The G20 Delhi declaration (Delhi declaration) read along with the declaration from the meeting of G20 health ministers is a good example of the challenges facing global public policy. Both documents bring a welcome focus on the Global South and equity. The G20 declaration goes as far to state that it would “pursue development models that implement sustainable, inclusive and just transitions globally, while leaving no one behind,” and mentions reforming International Financial Institutions.
When looking at the details of the outlined development strategies, however, one finds the same neoliberal policy package that got the world in the state of crisis that it is in. The G77+ summit, in calling for “the establishment of a new economic world order,” has made an important effort in this direction. Unsurprisingly, this did not happen in G20 and it was surely not informed by discussions in larger democratic, Global South based platforms, which have articulated possible alternative and Indigenous development models.
A few glaring examples of the Delhi declaration’s promotion of iniquitous and unjust solutions, contradictory to its preambular statements, are its refusal to call out for debt cancellation and restructuring and its emphasis on credit rating. This list also includes the projection of unemployment as related to skill development rather than to the way that capitalism in the globalization era has promoted jobless growth and precarious jobs, while eroding labor rights and social protection for workers.
Financing health care
From the lens of health policy, ill health is largely structurally determined, a consequence of an unequal and unjust world economic order. Merely improving the delivery of healthcare services is no solution at all.
The Delhi declaration introduces a distinct section on finance-health collaboration, largely for pandemic prevention, preparedness, and response through cooperation between Finance and Health Ministries, under a proposed Joint Finance and Health Task Force. Yet the document lacks a clearly defined plan elucidating details of this ‘collaboration’. While the declaration’s text calling for “Reforming International Financial Institutions” is welcome and much needed, past experience with similar calls have not been very encouraging. Much of the current health governance and policy implementation has been largely driven by the World Bank, the big US philanthropies, the G7, and the big bilateral aid providers. Many reports and studies shed light on critical issues in transnational and development finance investments in healthcare, especially in private hospitals from low and middle income countries. These concerns encompass engaging in commercial investments with the for-profit private sector, the absence of transparent and accountable mechanisms, and related challenges.
While foreign aid to healthcare played a crucial role during the COVID-19 pandemic, some reports have highlighted the related challenges. For instance, the German Development Finance Institution provided funding to a major private hospital in India for essential infrastructure and equipment to treat COVID-19 patients. The hospital then predominantly utilized these resources to generate revenue from critically ill patients, charging exorbitant amounts up to INR 60,000 (approximately USD 700) per day.
Several international financial institutions approved 16 health loans, grants, and technical assistance projects for the health sector in India between 2020-2022. A considerable portion of these pandemic preparedness projects did not substantially contribute to the long-term strengthening of India’s public health system, particularly in addressing staff shortages, improving working conditions, or enhancing treatment facilities. In the light of such experiences, the Delhi declarations’ call for leveraging ‘private capital through innovative financing models’ is a matter of great concern. Too often innovative financing approaches only mean different market mechanisms and resort to private financing. There is simply no evidence that such mechanisms help, and on the contrary, existing evidence shows that many of these harm progress towards health for all.
The health declaration applauds and recognizes “the financing efforts made by WHO members, particularly low- and middle-income countries, and welcome the decisions at the 76th World Health Assembly (WHA) in this respect.” However, health activists have warned that the decisions on financing adopted during the last WHA could easily prove to be dangerous. They institutionalize ‘earmarked funding’ (meaning, among other things, funding from private sector) through the creation of a World Health Organization (WHO) Investors Forum. This move will further constrain WHO’s autonomy in deciding its scope of work, although it has been proven over and over again that an independent, sustainably funded WHO is one of the key necessities for achieving equitable global health governance. On the other hand, the G20 health declaration calls for at least 50% of WHO funding to come from assessed funding from member states, opening the door for a different vision of health governance.
Strengthening cooperation in the pharmaceutical sector
In one of its sections, the WHO Gujarat declaration talks about access issues around vaccines, diagnostics and technologies. The recognition of ‘market failure’ and strengthening of local and regional manufacturing capacities in low- and middle-income countries in this regard is indeed welcome. Yet the same declaration, in another paragraph, encourages collaboration between different ‘stakeholders’, including philanthropies, global partnerships and private players. This shows an inability to learn from the experiences of the COVID-19 pandemic and a business-as-usual approach. Institutions like Global Fund and GAVI hold a huge sway in global health governance but without any accountability that governments have. They also operate within relationships which have been known to have conflict of interest. Many of these institutions were known to support Intellectual Property Protections in the face of the pandemic. Placing faith in them shows an inability to understand the root causes of the problems we face today and the entrenched power of these institutions. Both the Delhi and the Gujarat declarations’ failure to address this problem shows that there is still little understanding of how the current intellectual property framework hinders access to essential medical products.
Organization of health care
The Delhi declaration embraces Universal Health Coverage (UHC). While the concept has been largely embraced as one of the paths leading to health equity, networks including the People’s Health Movement have been pointing major concerns about UHC. Behind the rhetoric on UHC, there is a deep tension between two models of healthcare delivery. Universal Health Coverage, as promoted on the ground, has come to mean ‘publicly funded’ health insurance, but in which provision and strategic purchasing of a ‘basic package of essential services’ is done by a mix of public and private health providers. This is then complemented by a marketplace of private health insurance plans and private providers for services beyond the basic package.
Such an approach is opposed to a vision of health through publicly funded and publicly administered health care services, which requires strengthening of public health systems and action on social and structural determinants of health. PHM believes that equitable, dignified and quality health services can only be provided within a public goods framework, by a democratic government, and where people’s health is not left to the vagaries and interests of the market. Though the Delhi declaration does not call directly for expanding insurance or purchasing mechanisms, it does not mention the strengthening of public health systems or of better regulation of the private sector.
The focus on traditional and alternative medicines brought by this summit and India’s presidency is positive and we look forward to this concept being followed up. Similarly, the Delhi declaration brings up the concept of Primary Health Care [better captured in the term Comprehensive Primary Health Care]. While this is, in itself, most welcome, the declaration remains silent on how it can be achieved. This brings us to concerns over decades of failed attempts by governments to achieve Comprehensive Primary Health Care, which was shelved in favor of offering selective primary health care packages and enabled market participation. Today, the concept of Primary Health Care has been replaced by UHC, bringing us even further from the original idea.
Despite some positive developments in the declaration, there remains a huge gap to offering concrete solutions that challenge existing hierarchies to address health inequities. Therefore, the Delhi declaration fails to embody the voice of the Global South.
The article was written by Deepika Joshi and Shweta Marathe of the PHM Equitable Health Systems Circle with inputs and editing support from T Sundararaman. Deepika Joshi is associated with PHM’s thematic circle on Equitable Health Systems and supports the PHM secretariat. Shweta Marathe works as a health system researcher with SATHI, India.
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