calling on countries to refrain from “unilateral” trade and economic sanctions. But the rift also goes to the heart of the world’s major geopolitical battles, and the political and social conservatism of the countries involved (see related story). 

The first in-person appearance of Ukrainian President Volodymyr Zelensky at the UN General Assembly has heightened political tensions. At a critical juncture for the SDGs that are supposed to help the world’s poorest people, experts worry the week could be derailed by politics. 

“Rising authoritarianism, democratic backsliding, but also geostrategic competition and economic distress: those are likely to overshadow other fundamental issues related to climate change and global development,” Noam Unger, a development expert at the Center for Strategic and International Studies told AFP.

At half-time, the world is not close to SDGs

The world is set to miss its 2030 hunger eradication target by 600 million people.

The SDG targets were set in 2015, and the deadline was fixed for 2030. At halftime, the score is depressing: just 15% of the 17 targets to transform the world are on track to be achieved by 2030, and eight are going backwards.

Half a billion people are on course to remain in poverty in 2030, while nearly 100 million children will be out of school. Last year, 735 million people faced acute hunger.  

“Can we accept these numbers? Or because they make us uncomfortable, should we pretend they do not exist and carry on with business as usual?” said UN General Assembly President Dennis Francis.  

Poverty eradication, gender equality, education and hunger have all faced setbacks amid several crises, including the COVID-19 pandemic, Russia’s invasion of Ukraine, a food and energy crisis and climate shocks.

Finance is “fuel”

The success of Guterres’ rescue plan hinges on several key financial provisions that all have one thing in common: more money.

The provisions in the draft declaration include a call to recapitalise the multilateral development banks – the International Monetary Fund and the World Bank – and rework the “international financial architecture” that forces developing countries to pay more to borrow money and blocks foreign investment.

“Instead of leaving no one behind, we risk leaving the SDGs behind,” said Guterres. “This can be a game changer … [we] need to reform the international financial architecture that I consider outdated, dysfunctional and unfair.”

Financing is the lifeblood of the Sustainable Development Goals (SDGs), but developing countries are falling short on the trillions of dollars they need to achieve them, Guterres warned. 

“I accept that there may not be enough public money, and to that extent, how do we mobilise money?” said Barbados Prime Minister Mia Mottley, a leading figure in the fight for global financial reform. “The major multinational corporations have balance sheets that dwarf and miniaturise the majority of countries in this room.

 “We have to find a way of them contributing to the financing of global public goods,” said Mottley.

 In some regions of the world, the deadly interplay between conflict, climate and poverty means money is just one part of the solution. Conflict hits women, children and other vulnerable groups the hardest. 

“[We] need to recognise the intertwined nature of the challenges that we are facing with climate, with pandemics, with fragility, with war, and with food insecurity,” said World Bank President Ajay Banga. “We cannot solve one without having a holistic view of the total.

Hunger: missing SDGs leaves people behind

Global hunger took centre stage as a stirring example of the lives changed by missing the SDGs.

The world is currently set to fall 600 million people short of its goal of ensuring not a single person goes hungry. Some 2.4 billion people, 30% of the global population, did not have constant access to food in 2022.

“In our world of plenty, hunger is a shocking stain on humanity and an epic human rights violation,” said Guterres. “It is an indictment that millions of people are starving in this day and age.

“The SDGs aren’t just a list of goals. They carry the hopes, dreams, rights and expectations of people everywhere,” said Guterres.

Image Credits: Mohammed Omer Mukhier/Twitter , UNCTAD.