Global health and its discontents

A year ago, a group of us gathered to reconsider how to build healthy and equitable societies.¹ During that meeting, we rehearsed critiques of the current practice of global health.² The COVID-19 pandemic has laid bare the truth in these charges, highlighting deficiencies in the pursuit of equity and in the capacity for multisectoral action—yet the pandemic has also provided inspiring examples of effective national and global public health action. After the 1918 influenza pandemic, many countries built new institutions, laws, and practices that laid the foundation for modern public health. As a global health community, we should not miss the opportunity from this crisis to reflect upon and remedy our shortcomings to better support global health equity.

First, despite genuine desire and goodwill, and the Paris and Accra declarations, global health remains insufficiently country-centred. COVID-19 has provoked impressive examples of global solidarity, but it has also shown that individual decisions at the national level matter more for health than regional and multilateral institutions and mechanisms, including global health treaties and strategies. Global health practice often fails to fully engage with the individual context, policy cycles, and political economy of national health and social systems. Too many global technical and policy documents provide insufficient direct guidance and detail for national decision makers or are pitched at the wrong level. The unpredictable, short-term, feast-or-famine nature of overseas development assistance for health has proved difficult to improve. Yet navigating the sometimes conflicting internal and external incentives that give rise to this incoherence remains essential to improving the utility, efficiency, and equity of global health efforts.³

Second, COVID-19 has already questioned and reworked the tools of global health. Resolutions, special sessions, high-level commissions, reports, frameworks, and global action plans can still be useful, but too often global health practice is delivered using the same means as were being used many decades ago. COVID-19, with its limitations on travel, has shown that a strong physical presence within countries is more important than ever.⁴ Institutions dependent on fly-in, fly-out missions need to rethink their operations. At the same time, COVID-19 has also shown how much of global health travel, especially for generic stakeholder meetings, can be avoided, with benefits for staff, countries, and the planet.

Third, COVID-19 has brought to the boil the already simmering discontent about who gets to make decisions in global health and their relationship to global health's intended beneficiaries.5, 6 The discourse on the need to decolonise global health has become prominent and persuasive (although still itself dominated by those based in high-income countries), and the struggle for greater gender equality in its practice and leadership has made important gains. Moreover, the poor performance of many high-resource contexts, including in preventing inequities in outcomes of COVID-19, has made prominent the shifting poles of where public health excellence actually occurs and questioned why global health leadership continues to be dominated by and concentrated in a handful of countries.⁷ The HIV movement has already shown what is possible in terms of participation and ownership by communities, albeit in unique circumstances. COVID-19 has just re-emphasised lessons that were thought to have been learnt during the west Africa Ebola virus disease outbreak on the importance of community leadership.

Fourth, COVID-19 has again shown the limitations of global and national governance in stewarding multisectoral action to tackle complex problems, notwithstanding prominent national exceptions. The construction of false conflicts between public and economic health in response measures has proved disastrous. The siloed nature of health and development policy making and assistance needs urgent attention; global health practice must no longer ignore the essential truth that health is mostly created and destroyed outside of the health sector.

Finally and most importantly, the dismal performance in terms of equity for COVID-19's impacts demands a reckoning. Whether in terms of the distribution of commodities such as vaccines, the sadly predictable concentration of mortality in disadvantaged groups within countries, the social and economic impacts of non-pharmaceutical interventions, or access to health care, COVID-19 has shown that, despite decades of rhetoric on the importance of health equity, little has been achieved in terms of mainstreaming its priority within approaches to health. It has never been clearer that attention to the social determinants of health is neither utopian nor abstract but instead fundamental to the effectiveness of public health practice.

None of these deficiencies need be terminal. COVID-19 has made the case more persuasively than ever for an effective global health. It is time to use the political oxygen of the current prominence of global health to construct a more participatory, just, and effective practice out of the cruelty and misery of COVID-19 (panel ).

Panel. Improving the effectiveness and equity of global health practice in the wake of COVID-19.

Construct a global health practice that is much more customised and driven by the individual needs of countries and specific populations within countries, elevating decision makers and communities in low-income and lower-middle-income countries to priority actors and audience in global health over global elites.

Reboot the global health toolkit, strengthen the focus on in-country presence, and take advantage of the possibilities of remote cooperation, enabling smarter use of virtual and in-person interaction.

Centre the rights and perspectives of communities intended as beneficiaries of global health, evaluate the impact of global health in these terms, and accelerate the democratisation and representativeness of global health leadership (including recognising the importance of class and societal position, rather than just diversifying elites).

Genuinely transform governance of global health and development to be fit to act across sectors (to prepare better for future infectious disease outbreaks) and revitalise the vision of the Sustainable Development Goals by paying as much attention to required actions outside of the health sector as those within it.

Integrate a social determinants approach into pandemic preparedness and global health security efforts, with a proactive focus on equity and identification and prioritisation of marginalised groups between and within countries.

The views in this Correspondence are mine alone and do not necessarily reflect the views, policies, or decisions of any of the institutions I have been associated with. I declare no competing interests.