G20 Okayama Health MinistersMeeting: lessons learned and way forward

Summary

The third G20 Health Ministers' Meeting was held in Okayama, Japan on October 19-20, 2019. The authors were involved in the decision making of the substantial issues of this meeting including theme setting, schedule management, facilitating the discussion, and preparation for the ministers' meeting. Here, we summarize our lessons of experience from hosting G20 Okayama Health Ministers' Meeting as: i) Utilizing the occasion of existing major health related meeting to gain efficiency; ii) Collaboration with other G20 tracks such as finance can function as a tool to facilitate inter-sectoral collaboration within other G20 members; iii) Two-day Health Working Group before the ministerial meeting provides sufficient time for negotiation of the declaration text; and iv) Inclusion of residents and representatives of the host city provides great opportunity to create G20 legacy. Such an experience of Japanese policymaking is rarely shared in English and the lessons learned from our experience shall provide meaningful advice for Saudi Arabia colleagues who are to hold the next G20 Health Ministers' Meeting as well as for the preparation of other G20 ministerial meetings.

Introduction

On October 19-20, 2019, the third G20 Health Ministers' Meeting was held in Okayama, Japan. The authors were involved in the decision making of the substantial issues of the G20 health track which led to this meeting including theme setting, schedule management, facilitating the discussion, and running the ministers' meeting. We were also involved in the negotiation of the first ever joint session by the Health and Finance Ministers as well as the health component of the G20 leaders' declaration. Such an experience of Japanese policymaking is rarely shared in English and the lessons learned from our experience shall provide meaningful advice for Saudi Arabia colleagues who are to hold the next G20 Health Ministers' Meeting as well as for the preparation of other G20 ministerial meetings.

Reviewing the progress of G20 Health Ministers' Meeting

The first G20 Health Ministers' Meeting was held under the German presidency in Berlin in 2017. Given the rising interest in health emergency preparedness starting from the Ebola outbreak in West Africa (1), the meeting's main focus was global health crisis management (2). The discussion was taken over from the G7 Health Ministers' Meeting in Kobe in 2016, which placed a strong emphasis on health emergencies as well. The German G20 Health Ministers' Meeting included a first-ever tabletop simulation exercise participated in by health ministers from the G20 members which focused on core issues in global health crisis management including communication, collaboration, contributions, coordination, and compliance (3). The following G20 presidencies, Argentina and Japan, took over this unique feature to involve ministers in simulation exercises. Another major achievement of the 2017 G20 health track was the launch of the Global AMR Research and Development (R&D) Hub. The initiative, which aims to expedite R&D of new antibiotics through cross-sectoral collaboration, emerged from a call from the G20 Leaders (4).

Under the Argentina presidency in 2018, it inherited most of the main themes in the German presidency (Figure 1). The main themes included antimicrobial resistance (AMR), malnutrition, health system strengthening, and health system responsiveness (5). Malnutrition, in particular, focused on childhood overweight and obesity. In Latin America, childhood overweight and obesity have been an alarming problem as researched in a systematic review (6). This was a good example to show how high-level global dialogue could cast light on emerging regional public health issues. A simulation exercise featuring AMR was also performed in the G20 Health Ministers' Meeting in Argentina. Through the opportunity, the G20 health ministers cultivated their practical knowledge and skills to combat resistant pathogens.

Figure 1.

Names of host cities, time-line and major themes of G20 Health Ministers' Meetings are listed in chronological order. Key pillars discussed in Berlin in 2017, including health systems strengthening, health risk management, and AMR, have been taken over by the subsequent presidencies. Malnutrition and response to population aging are unique themes discussed in Mar del Plata and Okayama. Abbreviations: AMR, antimicrobial resistance; UHC, universal health coverage.

In 2019, the Japanese presidency adopted several main pillars: the achievement of universal health coverage (UHC), response to population aging, management of health risk and health security, and AMR (7). As a country that achieved UHC nearly 60 years ago in 1961, Japan has identified UHC as a priority in global health. Regarding aging, it was a new theme for the G20 health ministers to discuss. As the World Health Organization (WHO) projected, we are experiencing global population aging at its fastest pace (8). Being the most advanced country in the world on aging, Japan was responsible for playing an important role to lead the discussion with G20 members. The summary of major themes and timeline of the G20 Health Ministers' Meeting found in Figure 1 and Table 1 provides an overview of key outcomes for each meeting by major themes.

Table 1. Major themes and key outcomes in the G20 Health Ministers' Declaration.

Items	2017, Germany	2018, Argentina	2019, Japan
UHC/HSS	• Appreciate the establishment of the UHC2030. • Request for reliable evidence base and appropriate indicators to monitor progress. • Encourage investment in building a skilled and motivated health workforce.	• Encouraged investment in building the health workforce. • Encouraged sharing best practices of e-health including effective policy design and implementation.	• Promote use of data and digital technologies. • Highlight the importance to build institutional capacity, including human resources for developing health policies. • Work with Finance Ministers and relevant stakeholders for financial sustainability.
Aging	‒	‒	• Affirm active and healthy aging as priority. • Commit to develop and implement multi-sectoral national action plans on dementia.
AMR	• Highlight the importance of the R&D initiatives to examine push and pull mechanisms. • Commit to create an AMR National Action Plan and aim to implement them by the end of 2018.	• Welcome the establishment of the Global AMR R&D Hub and encourage investment in R&D.	• Encourage investment in R&D and reaffirm the need to further examine practical market incentives. • Enhance implementation of policy measures to prevent infections and stewardship of antimicrobials.
Health Emergency	• Highlight the need for monitoring and evaluation measures of IHR implementation and the importance of implementing IHR, including building core capacities within the context of HSS.	• Encourage member states to contribute to the CFE. • Emphasize the need for multi-sectoral preparedness efforts.	• Encourage WHO to broaden donor base for the CFE and contribute to it.
Nutrition	‒	• Commit to take action to tackle malnutrition, with a particular focus on childhood overweight and obesity, including through enhanced inter-sectoral efforts.	• Acceleration of efforts to enhance nutrition in the framework of the UN Decade of Action on Nutrition (2016- 2025).

Note: Names of host cities, time-line and major themes of G20 Health Ministers' Meetings are listed in chronological order. Key pillars discussed in Berlin in 2017, including health systems strengthening, health risk management, and AMR, have been taken over by the subsequent presidencies. Malnutrition and response to population aging are unique themes discussed in Mar del Plata and Okayama.

Abbreviations: AMR, antimicrobial resistance; HSS, health systems strengthening; UHC, universal health coverage; UHC2030: International Health Partnership for Universal Health Coverage 2030.

Process of G20 Okayama Health Ministers' Meeting and lessons learned

The preparation process for the Okayama meeting started from summer 2018 as we started our internal discussion on the theme of the meeting. Following this internal discussion, we presented the theme to the G20 members in January 2019 and had 4 rounds of Health Working Group discussions on the leaders' declaration health section as well as the ministers' declaration (see Figure 2 for G20 health track schedule). Alongside the Health Working Group discussion, we closely collaborated with our foreign ministry regarding the leaders' declaration and finance ministry regarding the G20 Shared Understanding on the Importance of UHC Financing in Developing Countries which was the output for the Joint Session of Ministers of Finance and Health. The following sections describe the details of i) setting the theme, ii) managing the schedule of Health Working Groups and other relevant meetings, iii) facilitating the G20 member discussion, and iv) preparing for the G20 Health Ministers' Meeting and the lessons learned (Table 2) through this process.

Figure 2.

2019 G20 health track schedule.

Table 2. Lessons learned from our experience of hosting G20 Okayama Health Ministers' Meeting.

Items	Lessons learned
Lesson 1	Utilizing the occasion of existing major health related meeting is the key to facilitate efficient G20 member discussion.
Lesson 2	Collaboration with other G20 tracks such as finance can function as a tool to facilitate inter-sectoral collaboration within other G20 members.
Lesson 3	Two-day Health Working Group before the ministerial meeting provides sufficient time for negotiation of the declaration text.
Lesson 4	Inclusion of residents and representatives of the host city provides great opportunity to create G20 legacy.

Setting the theme

In identifying the main pillars of discussion, we put importance both on the continuity from the previous presidencies and accommodating new agenda. We also needed to consider the diversity of G20 members, which includes both developed countries and emerging economies and select the themes which are relevant for all G20 members.

Since the late summer of 2018, we had an internal discussion in the government. As the Leaders' summit was to be held before the Health Ministers' Meeting, we needed to align the discussion in the Health Working Group and the Sherpa track. Therefore, we worked together particularly with the Ministry of Foreign Affairs. We also had close collaboration with the Ministry of Finance, as the Joint Session of Ministers of Finance and Health was to be held in the margin of the Leaders' Summit. After internal coordination among those ministries, the Ministry of Foreign Affairs sent an issue note on health, which showed the three main pillars, on December 20th 2018 to G20 members.

Following the practice of Argentina, we hosted an information session in the margin of the WHO's Executive Board (EB) meeting in January. We explained our idea on the agenda and way forward to the Health Ministers' Meeting, which were both supported by G20 members. Utilizing the occasion of existing major health-related meetings, such as the EB meetings, was effective in gaining efficiency as many health experts from the capital were present (Lesson 1).

Managing the schedule of Health Working Groups and other relevant meetings

The first Health Working Group was held from January 31 to February 1, 2019 in Tokyo. We had an intensive discussion on the agenda and received valuable input from G20 members, invited countries and international organizations to develop the draft health paragraph in the Leaders' declaration and Health Ministers' Declaration.

The outcome of the Joint Session of Ministers of Finance and Health was coordinated through the finance track. Ministry of Finance in each G20 member country had coordination with its health counterpart and made input into the outcome document of the Joint Session of Ministers of Finance and Health with "one voice". This process facilitated a dialogue between the Ministry of Finance and Health within each country. Thus, the process of developing the outcome, "G20 Shared Understanding on the Importance of UHC Financing in Developing Countries" has functioned as a tool to enhance inter-sectoral collaboration between finance and health sector in each G20 country (Lesson 2).

Based on the discussion in the first Health Working Group, the draft paragraphs on health in the Leaders' Declaration were developed and discussion by the Sherpas started in May. The discussion continued until the day of the Leaders' Summit. Finally, the Leaders' declaration including 4 paragraphs on health was agreed upon. The health paragraphs which consist of UHC, responses to aging, health risk management, and health security and AMR guided further discussion in the Health Working Group.

The discussion on the Ministers' declaration started in May. We hosted the Second Health Working Group from May 29 to 30, 2019 in Geneva at the margin of the World Health Assembly (WHA). It was also very efficient to utilize the occasion of WHA for the same reason as the information session in January. We hosted the 3rd Health Working Group from July 1 to 2, 2019 in Tokyo, just after the Leaders' Summit and the Joint Session so that participants can attend both meetings with one trip to Japan. As we highlighted as our 1st lesson, in order to have an efficient process, the presidency needs to consider how they can host meetings to which G20 members can easily attend.

Facilitating the G20 member discussion

From the beginning, each member supported the themes and contributed to constructive discussion. Especially, the support from Troika countries, Argentina and Saudi Arabia was valuable for facilitating the discussion.

While fully considering existing agreements such as Political Declaration for the UN High-Level Meeting on Universal Health Coverage, WHA resolutions, G20 Leaders' communique, and the shared understanding by the G20 Finance and Health Ministers, our discussion centered on points that should be agreed upon and implemented by G20.

Emphasis was placed on dialogue with health-related engagements groups such as C20 (Civil Society) and T20 (Think Tank), as these dialogues have been employed by the previous G20 Presidency. Their inputs as a form of policy proposals and in person discussion at the 2nd G20 Health Working Group facilitated our discussions and was effective to incorporate various opinions of stakeholders into our final deliverables.

Another emphasis was collaboration with the Global AMR R&D Hub which is one of the legacies from the G20 German presidency. This collaboration resulted in the workshop held at the occasion of the 2nd Health Working Group Meeting, providing G20 participants with the current landscape of AMR R&D and the importance of deepening discussions on AMR.

When we reached the 4th Health Working Group, we had agreed on majority of the text thanks to the intense e-mail based communication in August and September. At the final 4th Health Working Group Meeting, constructive cooperation among countries enabled smooth and efficient discussion. We considered that two days (not one day) of the final meeting provided sufficient time for G20 members to consult with their headquarters during the first and second day which contributed greatly to smooth consensus building. This two-day Health Working Group before the ministerial meeting could be a good example method for future multi-lateral negotiation (Lesson 3).

Running the G20 Health Ministers' Meeting

Representatives from G20, invited countries and international organizations, including 9 Ministers, attended the Ministers' Meeting and the number of delegates amounted to 157. After the active discussion chaired by Mr. KATO Katsunobu, Minister of Health, Labour and Welfare who shared Japan's experiences and commitments relevant to themes, the Okayama Declaration of the G20 Health Ministers was adopted. Particularly, responses to population aging was first included as one of the main pillars in the G20 Health Ministers' Declaration and we believe that this new commitment will mobilize active policy responses in all G20 members and generate global momentum on this important issue.

Alongside the discussion by Ministers and representatives, we invited representatives from the host city, Okayama. Mr. OMORI Masao, Mayor of Okayama City, made a presentation to show their local efforts to extend healthy life expectancy. The representatives from local high school students presented their recommendations to G20 on women and children's health. Local elementary school students cordially welcomed delegations at the meeting venue. These involvements by the host city impressed the delegates and became a valuable legacy for the community. Collaborations with the host city was a key to the success of the meeting (Lesson 4).

Following the practice of previous presidencies, we had a simulation exercise on the 2nd day of the Health Ministers' Meeting. The theme was public health response to a health emergency during a mass gathering: according to a fictitious scenario and questions which request political decision, participants had a lively discussion facilitated by moderators, Dr. SUZUKI Yasuhiro, Chief Medical & Global Health Officer of the Ministry of Health, Labour and Welfare and Dr. KURANE Ichiro, former Director-General of National Institute of Infectious Diseases. The topic was relevant to all G20 members which often host large scale gatherings.

Way forward

The G20 presidency for 2020 is succeeded by Saudi Arabia. We would be very pleased if our lessons and experiences discussed in this article are useful for their preparation of the next G20 Health Ministers' Meeting.

Besides G20 meetings, we would like to highlight two upcoming meetings. Regarding UHC, which was one of the major topics of the G20 Okayama Health Ministers' Meeting, Prince Mahidol Award Conference (PMAC) 2020/UHC Forum 2020 to be held from January 31st to February 2nd in Bangkok will provide a great opportunity to follow up on the Okayama declaration and call for further concrete actions including developing a PHC-based health system, strengthening health financing and investing in promoting innovations of health technologies.

Moreover, the importance of collaboration between finance and health authorities was strongly emphasized in the shared understanding by the G20 Finance and Health Ministers. To keep this momentum, the Asian Development Bank (ADB), WHO, and the Government of Japan plan to coorganize a ministerial-level symposium on May 3rd 2020, at the time of the 53rd Annual Meeting of ADB's Board of Governors in Incheon, Republic of Korea.

We expect the above mentioned meetings would be a good occasion to call for further concrete actions, building upon strong global political commitments we shared at the G20 Okayama Health Ministers' Meeting.

Statement

Views expressed in this article are written in authors' individual capacity and does not represent any organization.