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The G20's Health Performance:
Anticipating the Overdue COVID-19 Videoconference

Brittaney Warren, G20 Research Group
March 17, 2020

Saudi Arabia, as president of the 2020 G20, has finally announced that it is organizing a videoconference for G20 leaders next week to discuss coordinated action on the COVID-19 crisis. In order to anticipate what G20 leaders will do and the prospects for success, it is important to recall how the G20 summit has governed health since its first summit in Washington in 2008, across the six dimensions of summit performance (see Appendix A).

The G20's Health Performance

The first dimension of performance is domestic political management, measured as compliments on health given to specific G7 members in their public communiqués. No compliments have been given to date.

The second dimension is public deliberations, measured as the number of words on health. Here the G20 has dedicated 6,744 words, starting at the first summit in Washington in 2008 with 118 words. This declined to 59 words six months later at the 2009 London Summit. For the next five summits the number of words stayed above 100, but fluctuated quite a bit: there was a low of 139 words at the Toronto Summit and a high of 643 words at the Seoul Summit, both of which were held in 2010. The next high point was at the St. Petersburg Summit in 2013, with 1,340 words, which fell to 769 words at the 2014 Brisbane Summit and then further to 481 words at the 2015 Antalya Summit. In the most recent years, there were similar fluctuations: the 2016 Hangzhou Summit had 234 words, the 2017 Hamburg Summit had 707, the 2018 Buenos Aires Summit had 316 words and the 2019 Osaka Summit had 934 words.

On substance, from 2008 until the 2013 St. Petersburg spike, the G20's focus was on meeting the health-related Millennium Development Goals (MDGs), including access to health care for the most vulnerable segments of the population, nutrition, and water safety and quality. In 2014, the Ebola outbreak put infectious disease on the G20's agenda for the first time, with a stand-alone statement on the disease. Antimicrobial resistance (AMR), which prevents the treatment of infectious disease, followed at the 2015 Elmau Summit, and has stayed on the leaders' agenda since that time. To deal with these threats, especially AMR, the 2017 Hamburg host put health systems strengthening on the agenda. The 2018 Buenos Aires Summit began using the term "universal health care" or UHC, which the 2019 Osaka Summit also adopted.

The third dimension is direction setting, measured as the number of links made by the G20 between health and the G20's foundational missions of promoting financial stability and ensuring globalization works for all. There have been 20 links, all referring to globalization and none to financial stability. An additional unit of measurement is linkages between health and other subjects. Throughout most of the G20's health governance, the main subject linkage has been on food security and nutrition. The 2017 Hamburg Summit linked health with climate and energy, sustainable development, and the digital economy. And the 2019 Osaka Summit linked finance and health. A final indicator of this dimension is causal linkages. This indicator reveals a major gap in the G20's health governance, and in particular its governance of infectious disease, as the causal links between infectious diseases and their animal origins have not been strongly made. This is significant because overlooking the human-nature interface in this context keeps the risks of another global pandemic higher that they need to be.

The fourth dimension is decision making. The G20 has made 75 core health commitments, as well as a few MDG ones. On the core health ones, the first related to infectious diseases — with 32 on Ebola and one on AMR at the 2014 Brisbane Summit. Another two were made at the 2015 Antalya Summit and three at the 2016 Hangzhou Summit, all on AMR. Nineteen were made at the 2017 Hamburg Summit, with 10 on AMR, eight on health systems strengthening and one on polio, another infectious disease. Four were made at the 2018 Buenos Aires Summit, on health systems strengthening, UHC, health financing and obesity. Of the 14 commitments made at the 2019 Osaka Summit, five were on infectious diseases (Ebola, AMR, polio, and AIDS, tuberculosis and malaria), four were on health systems strengthening and four were on aging populations, a highly vulnerable demographic when it comes to disease outbreak.

The fifth dimension is delivery. Here, compliance by G20 members with their decisions averaged 73% on the five commitments assessed by the G20 Research Group. Compliance averaged 72% with the four commitments on Ebola made at the 2014 Brisbane Summit. This was followed by 60% with the two AMR commitments made at the 2015 Antalya Summit, 30% with the one AMR commitment assessed from the 2016 Hangzhou Summit, 98% with the one health systems strengthening commitment from the 2017 Hamburg Summit, and 93% with the one UHC commitment from the 2018 Buenos Aires Summit.

The sixth dimension is the development of global governance, measured as references to outside and inside institutions in the G20's communiqués. There have been 42 and 36 references, respectively. As expected, on outside institutions, the majority of the references have been to the United Nations and the World Health Organization. Others include the financial institutions of the International Monetary Fund and the World Bank, as well as the Food and Agriculture Organization and the World Organization for Animal Health (OIE) on AMR. On inside institutions, the majority of references have been to the G20 leaders and ministers.

Conclusion

This analysis shows that the G20's governance on health has two subject phases. The first phase, from 2008 to 2013, focused on non-communicable diseases, especially those related to the MDGs and sustainable development. The second, from 2014 to today, is on global outbreaks of infectious diseases. This started with the Ebola outbreak in 2014, moving to AMR in 2015 and it is now focused on the current COVID-19 pandemic. In this second phase, infectious disease has overshadowed non-communicable diseases, bumping them off the agenda almost entirely. However, health systems strengthening and UHC have also appeared on the agenda in this period, and, if implemented, would support reducing, preventing and responding to both non-communicable and infectious diseases. Thus far, the G20 has complied well with its health systems strengthening and UHC commitments. However, these data show short-term compliance rather than medium- to long-term impact, and the G20 has yet to take collective action to respond to COVID-19.

A key determinant of success of the upcoming G20 leaders' videoconference will be the ambition of their commitments, their willingness to take coordinated actions rather than unilateral ones and to learn from each other's experiences (such as Korea and Singapore's success in containing the spread of the virus), and whether money is immediately injected into the global healthcare system to prevent further deaths and socioeconomic damage from this outbreak.

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Appendix A: G20 Health Performance

Year Domestic political
management
Deliberation Direction setting Decision
making
Delivery Development of
global governance
Attendance Communiqué
compliments
Words Documents Financial
stability
Globalization
for all
#
made
%
overall
Compliance #
assessed
Inside Outside
# %
2008 Washington 100% 0 118 3.2 1 0 0 0 0 n/a n/a 0 1
2009 London 100% 0 59 0.9 1 0 0 0 0 n/a n/a 0 0
2009 Pittsburgh 100% 0 284 3 1 0 0 0 0 n/a n/a 0 0
2010 Toronto 90% 0 139 1.2 1 0 1 0 0 n/a n/a 0 1
2010 Seoul 95% 0 643 4.1 4 0 1 0 0 n/a n/a 3 2
2011 Cannes 95% 0 470 2.9 3 0 1 0 0 n/a n/a 1 0
2012 Los Cabos 95% 0 250 1.9 2 0 0 0 0 n/a n/a 0 1
2013 St. Petersburg 90% 0 1,340 11.2 5 0 2 0 0 n/a n/a 6 4
2014 Brisbane 90% 0 769 8.4 3 0 1 33 16 +0.43 (72%) 4 4 9
2015 Antalya 90% 0 481 3.5 3 0 1 2 2 +0.20 (60%) 2 5 3
2016 Hangzhou 100% 0 234 1.4 4 0 0 3 1 −0.40 (30%) 1 4 5
2017 Hamburg 100% 0 707 2 3 0 3 19   +0.95 (98%) 1 2 6
2018 Argentina 100% 0 316 4 2 0 4 4   +0.85 (93%) 1 2 2
2019 Osaka 100% 0 934 14 1 0 6 14   9 8
Total n/a 0 6,744 n/a 34 0 20 75 N/A 5 36 42
Average 95% 0 482 4 2 0 1.4   1.7 +0.45 (73%) 1.3 2.1 2.4

Notes: N/A = not applicable. – = no data available yet.

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