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Germany adopts a new Global Health Strategy

Date:17 November 2020

Dr. Pieter de Coninck, senior policy advisor at the Dutch Ministry of Health, Welfare and Sport, currently seconded to the German Federal Ministry of Health in Berlin. The author is writing in a personal capacity.

The current COVID-19 pandemic seems the ultimate proof that health at national level has global dimensions, regarding not only the origin and spread of diseases but also the efforts to prevent and control them. Infectious or communicable diseases may be the most striking example, but they are definitely not the only one: e.g. antimicrobial resistance, alcohol, and tobacco. In various ways, many health issues have cross-border, global aspects. That national governments work together to address health issues and to improve and protect people’s health around the globe, has two main reasons. One is a set of moral and legal obligations to do so, which are based in multiple international agreements and treaties. Altruism is definitely a reason for signing and ratifying such international agreements and treaties. However, enlightened self-interest seems at least equally important, as national borders are of limited significance for many health issues.

The concept of global health has gained prominence in recent years.[1] Germany is an example of a country that has thoroughly reflected on global health, and has developed into a prominent actor in this area.[2]. In 2013, the German Federal Government launched a first Global Health Strategy.[3] On 7 October 2020, the German Federal Government adopted a new Global Health Strategy, with the subtitle: Responsibility – Innovation – Partnership: Shaping Global Health Together.[4] The objective of the strategy, as defined in its foreword, is ‘to ensure that Germany’s engagement in the field of global health is effective and sustainable to make an important contribution to the health of all people worldwide by 2030’.

The Sustainable Development Goals (SDGs) of the UN Agenda 2030 provide the framework for the German Government’s political commitment in the area of global health. This entails i.a. the recognition that (good) health and well-being (SDG 3) are inextricably linked to the social, economic and environmental dimensions of sustainable development. In the context of UN Agenda 2030 governments have a duty to promote and safeguard public health at national level, but also as part of their international engagement. In this context, Germany is confirming its commitment to multilateralism in general and to the World Health Organization (WHO) in particular.

The foreword of the strategy is followed by a section on ‘guiding principles for German engagement’. One of these principles is that all actions in global health need to be based on values and rules, such as democracy, human dignity, human rights, and the rule of law. Based on this, the Federal Government commits itself i.a. to ‘facilitate continuous progress in fulfilment of the human right to the highest attainable standard of health’. Other commitments concern e.g. ‘non-discriminatory, gender-sensitive, inclusive and barrier-free health structures and services’ and consideration of ‘all systems in their entirety’. The latter results in a strong advocacy for the One Health approach (the interdisciplinary approach focusing on the interface of human and animal health and the environment). The ‘health in all policies’ approach is another guiding principle, urging to ‘do no harm’ (to health).

A holistic or synergistic approach to health (policy), which is also essential for the WHO’s 13th General Programme of Work (GPW13) and the SDGs, is characterizing the most extensive part of the strategy: ‘establishing strategic priorities’. These priorities include i.a. the prevention and control of non-communicable diseases (NCDs), strengthening health systems, and addressing cross-border health threats. As regards the chosen holistic or synergistic approach, the German strategy is significantly meeting the criteria for a global health strategy, as formulated by Kickbusch and Franz: ‘Global health can neither be confined to global health policies in a narrow sense (e.g. managing cross-border health threats) nor can it be limited to “external” policies (e.g. official development aid for health). The Sustainable Development Goals call for a reduction of (health) inequalities within and between member States.’ According to Kickbusch and Franz, countries also ‘need to acknowledge the effects their policies have with regard to health. This naturally includes the effects of policies such as trade agreements, (health) data policies, as well as food safety regulations on the health and wellbeing of the people living within their national borders as well as in partner countries. This awareness needs to go beyond avoiding harmful effects on health. Countries need to continue to explore how and to which global public goods they can or should contribute.’[5]

The last two sections of the strategy set out how Germany will operate with a view to achieving the objective of the strategy. The section ‘tackling challenges together, exploring new avenues’ is focusing on how Germany is acting at international level, and argues in favor of international collaboration and partnerships in multiple ways and in various relevant forums, such as multilateral organisations (e.g. WHO), the EU, the Global Health Security Agenda (GHSA), and the G7 and G20. According to Germany, WHO has to play a leading and coordinating role in strengthening international coordination of global health policy.

Over a period of decades, the World Health Organization, founded in 1948, was the only organisation dealing with global health. In recent years, the picture has changed drastically. As a result, the role and position of WHO within today’s complex ‘global health architecture’ is much discussed.[6] Germany’s position is clear: WHO has to be the leading and coordinating agency in global health. To this end, WHO should be well equipped, and therefore strengthening WHO is part of the strategy’s actions. As the current President of the EU, Germany initiated Council Conclusions on the EU’s role in strengthening WHO.[7] Providing the organisation with sufficient, sustainable and well structured funding is an important, although not the only, way to strengthen WHO. In this regard, Germany cannot be blamed for parsimony.

The last section of the strategy is, with just two pages, the briefest, but nonetheless dealing with an important topic: ‘ensuring coherent action’. One could say that this is about global health policy in Germany. An important means of achieving policy coherence within the Federal Government are the regular meetings of the State Secretaries’ Committee for Sustainable Development on questions of global health.[8] Regular and ad hoc meetings of all relevant ministries are also taking place at ‘working level’. Also important is the structural involvement of and dialogue and exchange with many, most German, non-state actors that are active in global health, such as civil society organisations, scientific institutes, and the private sector. Instrumental in this regard is the Global Health Hub Germany, which was established in 2019 (with a start-up grant from the Federal Ministry of Health) as a networking and exchange platform.[9]

What may also contribute to ensuring coherent action is the existence of a subcommittee on Global Health in the German Federal Parliament (Bundestag), which was established after the elections for the current (19th) Bundestag in September 2017. The subcommittee is made up of Members of the Parliament from other committees.[10] The reason why the subcommittee is not mentioned in the strategy, is probably that the Bundestag is autonomous with regards to its internal organisation. Interestingly, the new Global Health Strategy is (also) the result of the Coalition Agreement of the current Federal Government.[11]

All in all, the German experience with shaping global health both at home and abroad provides an interesting case, especially for other countries considering the development of a global health strategy or being more ambitious on global health. The Netherlands is one of the countries, where the need for a global health strategy is being raised with some regularity, at least since the Ebola outbreak in western Africa in 2014-2015.[12]

[1] There is a vast body of literature on global health; see e.g. Sebastian Taylor, ‘Global health’: meaning what?, BMJ Global Health 2018;3: 1-4.

[2] Ilona Kickbusch et al, Germany’s expanding role in global health, The Lancet 2017;390: 898-912.

[3] Shaping Global Health. Taking Joint Action. Embracing Responsibility. The Federal Government’s Strategy Paper, accessed at: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Gesundheit/Broschueren/Screen_Globale_Gesundheitspolitik_engl.pdf.

[4] https://www.bundesgesundheitsministerium.de/en/press/2020/global-health-strategy.html.

[5] Ilona Kickbusch and C. Franz, Towards a synergistic global health strategy in the EU (Global Health Centre, Working Paper No. 19, Geneva 2020), accessed at: https://www.graduateinstitute.ch/communications/news/towards-synergistic-global-health-strategy-eu. The passages cited here (page 18 and 19) are slightly adapted, as Kickbusch and Franz are setting out how, according to them, an EU Global Health Strategy should look like.

[6] See e.g. Charles Clift, What’s the World Health Organization for? Final Report from the Centre on Global Health Security Working Groupon Health Governance (Chatham House Report 2014), accessed at: https://www.chathamhouse.org/2014/05/whats-world-health-organization, and Chelsea Clinton and Devi Sridhar, Governing Global Health. Who Runs the World and Why? (Oxford University Press 2017).

[7] https://www.consilium.europa.eu/de/press/press-releases/2020/11/06/strengthening-the-world-health-organization-the-eu-is-ready-to-take-the-leading-role.

[8] Within the German Federal Ministries the State Secretary is the highest ranking civil servant.

[9] Andrew Green, Germany’s Global Health hub, The Lancet Vol 393 (2 March 2019) 862. See also: https://www.globalhealthhub.de/.

[10] https://www.bundestag.de/globale_gesundheit. The website of the Bundestag can be accessed in various other languages (than German). Unfortunately, the Parliament’s subcommittees are excluded from this.

[11] Ein neuer Aufbruch für Europa. Eine neue Dynamik für Deutschland. Ein neuer Zusammenhalt für unser Land. Koalitionsvertrag zwischen CDU, CSU und SPD, 19. Legislaturperiode (Berlin 2018) 102. Accessed at: https://www.bundesregierung.de/resource/blob/975226/847984/5b8bc23590d4cb2892b31c987ad672b7/2018-03-14-koalitionsvertrag-data.pdf?download=1.

[12] See e.g. IOB, Voorkomen is beter dan genezen. Evaluatie over Nederland en de WHO (2011-2015) and reaction from the Cabinet, i.a accessible at: http://archief.iob-evaluatie.nl/WHO.html, Louise van Schaik et al, Why the Netherlands should step up its ambitions on global health (Clingendael Report 2017), and RIVM, Dreigingen uit het buitenland voor de volksgezondheid in Nederland. Een quickscan (Bilthoven 2019). In July 2020 the Dutch Global Health Alliance was launched, see: https://www.wemos.nl/en/kick-off-webinar-of-the-dutch-global-health-alliance-local-data-local-decisions/.