Philip Kenol

Next week, the World Health Organization’s (WHO’s) 152nd Executive Board (EB) meetings kick off in Geneva, with delegates and civil society representatives participating in person for the first time in two years. Recent months have seen a shift away from COVID-19 and an increased focus on long-term reforms to the broader global health architecture. While the dialogue around designing global frameworks and new mechanisms to address future health threats is vital, many of the discussions on poverty-related and neglected diseases are seemingly absent from this year’s discourse.  Here are the four issues to watch at this year’s meetings: Continued focus on global health security  2022 was a fruitful year for advancing two processes that will significantly influence the future of pandemic response. First, the intergovernmental negotiating body tasked with shepherding the Pandemic Accord process developed its first conceptual draft for the new framework. This comes following multiple public hearings, member state negotiations, and consultations on specific elements including equity, access and intellectual property, and antimicrobial resistance. Encouragingly, the document includes some strong research and development (R&D) focused language and recognizes R&D as an integral pillar of health preparedness. However, the current draft emphasizes downstream response measures such as manufacturing and registration, with less of a focus on early-stage research, clinical development, and even post-registration access and delivery of health tools. Additional focus on early-stage discovery research, clinical development, regulatory processes, and access and delivery of medical countermeasures is needed to ensure the type of true end-to-end approach critical to global health security. The second major global health security focused process has been centered around targeted amendments to the International Health Regulations. This policy discussion primarily focused on changes to provisions on trade and travel health certificates, as well as data-sharing and reporting requirements. Though perhaps less prominently discussed, disputes over intellectual property, in particular those centered on genetic sequence and pathogen sharing, remain major barriers to consensus. Both of these processes will be debated during EB, and we can expect a concerted effort to clearly delineate these processes and advance dialogues around defining the terminology and scope of both endeavors.  Limited progress on the implementation of the clinical trials resolution Last year, member states passed a resolution on clinical trials with the intent to build on lessons learned from the COVID-19 pandemic. The crisis drove a surge in funding for clinical research on COVID-19 tools, but we also saw many trials that were not large enough or that failed to employ consistent protocols and outcome measurements across geographies, making it difficult to pool and compare data to turn conclusions into medical practice. Among other matters, the resolution urged countries to better coordinate research, standardize protocols, improve reporting on trial registration and results, and work to increase clinical trial capacity globally, particularly in low- and middle-income countries—though none of these actions are binding. It also requested that WHO develop a global action plan to strengthen clinical trial practices to be presented for consideration at this year's assembly.EB will provide a chance to level set the current status of the implementation of the clinical trials resolution and figure out which elements of the framework could be improved. Previous discussions suggest that the current progress in implementing the resolution has been limited. During consultations held last fall, member states highlighted gaps in data on specific population groups and disease targets, as well as gender biases in data, which may result in these groups being precluded from access to needed interventions, as a point of inequity that must be addressed. The public consultation also noted the crucial importance of strengthened national regulatory authorities and national ethics committees, as well as increased international collaboration and coordination for efficient funding of agreed-upon priorities for multinational and multiregional trials, where appropriate.  The EB now has a chance to build on the progress and push WHO to follow through on their global action plan and for member states to support mechanisms like the WHO International Clinical Trial Registry Platform to push this agenda forward.  A new resolution on diagnostics could be passed New on the docket this year is a resolution that focuses on the development of—and access to— diagnostics. A recent Lancet report sounded alarm bells, highlighting that almost half of the global population has little or no access to diagnostics. The COVID-19 pandemic has clearly shown that a country’s diagnostic capacity is directly linked to its ability to respond to pandemics with appropriate public health measures and effective monitoring of emerging variants. Given the depth of the challenge, sustained access to quality, affordable diagnostics will require multi-decade prioritization, commitment, and investment.  This resolution is a good first step in acknowledging the need for more political will in addressing the diagnostics gap. Notably, it urges member states to develop a National Essential Diagnostics List, adapting the WHO Model List of essential in vitro diagnostics and the WHO List of Priority Medical Devices. The resolution further urges countries to invest in R&D, expanding manufacturing capacity for diagnostic medical devices and surveillance and strengthening international collaboration and assistance during epidemics and pandemics.  The resolution also calls on WHO to support member states to strengthen national and regional regulatory systems for diagnostic medical devices, collect data on the affordability and availability of essential diagnostic medical devices, and consider and support mechanisms for procurement that will enable access to high-quality, affordable diagnostic technologies for all member states. Some hurdles to approving this resolution remain, including outstanding disagreements on whether to include provisions pertaining to intellectual property and access, but there appears to be broad support from member states to get this resolution across the finish line in Geneva.  UHC back in the spotlight Universal health coverage (UHC) is also back in focus for this year’s EB, especially with September 2023 marking the halfway point of the timeline to reach the Sustainable Development Goals (SDGs) and leaders preparing for a United Nations High-Level Meeting on them at this year’s General Assembly. While some progress toward the SDGs has been made, the COVID-19 pandemic caused major disruptions in both health services and the development of health system capacities globally.  From a research perspective, a report by WHO ahead of EB highlighted that research and innovation continues to play a crucial role in UHC. Inequitable access to medical products is among the main causes of financial hardship in many lower- and middle-income countries. The report also notes how the recent World AIDS Day 2022 campaign highlighted the dangers of these inequalities, calling on global leaders and citizens to equalize access to essential HIV services, particularly for children and key populations, in order to end AIDS as a public health threat.  EB is a chance to hit reset on the UHC dialogue and for countries to reaffirm their commitment to the SDGs. It is also an opportunity to reassert that health system strengthening supports all health areas, including pandemic preparedness and poverty-related and neglected diseases. It is vital that leaders break down silos and take a more holistic approach to ensure progress toward advancing the global development agenda and 2030 targets. As discussions on global health architecture reforms advance, and new investments in pandemic preparedness are made, it is vital that global decision-makers ensure the benefits of these resources are also leveraged to benefit the fights against tuberculosis, HIV, malaria, and neglected tropical diseases. 

How highly will global health be prioritized on the G20 agenda? That is the question leaders must grapple with as the final G20 summit of the Indonesian presidency commences next week. Amid a smorgasbord of geopolitical crises, and as COVID-19 fatigue spreads globally, there is a danger that countries will take their eye off the global health ball at the exact moment we need them to be most dialed in. With live negotiations over new funding mechanisms for pandemic preparedness and the future of existing frameworks, the next few months will decide the future of the global health architecture, meaning that there is now a tremendous opportunity to develop new systems that will support and catalyze product development. Here are three key opportunities for G20 leaders to help significantly advance global health, enhance health equity, and support research and development (R&D):1. Act to ensure equity in the administration of The Pandemic Fund.In June, the World Bank board approved the creation of a financial intermediary response for pandemic prevention, preparedness, and response. The Pandemic Fund has been a centerpiece of the Biden administration's health security agenda, and its core focus is to ensure all countries, particularly low-income countries, have the health systems, resources, and infrastructure required to prevent, detect, and respond to future pandemics. Key investment priorities will be strengthening the health workforce, expanding manufacturing capacity for medical countermeasures, and reinforcing health surveillance systems.While this is a very promising initiative, the fund and its underlying structures have been developed at a blistering pace, creating mistrust and confusion regarding its eventual operations and decision-making processes for countries and civil society alike. This is, therefore, a golden opportunity to channel the lessons we have learned from the ongoing COVID-19 pandemic by committing to equity and collaboration now to bolster confidence in the fund and its future administration.Civil society must be included at all levels of priority setting for investment. While there are two civil society seats with voting rights on the board of The Pandemic Fund, it remains unclear what additional mechanisms will be available for outside organizations to provide their expertise and input on where the investments are made. G20 leaders should ensure that The Pandemic Fund’s technical advisory panel has strong civil society representation, including from low- and middle-income countries (LMICs) and affected communities.To further include equity provisions, G20 leaders should also consider creating greater linkages between other elements of the global health security architecture. This includes ensuring that the Global Health Security Agenda has a seat at the table, as the ongoing Global Health Security Agenda framework is an invaluable platform to advance informal, technical discussions and collaborations between an inclusive and important set of stakeholders. Lastly, G20 leaders should support prioritizing interventions that expand country-level capacity, especially investments that strengthen the R&D capacity of LMICs. The fund is set to issue a call for proposals to countries for the first tranche of funds in December. Responses will likely set precedent for the scope of the fund’s activities. Therefore, it is imperative that development and access to medical countermeasures remain key pillars in the gap the fund is looking to address.2. Further establish an equitable, R&D-focused agenda in the next phase of the Access to COVID-19 Tools – Accelerator (ACT-A).There has been much recent speculation on what will become of ACT-A, as the framework’s mandate was set to expire this September. Talks of sunsetting the platform have proved premature, as it recently unveiled a transitionary plan, which kicked off in October and will continue through March of 2023.As ACT-A prepares to enter a new phase, it is vital to address the ongoing concerns and shortcomings of the platform. A recent evaluation of ACT-A’s performance highlighted that LMICs were insufficiently represented and consulted in ACT-A’s model, resulting in a lack of ownership affecting the delivery of COVID-19 tools in LMICs. The evaluation also found that the agencies working on R&D did not sufficiently coordinate their R&D efforts across the vaccine, therapeutics, and diagnostic workstreams.G20 leaders must push ACT-A stakeholders to build on the progress made since the early days of the initiative and enshrine even greater equity and inclusivity structures in their framework. Increased R&D coordination and leadership are also essential to developing medical countermeasures for future pandemics. The G20 Leaders’ Summit is a great opportunity to outline a roadmap for enhanced R&D coordination between the various ACT-A pillars and highlight what additional structures could be developed to ensure progress across the pipelines for the delivery and uptake of new tools for all product types.3. Reestablish commitment to addressing enduring health threats through R&D.While COVID-19 has dominated global health programming, dialogues, and investment for nearly three years, global leaders must take advantage of next week to recalibrate their efforts and underscore their commitment to advancing other health priorities as well. That means recommitting to the fights against malaria, tuberculosis, and HIV/AIDS, which have suffered losses of progress amid the COVID-19 pandemic and addressing the rising threat of antimicrobial resistance. We expect that many countries will use the summit to underscore their pledges to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, with a few stragglers announcing their contributions for this year’s replenishment. While those commitments are vital, funding institutions will not be enough, and additional investment in R&D is needed, particularly in the local production of medicines, vaccines, and diagnostics. G20 countries should also invest in essential public health function gaps; support the capacities of national and regional public health institutes in sub-Saharan Africa (including in field epidemiology, disease detection, laboratory diagnosis, and optimization of the health workforce skill mix); and convene all stakeholders to jointly define targets to accelerate the regional production of vaccines, therapeutics, and diagnostics. These steps will be part of a difficult but long overdue pivot back to health areas that have begun to backslide due to the pandemic. For the last couple of years, leaders have focused disproportionately on COVID-19 to the detriment of several key health areas. We cannot afford to ignore these persistent and reinvigorated crises any longer. Next week will be a chance to recommit to a comprehensive approach to global health that centers both R&D and equity, but G20 leaders need to step up to the plate to advance that vision.

The annual opening of the United Nations General Assembly (UNGA) is always a key moment on the diplomatic calendar. For the first time since the COVID-19 pandemic began, UNGA was held in person. This provided opportunities to renew relationships, forge new partnerships, and debate in-depth in ways that are difficult in the Zoom world. And while many want to say that the pandemic is behind us, as President Joe Biden pronounced on his recent 60 Minutes appearance, COVID-19 and the possibility of future health threats still loomed large during the first half of UNGA discussions.Concurrently, leaders gathered for the replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria and to contend with the erosion of progress in other global health areas as a result of resources being diverted to COVID-19. Chief among the backslides are three of the world’s leading infectious killers: HIV, tuberculosis, and malaria, which all suffered setbacks during the pandemic with a reduction in access to testing and treatment coupled with a troubling rise in cases. If that were not enough, the rising threat of antimicrobial resistance was also top of mind for many leaders.Below are some of the key highlights from the first half of UNGA.Major focus on pandemic preparedness and global health architectureWhile some major speeches at UNGA, such as those by German Chancellor Olaf Scholz or US President Joe Biden, barely acknowledged the pandemic, plenty of events and meetings throughout the the first half of UNGA highlighted a sustained and strong focus on current and future health crises.Underscoring the need for a robust discussion on reforms to global political structures and recommendations put forth over the last two years by the Independent Panel for Pandemic Preparedness and Response and the Global Preparedness Monitoring Board, the UNGA overwhelmingly adopted a resolution to hold a high-level meeting at the heads-of-state- and government-level on pandemic preparedness and response no later than the 78th session of UNGA in September 2023. The agreement—co-sponsored by more than 100 countries—instructs the next General Assembly's president to organize the meeting in collaboration with the World Health Organization (WHO) and to “adopt a succinct political declaration aimed at, inter alia, mobilizing political will at the national, regional and international levels for pandemic prevention, preparedness and response.”Discussions were also centered on the future of the Access to COVID-19 Tools Accelerator. Civil society and other global health stakeholders questioned whether Accelerator is winding down, but stakeholders like WHO Special Envoy Dr. Ayoade Alakija assured the community that the framework is simply moving into a new phase. Questions remain on what the initiative will look like post-COVID-19, yet it is clear that there is a desire to retain some of the coordination functions of the framework, even as advocates continue to highlight the stark inequities and the sometimes-mismatched priorities that the framework created, highlighted by the lack of focus and resources for testing in LMICs.Bolstering local manufacturing capacity The COVID-19 pandemic laid bare what stakeholders across the Global South have long known: severe shortages in lifesaving medical products result when low-income countries are left to rely on the Global North and Asia as primary suppliers. The lack of local manufacturing capacity has been a driver of extreme global disparities in access to lifesaving COVID-19 vaccines, diagnostics, drugs, and devices. More than two years into the pandemic, it has become increasingly clear that strengthening health security in low- and middle-income countries (LMICs) will require long-term investments to fortify local capacity.This realization was echoed throughout discussions. Multiple stakeholders and events focused on the need to bolster manufacturing capacity in LMICs. PATH, in partnership with Foreign Policy, explored the investments, partnerships, and models that can inform a strategy for fostering a sustainable African manufacturing industry and distribution networks across the continent, addressing chronic inequities, and strengthening regional health security. At the Clinton Global Initiative, PATH committed to partnering with the African Union to develop principles for drug, vaccine, and diagnostic manufacturing on the African continent. We also witnessed firsthand commitments being made to strengthen this capacity, including by the Distributed Vaccine Manufacturing Collaborative. The Collaborative is co-chaired by Dr. Richard Hatchett from the Coalition for Epidemic Preparedness Innovations and Dr. Victor Dzau from the US National Academy of Medicine in partnership with the World Trade Organization; Gavi; WHO; the Wellcome Trust; Africa Centres for Disease Control and Prevention; the Oswaldo Cruz Foundation, or Fiocruz; and various governments and industry partners. The goal of the Collaborative is to increase vaccine access in LMICs through the establishment of a versatile global vaccine manufacturing network capable of producing vaccines during pandemic and non-pandemic times. Sustainable financing for pandemic preparedness Another focal point of the first half of UNGA was the need for incremental and sustained financing. While the elephant in the room was clearly the Global Fund replenishment, which raised a record-breaking US$14.25 billion, despite falling short of the ultimate target of $18 billion, broader conversations on financing for pandemic preparedness also attracted plenty of attention. COVID-19 has highlighted that the world has consistently underinvested in preparedness and specifically in the frontline health workforce, resilient supply chains, and research and development for new countermeasures including novel vaccines, therapeutics, and other platforms and technologies that can be deployed during a pandemic.Many dialogues prioritized equity, and the idea that regardless of location or income level, all people must be able to access the science, tools, and resources they need to both better prepare for and respond to health crises. Cross-sector leaders, including the World Trade Organization Director-General Ngozi Okonjo-Iweala, came together for a frank conversation about pandemic preparedness, prevention, and response financing needs, and how we can sustainably mobilize resources for the full range of needs.Much of the attention and debate zeroed in on the newly created financial intermediary fund. This fund is meant to provide a dedicated stream of additional, long-term financing to strengthen pandemic prevention, preparedness, and response capabilities and address critical gaps in LMICs through investments and technical support at the national, regional, and global levels. Yet at UNGA, with the backdrop of the recent disparities in the COVID-19 response still fresh, conversations swirled around how the Fund would ensure a broad set of voices were represented, its ability to achieve its full scope given limited catalytic funding, and how it connects to the broader health security architecture.  This year’s formal UNGA agenda did not feature health as prominently as in the past, perhaps a signal that the outsized attention our community has received due to COVID-19 is waning, as concerns about climate change, a global food crisis, and ongoing global conflicts rise on the list of the world’s most pressing challenges. In the coming months, advocates must pivot to ensure that pandemic needs are not forgotten, and that we start to build the fit-for-purpose architecture of the future, while also recommitting to non-COVID-19 health priorities and addressing the backslides we have seen since the onset of the pandemic.

As the world enters the third year of the COVID-19 pandemic, with new variants spreading around the globe and continued inequities in global vaccination and access to critical health tools, this year’s meeting of the World Health Organization (WHO) Executive Board (EB) felt like a make-or-break moment. Global leaders met to determine ways to not only address the current crisis, but also to build and strengthen the very institutions necessary to combat future health threats and reprioritize key programs and diseases that have fallen dangerously off track.  While some incremental progress was made, this year’s forum still left us with more questions than answers, with many key topics of concern remaining unaddressed, and more traditional dialogues related to research and development (R&D) for tuberculosis (TB), malaria, HIV/AIDS, or neglected tropical diseases (NTDs) receiving less airtime than at previous board meetings. Here are my top four takeaways from last week’s proceedings:EB disappoints on R&D topicsOne thing that has repeatedly been made clear at virtually every multilateral meeting in the past two years is that the pandemic has massively disrupted other critical health priorities, and that progress toward the Sustainable Development Goals and other key global targets is under threat. The EB continued the conversation on these challenges, including for TB research and innovation, NTDs, and the Immunization Agenda 2030. Yet despite a clear consensus that more must be done, few member states articulated specific changes that should be made immediately or presented new pledges to change the current trajectory in these key areas. Instead, many, including WHO, highlighted steps taken over the course of the past year, which, while welcome, are clearly nowhere near enough to even bring us back to pre-pandemic levels as we look to progress toward the Sustainable Development Goals. The disconnect seemed particularly striking during the TB session, in which members stressed the need to meet the 2018 United Nations high-level meeting TB R&D investment target of at least US$2 billion per year and address access barriers and other bottlenecks, while also acknowledging that annual funding for TB research needs to more than double to reach the global target, and provided no major recommendations on how to catalyze product development. It is also noteworthy that meeting logistics also played a part in the less robust debate. Due to time constraints, most agenda items were taken up in bundles, which forced all stakeholders to water down their statements and provided little opportunity to delve into the various recommendations presented in the reports and updates by WHO.Incremental progress on WHO’s work in health emergencies One area that continues to receive the bulk of the attention is WHO’s work in health emergencies. While the EB was not expected to finalize decisions on all the various reform recommendations that have been proposed over the course of the last year, significant progress was made in negotiations, opening the avenue for more concrete decisions to be made in the coming months.The EB took its first step in approving a process, introduced by the United States, to consider amendments to the International Health Regulations (IHR). The decision integrates this workstream into the mandate of the Working Group on Strengthening WHO Preparedness and Response to Health Emergencies, positioning this forum as a platform for discussion and deliberation on ways to strengthen the existing IHR framework.The board also took steps to advance the formation of a standing committee under the EB on health emergencies. This committee, first proposed by Austria, would be designed to more closely oversee WHO’s emergency response efforts after a public health emergency of international concern is declared. Proponents argue that the goal is to coordinate a response within the EB, and that this new structure will not interfere with the IHR Emergency Committee. While some skepticism remains, member states were ultimately able to compromise to move the process forward.Dialogue on WHO financing stutters—but hope remainsAnother hotly anticipated topic was the item on sustainable financing. Although it was already clear coming into the EB that there is no consensus among member states on an increase in assessed contributions to WHO, it was nevertheless significant to witness many low- and middle-income countries expressing their support for WHO by showing their willingness to contribute more.Despite shouldering a massive burden as the global health multilateral institution, only a fraction of WHO’s financing comes through annual membership dues, leading to a lack of predictability and jeopardizing WHO’s independence and flexibility to carry out its mission. What’s more, an overreliance on heavily earmarked, voluntary, and short-term funding has left more than 25 percent of WHO’s staff on short-term contracts, further compromising its ability to meet its mandate.At the EB, the sustainable financing working group managed to win an extension of its mandate from the EB to continue discussions on these intractable issues until the World Health Assembly in May.The chair of the working group, Björn Kümmel, stated he would continue to push for consensus on the proposal, though he still faces some pushback from the United States, Brazil, and Japan, which cite their voluntary contributions, economic challenges, and WHO’s need for greater budgetary discipline and transparent governance as major considerations that should be considered in this process. The next few months will be a sprint to see whether an agreement can be reached going into the WHA with geopolitical speedbumps to be overcome along the way.Operational efficiency and non-state actor engagement remain challenges for WHOWHO’s finances were not the only existential concern that was thrown into sharp relief last week. As many officials and advocates slogged through the massive agenda, navigating the almost Kafkaesque processes of jumbling agenda items together haphazardly, one couldn’t help but wonder about the necessity of a major reset in how these meetings are run. In order to make it through the whole agenda, items that were tackled in the latter half of the week simply couldn’t be given their proper floor time. Many decisions were ultimately punted, and there was little practical debate. Much of the format remains archaic, with most of the updates and reports being simply text-heavy, and member states and non-state actors continue to have a difficult time picking up on key points or recommendations made by other participants. The engagement of non-state actors was also a topic of conversation, as several stakeholders called on member states to also prioritize interactions with civil society by actively participating in informal sessions and systematically sharing draft documents and resolutions to allow them to engage more robustly in policymaking and technical matters.After another whirlwind EB, member states now have the mammoth task of simultaneously advancing several initiatives, many overlapping, in the lead up to the World Health Assembly to secure the future of WHO and its status in the global health architecture and galvanize the world on the COVID-19 response.

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 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.