The G20 and G7 may be aligned in their prioritisation of health and well-being, but globalisation means that health and its related issues cannot be viewed in a silo
By Brittaney Warren, Global Governance Project
On 28–29 June 2019, Japan will host the G20 summit for the first time. One key issue on the agenda is universal health coverage. The World Health Organization defines universal health coverage as ensuring access to quality and affordable health care for all across the full spectrum of healthcare provision — prevention, promotion, treatment, rehabilitation and palliation. Universal health coverage is at the centre of the 2030 Agenda’s Sustainable Development Goal 3 on health, to reduce poverty and inequality worldwide. The G7 and G20 have steadily expanded their governance of universal health coverage since addressing it directly for the first time in 2016.
G7 leaders’ health conclusions
Since 1979 G7 leaders have dedicated more than 48,000 words to health in their communiqués, starting with malnutrition, drug addiction and HIV/AIDS. Throughout the 1990s, the agenda expanded to include ageing populations, thus addressing the palliative component of universal health coverage, and also child and maternal mortality and the environment-health link. The groundwork was laid for universal health coverage with references to healthcare funding and prevention, education, treatment and rehabilitation for specific diseases, namely HIV/AIDS.
Throughout the early 2000s more specialised subjects appeared, on micronutrients and food safety systems, active ageing, debt relief, AIDS orphans, healthcare technologies and workers. This decade ushered in globalisation and the Millennium Development Goals, and with them a broader view of health care as a system of services that should be equally accessible to all. This view included providing health care and responding in cases of emergency, particularly to natural and human-made disasters.
Thus strengthening healthcare systems acquired a greater place in the G7’s communiqué-recorded public deliberations since the mid-2000s. This started with a regional focus on systems strengthening for Africa, then expanded at the 2008 Hokkaido-Toyako Summit to a more global focus. However, the term ‘universal’ was still only used at that time to refer to health care for HIV/AIDS patients and to women’s reproductive health (introduced at the 2010 Muskoka Summit), a key health target of the MDGs.
The G7 first publicly used the term universal health coverage at its 2016 Ise-Shima Summit. Of the 164 paragraphs on health at Ise-Shima, 18 (11%) referenced universal health coverage. Other paragraphs discussed the global health architecture, global health security and the new SDGs, in particular on women’s health. The multisectoral One Health approach for the emerging anti-microbial resistance threat also appeared.
Yet at the subsequent 2017 Taormina Summit and the 2018 Charlevoix Summit, the term universal health coverage was not used, although health systems strengthening and access to health care were.
G7 health ministers’ conclusions
The G7 health ministers were ahead of their leaders, first referring to universal health coverage at their 2015 Berlin meeting. At their 2016 Kobe meeting, universal health coverage appeared in the preamble to the communiqué and received a stand-alone section. Although the leaders focused on the important gender aspect of health and universal health coverage, the ministers took an even more holistic approach, linking health with other targeted or neglected demographics, including the elderly, refugees and immigrants. They also linked the SDGs with water-borne illnesses and with digitisation.
At the 2019 Paris meeting, universal health coverage and the health-related SDGs were again referenced in the preamble. The 2019 United Nations High Level Meeting on UHC was mentioned in the following paragraph. Thus, while universal health coverage somewhat fell off the leaders’ agenda in 2017 and 2018, the health ministers maintained some momentum for 2019.
G7 leaders’ commitments
Since 1975, the G7 leaders have made 410 health commitments. As with their public deliberations, throughout the first two decades of the G7’s existence, commitments referred to some underlying concepts but not universal health coverage as a whole. Throughout the 1980s and ’90s, concepts related to universal health coverage were disease-specific and sought to prevent and treat diseases such as HIV/AIDS. At the 2000 Okinawa Summit, the G7 committed to develop equitable and effective health systems. The 2002 Kananaskis Summit made 10 commitments focused on sustainable health systems for Africa. Access to health care for the poorest arose at the 2003 Evian Summit.
At the 2006 St Petersburg Summit the overall number of health commitments rose sharply to 60. Some of these were on health systems strengthening, including implementing WHO’s International Health Regulations, and on funding, but none referenced universal health coverage. At the 2007 Heiligendamm Summit the G7 made commitments on primary and universal health care for HIV/AIDS patients, and on increasing affordability and accessibility to healthcare services in Africa.
The MDG-health link was made at the 2008 Hokkaido-Toyako Summit, taking the G7 health agenda from a regional to a global focus, while adding a funding commitment of $60 billion over five years. At Muskoka in 2010, the G7 made three commitments referencing universal health coverage concepts: universal health care for HIV/AIDS patients, strengthening healthcare systems for HIV/AIDS patients, and making progress on MDGs 4 and 5 regarding child and maternal health.
At the 2014 Brussels Summit the G7 put WHO at the centre, committing to support its Global Health Security Agenda and International Health Regulations. The 2015 Elmau Summit committed to put health promotion at “the centre of [their] growth agenda” and to base national action plans on the multisectoral One Health approach for AMR.
Of the 85 health commitments made at the 2016 Ise-Shima Summit, 20 (24%) referenced universal health coverage. The leaders also committed to implement the health-related SDGs, to achieve universal health care for women and girls, to promote the One Health approach for AMR and to support health systems strengthening.
Yet this progress was not sustained at the 2017 Taormina or 2018 Charlevoix summits, where health systems strengthening, access and affordability were committed to, but universal health coverage as a whole was not.
G7 health ministers’ commitments
The G7 health ministers have made 205 commitments at the five meetings they have held. The first meeting was in St Petersburg in 2006, with 14 commitments made. Two of these referenced the IHR, but none referenced universal health coverage. The next meeting was held in Berlin in 2015, with 36 commitments made. These included strengthening health systems and applying the One Health approach for AMR, but again no commitment on universal health coverage was made.
At Kobe in 2016, eight (21%) of the 38 commitments were on universal health coverage, including one that referenced the SDGs. Eleven other commitments were made on the global health architecture for public health emergencies, and there were commitments on ageing. No universal health coverage commitments were made at the 2017 Milan or 2019 Paris meetings, although other advances were made including on the environment-health and gender-health links.
The G7 Research Group has assessed 70 of the 410 leaders’ health commitments for compliance and found an average of 76%. Seventeen of these assessments referenced an aspect of universal health coverage and one referenced universal health coverage directly, for average compliance of 70%.
Three commitments, all on preventing and treating HIV/AIDS, were assessed from the 1998 Birmingham Summit. They averaged 68% compliance. Two, both on promoting affordable medicine in Africa, were assessed from the 2002 Kananaskis Summit, with 85% compliance. The one assessed from the 2003 Evian Summit, also on affordable medicine for the poorest, had 57% compliance. The two assessed from the 2005 Gleneagles Summit, on preventing and treating HIV/AIDS and on improving health systems in Africa, averaged compliance of 82%. The one on improving healthcare systems for disasters had low compliance at 56%. Another three commitments on HIV/AIDS prevention and treatment in
Africa were assessed from the 2007 Heiligendamm Summit with average compliance of 83%.
Three commitments were assessed from the 2008 Hokkaido-Toyako Summit: on access to basic healthcare services for children in Africa, on mobilising $60 billion to “strengthen health”, and on neglected tropical diseases, including a reference to universal health coverage. These averaged compliance of 56%. One commitment on universal access for HIV/AIDS health care was assessed from the 2010 Muskoka Summit, with 61% compliance.
Two commitments were assessed from the 2016 Ise-Shima Summit, one on the IHR and the Global Health Security Agenda for Ebola and Zika, and one on the One Health approach for AMR. They averaged compliance of 69%.
G20 health ministers’ conclusions
The first G20 health ministers’ meeting was held in Berlin in 2017. Implementing the health-related SDGs was referenced in the preamble to the communiqué. Universal health coverage was explicitly referenced in five paragraphs within a stand-alone section on health systems strengthening. At the 2018 Mar del Plata meeting, universal health coverage was referenced in two paragraphs, including a reference to the 2019 UN High-Level Meeting on UHC.
G20 leaders’ commitments
G20 leaders made their first 33 core health commitments at the 2014 Brisbane Summit. Of these, five committed to strengthen health systems globally, with a focus on Ebola. At the following two summits the G20 leaders made commitments on AMR but none on universal health coverage or any of its parts. At the 2017 Hamburg Summit, 17 commitments were made on health systems strengthening and three referenced SDG 3. The G20 leaders’ first and only commitment referencing universal health coverage was made at the 2018 Buenos Aires Summit.
G20 health ministers’ commitments
The G20 health ministers have made 120 commitments in all. Of the 51 commitments made at the 2017 Berlin meeting, one was on the health-related SDGs, seven were on global health crisis management, and five were on health systems strengthening. At the 2018 Mar del Plata meeting one commitment was on universal health coverage. It appeared in a stand-alone section containing 15 commitments on health systems strengthening.
The G20 Research Group has assessed eight of the 61 core health commitments for compliance by G20 members. It found they averaged compliance of 71%. One of the assessed commitments was on strengthening health systems worldwide. It tied for the highest compliance with another commitment on AMR at 98%, and all members except Mexico fully complied. Of the four assessed health commitments from the 2014 Brisbane Summit, the three on Ebola averaged compliance of 63% and the one on AMR averaged 98%. The two AMR commitments assessed from the 2015 Antalya Summit averaged 65%. The AMR commitment from the 2016 Hangzhou Summit averaged 30%.
There is thus a strong relationship between the health goals of both the G7 and the G20 and the UN’s SDGs.
The G7 has governed health always in the context of development, basing its health discussions on the MDGs and later making concrete commitments to implement the health-related aspects of the SDGs. The G20 has done the same on the SDGs, leaving the G7 and UN to lead in the early days of health governance by the three bodies.
As with many other issues, globalisation has made health a global issue that cannot be viewed in a silo. Thus both the G7 and G20 have begun linking sustainable development and health, including linking the environment, gender and digitalisation. Most recently they have introduced universal health coverage to their agendas, although not yet as a permanent feature and appearing only when an interested host chooses to champion it.
Yet with this year’s G20 summit and UN HLM highlighting universal health coverage and the G7 emphasising inequality, universal health coverage could find the convergence it needs to endure on the G7 and G20’s agendas and effectively advance health for all.