The Health Priority for Italy's G20 Presidency: Immunise the World, Equitably
Global health is often on the agenda of G20 leaders and given the breadth of this vast topic it is usually a challenge for the annual Presidency to propose priority themes and policies. Should the focus be on specific communicable diseases and if so which ones? Or should it be on the growing burden of non-communicable diseases, addressing the social determinants of health or promoting an approach to improve health, for example through primary healthcare or achieving universal health coverage?
This year is different: with the world now having the tools to overcome the biggest health crisis in over a century, but facing a “catastrophic moral failure” according to WHO’s Director General, over their unfair allocation, Italy’s task in setting the global health priority for the G20 is simple: How can the G20 vaccinate the world effectively, efficiently and equitably?
Given the scale of the impact of the COVID-19 crisis on global health and the world economy, one would hope that G20 leaders can quickly agree on the need to prioritise this issue and better prepare for the next pandemic. The shocking statistic of 2 million COVID-19 related deaths in 2020, plus alarming projections of deteriorating health indicators due to disrupted services should be enough to remind leaders that the virus is devastating the health and wellbeing of a large proportion of their people.
In addition, the unprecedented damage the pandemic has wrought on the global economy should be reason enough for G20 leaders and their finance ministers to put overcoming the coronavirus crisis at the top of their economic agenda as well. In fact, the attainment of all the sustainable development goals is threatened by the multidimensional impacts of the COVID-19 pandemic and so long as cases continue rising tackling the crisis should be the top priority.
A matter of urgency
In this respect, the focus of health discussions, resolutions and actions should be on how to reduce if not eliminate the spread of the COVID-19 virus and ensure that lessons are learnt so that there is not a repetition in the future. But with the crisis still raging and whole continents imposing lockdowns and restricting travel, there should be a much greater sense of urgency to suppress the virus quickly, which was lacking when the G20 last met in Saudi Arabia in November 2020.
Admittedly, last autumn, preliminary results from phase three vaccine trials were just being published and none had been approved by regulators for mass distribution. So discussions about how vaccines would be rolled out across the world would have been constrained by considerable uncertainty. The G20 leaders’ resolution was therefore vague and aspirational, recognising “extensive immunization as a global public good” without making any financial commitments to ensure universal and equitable coverage.
But thanks to the unprecedented collaborative efforts of the world’s scientific community in both the public and private sectors, everything has changed. Since the turn of the year, regulators have been approving new vaccines on an almost weekly basis and it is clear that humanity now has the scientific firepower to take on COVID-19 and potentially bring an end to the crisis.
Furthermore, thanks to the revolutionary research involved in the discovery of some of these vaccines, scientists are confident they will be able to edit the genetic make-up of their vaccines relatively quickly to fight new variants of the virus as it mutates.
At the start of 2021 the world’s scientists have now given us the tools to overcome the virus and so it is now over to the world’s governments and pharmaceutical companies to ensure they are manufactured and distributed in sufficient quantities to reach everyone who needs them.
The ultimate goal should be universal vaccine coverage, although as the virus usually only causes mild disease in children, effective protection against serious illness may be achievable by vaccinating only the world’s adult population – but this still represents more than 5 billion people!
The tug-of-war over vaccine distribution
As the world’s current supply of effective vaccines is nowhere near covering this number of people (as of 18 February, 130 countries had not received a single dose) allocating these relatively scarce commodities is a highly contentious and political issue. Objectively if the primary goals are to save lives and stop the virus, vaccines should be allocated efficiently and equitably, with greater priority given to those most susceptible to becoming infected and at greatest risk of serious illness and death.
This is why most countries rolling out vaccines in 2021 are prioritising their elderly populations, those with high-risk co-morbidities and front-line health workers who come into frequent contact with infected patients. Distributing vaccines to priority need groups first requires a high degree of solidarity from the rest of the population who are prepared to wait their turn.
But most importantly, if humankind is going to overcome the coronavirus pandemic quickly and minimise deaths, it is vital that such solidarity does not just occur within countries, but is also extended across national borders to encompass all the world’s people. This would mean relatively low risk populations in wealthy countries being immunised after high risk groups in developing countries. Regrettably the experiences of 2021 show this is not happening and instead, the world’s wealthy countries (many of whom are G20 members) appear locked in a race to see who can vaccine their populations first.
This has resulted in countries securing supplies of vaccines to immunise their populations many times over, whilst poorer nations await supplies from the pooled procurement mechanism (COVAX) established by the World Health Organisation, the Vaccine Alliance (GAVI) and the Coalition for Epidemic Preparedness Innovations (CEPI). To date, this has secured 6.3 billion US dollars funding from wealthy nations to finance vaccines for 92 developing countries. However, the first tranche of these supplies is projected to only cover 3 per cent of the needs of recipient countries by June, at a time when the United Kingdom predicts it will have covered 43 per cent of its citizens.
As well as being grossly inequitable and contrary to the principles of the sustainable development goals, this behaviour of wealthy nations (dubbed vaccine nationalism) is also inefficient, as it allows the virus greater opportunity to spread and mutate in un-immunised populations. This could potentially extend the pandemic leading to much greater loss of life and further unnecessary damage to the battered world economy.
The self-defeating lack of solidarity being shown by wealthy governments has been highlighted by the Director General of the WHO, leading economists and the Secretary General of the United Nations who lamented in a tweet that “science is succeeding – but solidarity is failing”.
As political leaders see themselves primarily accountable to their own electorates, building international solidarity on this issue will not be easy and that is why bodies like the G7, G20 and the United Nations have great importance in building multilateral collaboration on this issue. But to date the G7 and G20 have not risen to this challenge. This was illustrated recently when the G7 failed to agree on a coordinated mechanism to reallocate vaccines to developing countries, with the UK rejecting a proposal from the President of France to re-allocate 5 per cent of supplies in G7 countries to African nations. As Chair of the G7 the UK announced that it would donate “the majority of any future surplus vaccines” to COVAX but only once it had offered all its own adult population a vaccine.
As the G7 is made up of many of the wealthy nations who are benefitting unfairly from the current situation, one feels that the G20 perhaps offers a greater opportunity to challenge the status quo and catalyse a faster and more equitable global roll-out of vaccines. Also, the G20 is a mixture of wealthy nations where many of the vaccines are manufactured and big middle-income countries where hundreds of millions of the world’s most needy potential beneficiaries for vaccines are living.
A plan of action for Italy’s G20 Presidency
As the chair of the G20 and a G7 member, the Italian government could play an important role in delivering a meaningful resolution and concrete actions that would make the universal coverage of COVID-19 vaccines a reality.
What specific policy reforms could the Italian government propose to G20 members as they prepare for their summit in October and a special health summit in Rome in May?
Firstly, that all G20 countries commit themselves to vaccinating the entire world’s adult population against COVID-19 by an agreed date in 2022 and that systems are established to re-vaccinate people as required to maintain their protection against new variants of the virus.
Secondly, that countries agree to a global strategy to roll out vaccines equitably taking a whole of humanity approach, prioritising those with greatest needs, as opposed to prioritising their own populations first. Here it is to be hoped that the G20, which includes powerful middle-income countries, will perform better than the G7 which appears to consider redistributing vaccines as a charitable act that countries can initiate at a time of their choice.
Leaders often sign up to worthy aspirational development goals of this nature realising that they are unlikely to be held to account in delivering them, but their attainment will be much more likely if they are backed up by concrete actions that require funding. In which case G20 leaders should also agree to the following:
All G20 countries should agree to immediately make up the shortfall in funding for COVAX and the other elements of the Access to COVID-19 Tools Accelerator (ACT-A) – currently estimated be to be 22.9 billion US dollars. Furthermore, commitments should be secured to provide sufficient ongoing funding for 2022 and as long as is required. As this funding could potentially save trillions of dollars in lost economic output (most of it to the benefit of wealthy nations) this would represent the best investment decision the G20 has ever made.
Such a commitment to finance the global procurement system designed to vaccinate the world equitably was conspicuously absent from the 2020 G20 communique. It should be a top priority for Italy to rectify this.
A new platform for vaccine production
The failure of the current global pharmaceutical system to ensure adequate supplies of vaccines in a sufficient time frame should also trigger a debate amongst G20 nations about adopting more radical solutions to scale up the production of vaccines – especially in emerging economies. There is an appetite amongst G20 members for this debate, with India and South Africa calling on the World Trade Organisation to suspend patents for COVID-19 related products.
One specific mechanism that could achieve this objective is the COVID-19 Technology Assessment Pool (C-TAP) initially proposed by the President of Costa Rica and backed by the WHO. This platform would facilitate the sharing of vaccine manufacturing technology, intellectual property and know-how by waiving intellectual property barriers and expanding voluntary contracting between manufacturers.
To date, measures of this nature have been opposed by wealthy nations with highly-profitable pharmaceutical sectors, but if market failures in the supply of vaccines lead to an extended global recession, the G20 should be prepared to discuss radical solutions to protect the world economy and maintain financial stability. This after all is the primary mission of the G20.
Given the highly political nature of these debates it has been commendable how strong the leadership of the United Nations and the WHO have been in calling out the selfish behaviour of wealthy nations and their failings to meet the commitments they made towards universal health coverage. This illustrates once again why, from a whole of humanity perspective, it is vital to have a powerful and well-resourced World Health Organisation.
Therefore, the final challenge Italy could put to the G20 is to encourage its members to increase their financial contributions to enable the WHO to fulfil its mandate and implement its triple billion global programme of work, focussing on health security, universal health coverage and healthy populations.
Were the G20 leaders to agree a plan of action along the lines outlined above, the 2021 Summit and the Italian Presidency could make a tremendous contribution towards ending the pandemic quickly, improving health and economic indicators and getting the world back on track to achieve the SDGs. In so doing, it would go down as the most impactful G20 in history.
* Robert Yates is Executive Director of the Centre for Universal Health, Chatham House, The Royal Institute of International Affairs, London. This article was prepared in the framework of the Strategic Partnership between IAI and the Compagnia di San Paolo Foundation.
 Tedros Adhanom Ghebreyesus, WHO Director-General’s Opening Remarks at 148th Session of the Executive Board, 18 January 2021, https://www.who.int/director-general/speeches/detail/who-director-genera....
 G20, Leaders’ Declaration, Riyadh Summit, 21 November 2020, http://www.g20.utoronto.ca/2020/2020-g20-leaders-declaration-1121.html.
 Clive Cookson and Anna Gross, “What We Know About the Most Troublesome Covid Mutations”, in Financial Times, 8 February 2021, https://www.ft.com/content/71e53321-3719-4f10-9406-c614a5ddc1b8.
 Scott Andrew, “More than 130 Countries Don’t Have a Single Covid-19 Vaccine, While 10 Countries Have Already Dispersed 75% of All Vaccines, the UN Says”, in CNN, 18 February 2021, https://edition.cnn.com/2021/02/18/world/united-nations-130-countries-no-vaccine-trnd.
 GAVI, G7 Backs Gavi’s COVAX Advance Market Commitment to Boost COVID-19 Vaccines in World’s Poorest Countries, 19 February 2021, https://www.gavi.org/node/99631.
 António Guterres, “COVID19 vaccines are reaching high income countries quickly…”, Twitter, 16 January 2021, https://twitter.com/antonioguterres/status/1350545107725012993.
 Rhoula Khalaf, Ben Hall and Victor Mallet, “Emmanuel Macron Urges Europe to Send Vaccines to Africa Now”, in Financial Times, 18 February 2021, https://www.ft.com/content/15853717-af6c-4858-87d4-58b1826895a8.
 Jill Lawless, “G-7 Vows ‘Equitable’ World Vaccine Access, But Details Scant”, in AP News, 19 February 2021, https://apnews.com/article/7313ccb3ec3945a1f5e959f9253171f7.
 UNICEF, Access to COVID-19 Tools Accelerator (ACT-A), 23 February 2021, https://shar.es/aoyMuV.
 Jim O’Neill, “A No Brainer for the G20”, in Project Syndicate, 16 November 2020, https://prosyn.org/AnXDlkq.
 Ann Danaiya Usher, “South Africa and India Push for COVID-19 Patents Ban”, in The Lancet, Vol. 396, No. 10265 (5 December 2020), p. 1790-1791, https://doi.org/10.1016/S0140-6736(20)32581-2.
 WHO website: COVID-19 Technology Access Pool, https://www.who.int/initiatives/covid-19-technology-access-pool.
 WHO, Triple Billions: Targeting a Better Future, 13 May 2020, https://www.who.int/data/stories/triple-billions-targeting-a-better-future.