Breakthroughs Blog: G20

The health ministers of G20 nations concluded their annual meeting last weekend with the adoption of an “outcome document” that includes welcome commitments to advance the research and development (R&D) of health products. While normally such a ministerial-level meeting would end with the release of a formal consensus communique, broader geopolitics derailed this process, with Russia and China opposing the inclusion of language condemning the Russian war of aggression against Ukraine. Below we break down what R&D commitments are included in the outcome document, why it matters, and where conversations are expected to go from here. What’s in the declaration? At the highest level, G20 nations made commitments to strengthen the global health architecture and “build more resilient, equitable, sustainable and inclusive health systems equipped to address ongoing global health challenges and future public health emergencies with equitable access to safe, effective, quality-assured and affordable vaccines, therapeutics, diagnostics, and other medical countermeasures.” They also reaffirmed their commitment to ending the epidemics of AIDS, tuberculosis, and malaria; achieving polio eradication; advancing universal health coverage (UHC) and the Sustainable Development Goals (SDGs); and tackling antimicrobial resistance (AMR). On the latter issue of AMR, the ministers vowed to strengthen R&D for AMR and further the development of novel antimicrobials. They welcomed the work of various international initiatives and GHTC members including the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) and the Global Antibiotic Research and Development Partnership (GARDP) and voiced continued support for the Global AMR R&D Hub, which was established under the German G20 presidency to promote AMR R&D coordination. On the broader issue of R&D for pandemic prevention, preparedness, and response (PPPR), G20 leaders agreed to support a World Health Organization (WHO)-led consultative process to develop an interim (and potentially later permanent) medical countermeasures (MCMs) mechanism to coordinate the end-to-end R&D, manufacturing, procurement, and equitable delivery of MCMs during health emergencies. They advised that such a mechanism should consider a “network of networks” approach, building off existing international and regional partnerships, and should be coherent with the outcomes of ongoing efforts to amend the International Health Regulations (IHR) and advance a binding pandemic instrument. Additionally, the ministers underscored the need to strengthen local and regional R&D networks and manufacturing capabilities, especially in low- and middle-income countries, as well as voiced support for what many call the “100 Days Mission” to develop and make available safe and effective vaccines, therapeutics, and diagnostics within 100 days of the identification of a pandemic or epidemic threat. They also noted the importance of public-private R&D partnerships—calling out the contributions of GHTC members the Coalition for Epidemic Preparedness Innovations (CEPI), Medicines Patent Pool (MPP), and FIND—and technology transfer and knowledge sharing “on voluntary and mutually agreed terms.”Why it matters?  G20 nations currently conduct and fund the majority of the world’s health R&D. Thus, it is great to see G20 leaders reaffirm the importance of R&D to achieving UHC, SDGs, and PPPR and demonstrate political will to accelerate R&D efforts. However, the outcome document is short on specifics as to how G20 countries intend to operationalize their many promises, and it disappointingly includes no new funding targets or commitments.  Additionally, going into this year’s G20 cycle, many observers and health advocates also expected that the G20 under the Indian presidency would play a more active role in envisioning and detailing a specific proposal for the creation of an end-to-end MCMs mechanism or platform to succeed and build upon the Access to COVID-19 Tools Accelerator. Instead, the G20 simply promised to support a WHO-led consultative process to design an interim mechanism and punted it to the International Negotiating Body (INB) process for a pandemic instrument to determine the prospects for a permanent MCMs platform. What’s next? With G20 nations offering few specifics on a vision to reimagine the global health architecture and advance an MCMs platform, the focal point for change is now squarely within the separate but interrelated processes now underway to amend the IHR, advance a pandemic accord that will create a more comprehensive framework for how countries will prevent and respond to outbreaks, and design an interim MCMs platform. While these processes have been ongoing, the deliberations have been stymied as countries struggle to reach consensus around thorny R&D topics like access and benefit sharing, with some pushing for more aggressive legally binding commitments for transparency, conditions on public R&D funding, patent waivers, and new supply chain mechanisms for ensuring low- and middle-income countries access to medical countermeasures. Questions remain on the full scope of some of the processes, and how they will delineate which issues will be tackled where and with the target date of May 2024 for the adoption of an instrument rapidly approaching and the INB and IHR processes largely behind schedule, it remains to be seen what tangible changes for R&D can be realized. While it is impossible to know what exactly what the future of these negotiations hold, GHTC promises to continue to watch, weigh in, and report back in the months ahead as these interrelated processes unfold. Stay tuned! 

With the world still reeling from the pandemic and global inequities more exposed than ever when it comes to access to medical countermeasures and response capabilities, all eyes were glued on G20 leaders in Rome last week. This G20 heads of state meeting was supposed to be a key global moment for shaping effective, innovative, and equitable responses toward a new post-pandemic global health architecture, but world leaders failed to come together and deliver the necessary action to end the historic crisis still unfolding or create the structures to prepare for the next one. The meeting did offer a small glimmer of hope: research and innovation was firmly anchored as a core tenet of leaders’ strategies to address a myriad of global health challenges, whether COVID-19-related or focused on enduring health threats. While this very much feels like the G20 missed its opportunity, hope remains that the international community can utilize other upcoming forums to take up the torch.  Missing the mark As G20 leaders got together to hammer out agreements to address both current and future health challenges, expectations were high, as many global health advocates hoped the group would start taking concrete steps to act on the numerous initiatives and recommendations from the various review processes this past year. Unfortunately, the global health community was left disappointed, as G20 leaders failed to step up to the plate, providing little by way of concrete pledges, funding, or specific road maps on how to turn their words into action. While countries agreed to a target to vaccinate 40 percent of the world by the end of the year and 70 percent by the middle of 2022, they offered no concrete plans to achieve that goal and failed to make good on their earlier dose promises to COVAX by confirming actual delivery dates. Under current projections, close to 80 countries won’t hit that 40 percent mark by year’s end and would struggle to hit the target in the first quarter of 2022.  Funding also remains a concern, as G20 nations made no new commitments to help address the US$15.9 billion shortfall in monies needed by the Access to COVID-19 Tools Accelerator to accelerate the rollout of tests, treatments, and vaccines, as well as the continued investment needed in innovation to address variants as well as second-generation medical countermeasures that can be more easily deployed. There were also expectations that the G20 would agree to some framework for the creation of a financial intermediary fund for pandemic preparedness, a mechanism that would provide countries with financing to address their long-term preparedness capacity strengthening needs, including potential investments in surveillance, laboratory, clinical trial, and manufacturing infrastructure. However, the G20 didn’t jump at the opportunity to move this initiative forward at the summit, choosing instead to set up a finance-health task force to consider a potential financing facility, creating yet another process.  Silver lining on research and development Despite not spelling out major commitments, the G20 leaders did include several high-level pledges related to research and development (R&D) and broadly acknowledged that research and innovation are important cornerstones of pandemic preparedness and response capacity writ large. It is rare that the G20 leaders’ communique makes direct mention of R&D, so seeing that language included in the final document is remarkable in and of itself. What stands out in the declaration is a pledge by G20 countries to support science to shorten the cycle for the development of safe and effective vaccines, therapeutics, and diagnostics from 300 to 100 days following their identification. While this ambitious target was not supported directly by specific commitments, it does provide a principles framework for future discussions on R&D coordination and capacity strengthening. G20 leaders also had strong rhetoric on strengthening supply chains and manufacturing capacity in the long term, highlighting the need to support mRNA hubs in low- and middle-income countries in particular. Finally, it was also good to see explicit callouts underscoring the need to sustain investments in malaria, tuberculosis, and HIV/AIDS and tackle the growing threat of antimicrobial resistance.  Who will pick up the torch? While this year’s G7 and G20 processes did not lead to the kind of concrete commitments advocates were hoping for, there are still a few summits and milestones in the coming months that could help cement follow-through action to meet global vaccination targets, fully resource the global COVID-19 response including ongoing R&D needs, and enhance transparency around the global supply and delivery of COVID-19-related medical countermeasures. Today, US Secretary of State Antony Blinken will host a meeting with foreign ministers from several countries to discuss commitments to the global COVID-19 response in follow-up to the Global COVID-19 Summit in September. There are also the ongoing discussions being held by member states in the lead-up to the upcoming special session of the World Health Organization on how to strengthen the agency’s health preparedness capabilities, including a potential new framework convention or pandemic treaty. These deliberations have considered a number of changes to the global health security architecture, including developing and reforming governance and coordination mechanisms for R&D. The pressure is now on these forums to deliver solutions to the broad set of challenges that the G20 Ministerial didn’t deliver and to build on the strong rhetoric on R&D to create a fit-for-purpose global health system that provides true equitable access to the health tools the world needs. 

Last month, G20 health ministers convened for their annual summit to address today’s greatest challenges to global health. As usual, they concluded with a new health declaration, which this year included language in support of multilateral cooperation to end the COVID-19 pandemic and improve access to COVID-19 medical countermeasures. It also recommits to health priorities like combating antimicrobial resistance (AMR), preparing for health emergencies, and achieving universal health coverage (UHC), and provides a framework to prioritize these global health challenges through the lens of equitable access and research and development (R&D) coordination. These seem to be powerful commitments, but where do they fit in context? In this Breakthroughs Blog, we look back on commitments from previous years to reflect on how the declarations have evolved and what they have been missing.Reflecting on five years of ministerial commitments Since the first G20 health ministers’ meeting in 2017, the health declarations have been a powerful platform for confronting long-standing global health challenges and adapting to new ones. While some topics such as AMR, health emergencies, and UHC have been featured repeatedly over the past five years in hopes of achieving equitable quality of and access to care, the declarations have also been used to react in real time to urgent crises such as COVID-19. Here are some key takeaways that help us understand where we’ve been:  Antimicrobial resistance Since 2017, the G20 health ministers have remained consistently committed to combating AMR through international collaboration. R&D has been a critical component of AMR commitments since the establishment of the Global AMR R&D Hub, an independent initiative to identify research gaps and align funders that was launched in 2018 following a call from G20 health ministers the prior year. Health ministers continue to recognize the urgent need for sustained R&D to accelerate the development of safe, effective, and affordable antimicrobials and partnerships to maintain the global supply of existing antimicrobials. Additionally, these health commitments also focus on surveillance and data sharing. Specifically, the World Health Organization (WHO) Global Antimicrobial Resistance Surveillance System (GLASS) Report was a step toward increasing the systematic collection of quality data on antimicrobial sales, consumption, and resistance to understand and mitigate the risks posed by AMR. Though AMR continues to be a focal point and some important initiatives have been launched, it is crucial that health ministers follow through on their agreed-upon proposals.Health emergencies While pledges to combat health emergencies and improve global health security were made prior to COVID-19, this issue has now taken center stage for G20 health ministers. Many of the pledges made in the 2020 health declaration focused on COVID-19 and discussed the adverse effects the pandemic is having on other health areas. Health ministers also recognize the importance of R&D to address infectious diseases with epidemic and pandemic potential. This past month, they put R&D at the core of the G20 agenda with a focus on the Access to COVID-19 Tools Accelerator, new pandemic preparedness initiatives, and reinvestment in existing programs. In 2019, much of the messaging and commitments were similarly focused on containing the Ebola outbreak in the Democratic Republic of the Congo. Along with pledges focused on specific health emergencies, the G20 health ministers have maintained yearly commitments to international cooperation and health systems strengthening under WHO guidance and in accordance with the International Health Regulations (IHR), both critical components of global health security. Despite reaffirming the need for strong health systems and compliance with the IHR as essential for health preparedness, health ministers have fallen short or been unable to secure commitments to the sustainable financing necessary for prevention and response. The lack of sustainable financing has translated into a lack of capacity, particularly in low- and middle-income countries, and left WHO and other multilateral institutions without adequate resources to mitigate pandemic threats. Recognizing these limitations, in January 2021, the G20 established a High-Level Independent Panel (HLIP) that worked at breakneck speed to propose actionable solutions for reliable and sustainable financing of the global commons for pandemic prevention, preparedness, and response by June 2021.Universal health coverage G20 health ministers have consistently recognized that UHC will be best achieved through strengthening health systems and promoting international collaboration, especially through sharing data, exchanging best practices, and sustainable financing. Their commitments reflect the multifaceted elements foundational to achieving UHC including primary care; health care workforce capacity; nutrition; immunization; and water, sanitation, and hygiene, as well as R&D and equitable access to medicines and health services. Health ministers have recognized and articulated the continued need for global investment in those areas, while also emphasizing that countries need to develop their own pathways toward the achievement of UHC by accounting for national contexts and priorities through engagement with civil society and the private sector. Despite consistently reaffirming their commitment to UHC, G20 countries have made few pledges shaping tangible action.The missing wheel for the road aheadFor the past five years, G20 health ministers have agreed on powerful language in their declarations—and yet each year, with a few notable exceptions, progress has rarely been made beyond a stamped paper. Unsurprisingly, the most recent declaration includes strong language on COVID-19, AMR, UHC, and health emergencies, but outside of pandemic financing, it is not connected to a plan to meet those pledges. It is unfortunate that the standard has become all talk and no action. But this month, G20 leaders can set a new course. Following the G20 health ministers’ meeting last month, the G20 heads of state will convene for their annual summit later this month. Together, the heads of state have an opportunity to fulfill the vision set forth by their health ministers; follow through with specific HLIP recommendations on how to fill gaps in pandemic preparedness, prevention, and response; and ultimately set a new standard of combining commitments with tangible action for future G20 health-related meetings.

Last week, the world waited with bated breath to see whether G20 health ministers would seize the moment at their annual summit to take bold and necessary action to end the pandemic, build the global health architecture for the future, and recommit to health priorities that have taken a back seat during the past two years.The answer was rather muddled. The G20 health ministers did agree on several key principles and high-level priorities, many of which were positive, but their health declaration stopped short of providing a clear road map to translate these ambitions into concrete actions. Advocates were particularly disappointed in the lack of immediate actions, including calls for specific financial commitments, to address the shameful inequities in rollout and ongoing acute needs for COVID-19 vaccines and other tools.While the G20 didn’t provide much specificity regarding new pledges, it did highlight the importance of research and development (R&D) in all aspects of global health, including bolstering pandemic preparedness, combatting antimicrobial resistance (AMR), achieving universal health coverage (UHC), and strengthening digital health. As discussions in other forums such as the United Nations (UN) General Assembly, the World Health Organization (WHO), and the Global Health Security Agenda ramp up, G20 leaders have set the framework from which to build concrete reforms to the international system.Putting R&D at the core of the agenda This year’s G20 health declaration included strong language on R&D throughout. In discussing the Access to COVID-19 Tools Accelerator, pandemic preparedness initiatives, and reinvestment in key programs to achieve the Sustainable Development Goals (SDGs) and UHC, G20 leaders put R&D front and center. One particularly encouraging sign was the explicit callout from health ministers acknowledging R&D as a central pillar of pandemic preparedness, something that was notably absent in global health security frameworks, including the International Health Regulations, prior to the start of the pandemic. The COVID-19 crisis has exposed the need to enshrine greater global governance and coordination of R&D into the global health security architecture. The mention by G20 health leaders acknowledges a political shift on the issue and increases the prospects that R&D coordination and governance provisions will be integrated into a potential pandemic treaty and other WHO reform discussions in the coming months. The G20 health declaration also underlined the continued commitment toward combatting AMR, including by developing new safe and effective antimicrobials and sustaining reliable supply and production of existing antimicrobials. For the past few years, the agenda for the G20 has consistently included AMR with a focus on multidrug-resistant tuberculosis (TB), which is estimated to account for one-third of all AMR-related deaths globally. Leaders recognized that sustainable and robust resources for TB R&D are needed to accelerate development of new tools and deliver on previous commitments from the G20 and the UN high-level panels on TB, AMR, and UHC.Health ministers underscored the need to strengthen the resilience of supply chains; increase and diversify global, local, and regional vaccine manufacturing capacity; and build expertise for low- and middle-income countries (LMICs). Acknowledging that equitable access to medical countermeasures continues to be a major challenge, global leaders recognized the need to develop more balanced systems and infrastructure that provide greater coverage and capacity in LMICs. G20 leaders also reiterated that while vaccines have been at the top of everyone’s agenda, we must ensure that all countermeasures, especially therapeutics including oxygen therapies and diagnostics, are reprioritized as key elements of global response efforts and that the pipeline for new countermeasures continues to receive investments. Given the accelerated development of new diagnostic tools and the scale of testing needed for COVID-19, it was a positive development that G20 nations acknowledged that the introduction of testing capabilities should also be leveraged for other infectious diseases including TB, malaria, and HIV. To achieve the SDGs by 2030, the systems that are being built to respond to the pandemic must also serve to strengthen health systems overall and help in the fight against other disease threats.Where do we go from here?G20 health ministers reaffirmed their commitment to global solidarity, including by working toward equitable distribution of vaccines and supporting WHO’s goal of vaccinating 40 percent of the global population by the end of 2021. Despite this, no specific pledges were made to provide additional funding to the Access to COVID-19 Tools Accelerator, nor did leaders commit to increase vaccine dose sharing to address the acute needs of LMICs.The lack of specific targets or road maps for how to achieve the outlined principles and new investment pledges by G20 countries means that leaders must now work out how to operationalize these ideas in other multilateral meetings this fall. Many advocates are now pinning their hopes on the Biden administration’s call to convene heads of state at a Global COVID-19 Summit next week on the sidelines of the UN General Assembly and looking for tangible actions during the G20 Joint Health and Finance Ministers’ Meeting or World Health Assembly deliberations on a new pandemic treaty or framework convention.These forums will now have to pick up the baton, since we need global governance to be more inclusive, equitable, and accountable. This G20 health ministers’ declaration was a step in the right direction, as it set a framework for improving global health R&D coordination and governance, but it put the onus on other forums to follow through with concrete actions. Global leaders must now seize the moment and deliver on their promises.