Supporting Low-Middle Income Countries by Strengthening Global Health Governance to Reduce Inequalities


The COVID-19 pandemic exacerbated pre-existing inequalities and highlighted gaps in global health security. Global Health Governance and policymaking is a multi-stakeholder process, and the lack of an explicit institutional process and global health architecture has led to an uncoordinated proliferation of overlapping global health organizations with opposing frameworks. G20 can play a significant role in scaling up political commitment and catalyzing efforts to reframe the global health architecture in a more coherent direction to tackle emerging global health threats that require collective action. G20’s support is consequential in this changing epidemiological landscape, necessitating additional funding to strengthen WHO and IHR and its compliance. It is time to take bolder actions by providing a clear roadmap for inclusive solutions in their approach, holding themselves accountable, and following through on their financial commitments for global health preparedness.

Keywords: COVID-19; inequalities; low-middle income countries; G20; global health governance.



The COVID-19 pandemic exacerbated pre-existing inequalities and highlighted gaps in global health security (GHS) and emergency preparedness that allowed the virus to spread globally, given the inadequate real-time epidemiological surveillance and monitoring systems. Global Health Governance (GHG) and policymaking is a multi-stakeholder process, and the lack of an explicit institutional process and global health architecture has led to an uncoordinated proliferation of overlapping global health organizations with opposing frameworks. Moreover, WHO’s declining role as a sole international health agency and its limitations in interactions with the private sector has further fragmented GHG. Some critical barriers at global, national, and community levels that threaten the success of recent initiatives proposed in the wake of COVID-19 include: 1) fragmented approaches to public health and COVID-19 response, 2) weak health systems that are unable to address inequities amidst the fragility of highly interconnected economies and social systems. The concept of “equity” has atrophied to only address equity between countries while entirely overlooking in-country worsening health disparities. The fragmented global and national responses floundered not only because of gaps in technical skill or capacities but also due to failures in governance and leadership. Therefore, sustained political leadership and effective GHG remain the key factors for reducing inequalities and strengthening GHS (Bucher et al., 2022; Institute of Future Initiatives, 2022; The Independent Panel et al., 2022; Javed & Chattu).



We believe that G20 can play a significant role in scaling up political commitment and catalyzing efforts to reframe the global health architecture in a more coherent direction to tackle emerging global health threats that require collective action. G20’s support is consequential in this changing epidemiological landscape, necessitating additional funding to strengthen WHO and International Health Regulations (IHR) and its compliance. For an equitable outcome from the Intergovernmental Negotiating Body’s (INB) deliberations and to overcome any political constraints and challenges, low-middle income countries (LMIC) need a more concerted and sustained effort and a broader strategy to build on the momentum created by the Declaration of the G20 Health Ministers on equity. It is vital to develop and review policies using a COVID-19 equity lens, ensuring that equity plans cover the most vulnerable while also improving the equity plans that have existed before the pandemic.

Good governance requires that health decision-making processes and institutions at the international and national levels are accountable, transparent, equitable, inclusive, participatory, and consistent with the rule of law. These principles can and should inform the range of reforms to global governance for health. The national and global responses should apply human rights-based, gender-based analysis, and health-in-all-policies approaches to bridge the inequities and inequalities. Advancing global governance without global solidarity will continue to impede attempts to address a wide range of global health challenges, disproportionately threatening the Global South (Joint G20 Finance and Health Ministers Meeting Communiqué, 2021; Javed & Chattu, 2020; The Independent Panel et al., 2022).


1. Equity-based financial mechanism 

COVID-19 has revealed that the existing global health architecture is not adequately equipped to finance pandemic prevention, preparedness, and response (PPR). The G20 reached a consensus to address this gap by establishing a new financial mechanism, a Financial Intermediary Fund (FIF) (Bucher et al., 2022; WHO, 2022). Core global public health goods are underfunded, particularly the WHO Access to COVID-19 Tools Accelerator (ACT-A), which is essential in addressing the current gross inequity in access to Covid testing, treatments, and vaccine between vaccines high-income countries and LMICs. It is crucial that FIF does not undermine financing for existing urgent global health needs. The contributions by high-income countries to FIF must be in addition to existing Official Development Assistance (ODA). To avoid duplication and ensure collaboration and equitable global PPR response, the FIF must articulate a clear value-added and complementarity to existing PPR efforts. The decision-making process must incorporate multidimensional metrics that highlight the importance of health beyond the economic dimension while also holding the fund’s stakeholders accountable for the investment decision and its results. The FIF should have an effective evaluation mechanism to ensure efficiency and effective use of new investments; moreover, this evaluation mechanism must assure donors that there is a measurable return on their long-term commitment to the FIF (WHO, 2022; Institute of Future Initiatives, 2022).

In their October 2021 declaration, G20 Heads of State and Government recognized that universal access and participation in governance are needed to achieve the fairness, legitimacy, and inclusion required to generate buy-ins from LMIC (G20 Rome Leaders’ Declaration, 2021). The FIF needs to adopt a global public goods approach and move away from the inequitable donor-beneficiary framework. FIF’s formal governance structure should have equal representation across high and LMIC; it should also include core global and regional implementing institutions like the WHO and African CDC and experts from civil society (WHO, 2022). G20 must consult widely, including non-G20, on FIF (The Independent Panel et al., 2022). The failures to achieve equity must be remedied through legal reforms grounded in a human rights approach (Ooms, G et al., 2017). This includes ensuring equitable access to medical counter measures and affordable essential medicines and supplies, through the full utilization of flexibilities and waivers for public health such as those under the TRIPS agreement (Shah, R, 2021; Chattu VK & Singh B et al., 2021; Chattu VK & Dave V, 2021).

Meanwhile, FIF should be set up alongside complementary reforms, including adequately financed WHO. In addition to having a seat at the decision-making table, WHO should have a central role in implementing FIF. For a post-COVID-19 global health architecture and emerging global health challenges, G20 leaders should replenish and re-envision existing and upcoming global health entities (Shanmugaratnam, 2021; Mazzucato & KICKBUSCH, 2021; WHO, 2022).

2. Supporting WHO, IHR and pandemic instrument

The INB is developing the proposed pandemic instruments’ blueprint: a political framework for detecting, preventing, and responding to emerging infectious diseases and future pandemics. One of the crucial principles that underscored the pandemic instrument discussions at the World Health Assembly Special Session has been equity. However, equity in practice has not been related to access to and distribution of medical countermeasures in future pandemics. The success of global public good approaches such as COVAX has been undermined due to the failure of the patent-based system and advanced market commitments. Nations are facing inequities during the current pandemic, particularly LMIC, demanding that equitable access and distribution should be part of the pandemic instrument (Dentico et al., 2021; Wenham et al., 2022; Kickbusch & Holzscheiter, 2021). G20 members must agree that the discussion cannot end in stalemate and that there should be serious consideration of how the pandemic instrument should complement and strengthen existing institutions to address gaps seen during COVID-19.

G20 must also ensure the participation of civil society organizations and that a rights-based approach is central to the treaty, ensuring equity, particularly for the most venerable. In the future, comprehensive equity must also be central to pandemic governance. Particular attention should be paid to gender, racial, socio-economic, and geographical equity, as these intersectional policymaking areas have been previously ignored in infectious disease protocols. In addition to the involvement of political bodies such as the G20, important regional bodies such as the African Union, Mercosur, ASEAN and others would be crucial for the treaty not to be perceived as an instrument being pushed by the high-income countries. Such efforts, endorsed by the G20, can form a strong basis for a future consensus on best practices. That can support international cooperation when future threats emerge.

Moreover, The G20 should contribute by lending political support to existing agreements and multilateral organizations, particularly WHO and the IHR. The G20’s support can help revive and strengthen WHO’s credibility and reinstate its position as the designated global body in times of global health crisis. Political will from the highest levels of government, displayed at the G20, can propel the renegotiations of existing WHO agreements and arrangements and facilitate the introduction and quick ratification of new ones. G20 leaders must galvanize financial and political support to provide flexible funding to WHO, increase assessed contributions to the base program budget to 50%, and evaluate and amend IHR, which, if amended, could give authority to WHO to alert and investigate threats more quickly. The G20 must address inequities to stop any further degradation of global health and speed up the procedural aspects of global agreements needed during a health crisis. In a yet to be controlled pandemic, G20 governments must carry out multiple concrete actions rooted in real change, not charity (Moon & Kickbusch, 2021; Javed & Chattu, 2020; The Independent Panel et al., 2022).

3. To strengthen global health architecture, global solidarity is an obligation, not an option

According to the chair of G20, the focus in 2022 will be on strengthening global architecture, building resilience during pandemics, equitable procurement of vaccines, medicines, and diagnostics, and harmonizing international travel and health protocols (G20 Indonesia, 2021).However, we believe that as the first LMIC to chair G20, Indonesia can go beyond this agenda and use this opportunity to take bolder actions by advocating for global health issues plaguing, in particular, the Global South.

Global obligations have long been central to Global South’s call to transform global governance, with early advancement of a collective right to development explicitly looking to such extraterritorial obligations to advance global health equity and justice. To realize the right to health globally, global obligations can offer critical frameworks in restructuring global health governance, including responding to calls to decolonize global health, reforming multilateral institutions, including WHO, and addressing systematic inequities such as global vaccine apartheid. Human rights obligations have the potential to transform GHG even beyond pandemic response; it will require sustainable, well-resourced, global governance institutions to facilitate coordination across the international community to pursue health as a human right instead of a commodity and must commit to eliminating global health inequities. As long as States consider international aid and international cooperation voluntary, global solidarity will remain an elusive goal, one more regret upon the altar of failed political commitments.

Global health governance is undermined due to the rise in nationalism, which has exacerbated health and human rights inequalities between the Global North and Global South. The response to COVID-19 highlighted the need to reform GHG to remold global solidarity in global health and human rights. The changing global health governance landscape in the covid-19 and future pandemic response will require revamped attention to extraterritorial human rights obligations, including advancing global obligations in global governance to promote the right to health throughout the world. GHG is at the crossroad, entailing the development of new governance models taking global obligations for human rights realization into account (Meier et al., 2021; Millar, 2020).

The pandemic’s overall response globally does not kindle much confidence in the global health communities’ capacity to ignite changes that are consistent with Member State’s human rights obligations; UN Committee on Economic, Social and Cultural Rights has underscored that international cooperation and assistance are a global duty, the current crisis is a pandemic reinforces these obligations of States. Furthermore, under international human rights law, governments are obligated to cooperate internationally to realize human rights, meaning governments must not cause any harm beyond their borders or prevent other governments from meeting their human rights obligations. Particularly, high-income states have a duty to assist LMIC in fully realizing socio-economic rights for all – whether they act individually or in inter-governmental entities such as the G20 (Center for Economic and Social Rights, 2020; Meier et al., 2021).

The world leaders at G20 face a clear choice: to continue down an inequitable nationalist route or work collaboratively through global obligations to realize shared governance in global health. At this critical juncture, failure to strengthen human rights in global governance could permanently lead to nationalistic retrenchment and weakened multilateral organizations, diminishing hopes for the future of human rights in global health. On the other hand, in applying global obligations in GHG, these extraterritorial obligations can provide a legal foundation for global health, global solidarity, and global equity (Meier et al., 2021; McInnes et al., 2020; Gostin et al., 2020).

4. Upscaling R&D commitments

The COVID-19 pandemic has underscored the importance of a strong, united, and fully financed global health architecture into sharp relief. Instead of global solidarity, there has been fragmented response, geopolitical infighting, tepid leadership, and community inclusion (OKONJO-IWEALA et al., 2021).

R&D must be integrated into governance and pandemic prevention, preparedness, and response mechanisms. R&D is not included in the International Health Regulations (IHR) and Joint External Evaluations (JEE); R&D needs to be factored into any new pandemic framework developed by WHO. As the world leaders discuss the establishment of a new pandemic instrument or reforming existing frameworks such as IHR, any reforms or new instruments must include equitable access to medical countermeasures and strengthening the R&D capacity of countries through safeguards and conditions that incorporate access and benefits into their frameworks.

To end the acute phase of the COVID-19 pandemic, G20 should reinvest in progress towards Sustainable Development Goals (SDG), strengthen equitable global health architecture and address ongoing epidemics including malaria, tuberculosis, HIV, and neglected tropical diseases. In addition, G20 members should: catalyze new investments in R&D to fight poverty-related neglected diseases (PRNDs), mobilize new resources for the current and future pandemics, and build sustainable financing structures.

Access to COVID-19 Tools Accelerator (ACT-A) remains critically underfunded; G20 must fully and urgently fund ACT-A across all pillars, including closing the R&D funding gap. In addition, G20 countries must continue to support Global AMR R&D Hub in its work where it provides investors and countries with the updated AMR R&D landscape, which helps address the gaps in the market (G20 Rome Leaders’ Declaration, 2021; Institute of Future Initiatives, 2022; Global Health Technologies Coalition, 2022).

G20 partners must also support regional and national regulatory bodies to ensure that safe and quality-assured products reach those most in need, especially LMIC. Scaling up local manufacturing capacity to develop diagnostics, vaccines, drugs, and other health-related technologies, particularly in LMIC. The COVID-19 pandemic has exacerbated structural gender inequalities and barriers to women’s health care access. It is a similar phenomenon observed in the past health and economic crises; however, long-term, structural, intersectoral reforms are not prioritized. G20 must ensure that the specific R&D needs of children, women and vulnerable populations are met (Global Health Technologies Coalition, 2022).


COVID-19 put health at the top of the G20’s agenda. The shock-activated vulnerability of an acute outbreak event represents a window of opportunity and a duty for the G20 to unite under shared goals, move beyond being a reactionary body, and establish itself as a GHG steering committee. The time is now for world leaders to do more to help the world’s vulnerable in this time of crisis. It is time to take bolder actions by providing a clear roadmap for inclusive solutions in their approach, holding themselves accountable, and following through on their financial commitments for global health preparedness.


Bucher, A., Papaconstantinou, G., & Pisani-Ferry, J. (2022, February 17). The failure of Global Public Health Governance: A Forensic Analysis. Bruegel. Retrieved April 25, 2022, from https://www.bruegel.org/2022/02/the-failure-of-global-public-health-governance-a-forensic-analysis/

Center for Economic and Social Rights. (2020, October 25). COVID-19: Recovering Rights Series. https://www.cesr.org/covid-19-recovering-rights-series-0/

Chattu, V. K., Singh, B., Kaur, J., & Jakovljevic, M. (2021). COVID-19 vaccine, TRIPS, and global health diplomacy: India’s role at the WTO platform. BioMed Research International2021.

Chattu, V. K., Dave, V. B., Reddy, K. S., Singh, B., Sahiledengle, B., Heyi, D. Z., … & Eltom, A. A. (2021). Advancing African Medicines Agency through Global Health Diplomacy for an Equitable Pan-African Universal Health Coverage: A Scoping Review. International Journal of Environmental Research and Public Health18(22), 11758.

Dentico, N., van de Pas, R., & Priti Patnaik, P. (2021). (rep.). The politics of a WHO pandemic treaty in a disenchanted world. Geneva: Geneva Global Health Hub.

Global Health Technologies Coalition. (2022, March 23). G20 nations must strengthen the global R&D architecture to bolster health preparedness and equity. https://www.ghtcoalition.org/news/g20-nations-must-strengthen-the-global-r-d-architecture-to-bolster-health-preparedness-and-equity

Gostin, L. O., Moon, S., & Meier, B. M. (2020). Reimagining global health governance in the age of covid-19. American Journal of Public Health, 110(11), 1615–1619. https://doi.org/10.2105/ajph.2020.305933

G20 Rome Leaders’ Declaration. (2021, September). Declaration of the G20 Health Ministers. https://www.salute.gov.it/imgs/C_17_pagineAree_5459_8_file.pdf

G20 Indonesia. (2021, October 30). President Joko Widodo encourages G20 to strengthen global health architecture for economic recovery – G20 Presidency of Indonesia. G20 Indonesia 2022. https://g20.org/presiden-joko-widodo-dorong-g20-perkuat-arsitektur-kesehatan-global-untuk-pemulihan-ekonomi/

Institute of Future Initiatives. (2022, March). Restructuring global health governance through global solidarity japanʼs role beyond the COVID-19 pandemic. University of Tokyo. https://ifi.u-tokyo.ac.jp/en/wp-content/uploads/2022/03/policy_recommendation_tg_20220318e.pdf

Javed, S., & Chattu, V. K. (2020). Strengthening the COVID-19 pandemic response, global leadership, and international cooperation through global health diplomacy. Health Promotion Perspectives10(4), 300–305. https://doi.org/10.34172/hpp.2020.48

Joint G20 Finance and Health Ministers Meeting Communiqué. (2021, October 29). [Press release]. https://home.treasury.gov/news/press-releases/jy0444

Kickbusch, I., & Holzscheiter, A. (2021). Can geopolitics derail the pandemic treaty? BMJ. https://doi.org/10.1136/bmj-2021-069129

Kickbusch, I., & Holzscheiter, A. (2021). Can geopolitics derail the pandemic treaty? BMJ. https://doi.org/10.1136/bmj-2021-069129

Mazzucato, M., & KICKBUSCH, I. L. O. N. A. (2021, December 16). The who’s penny-wise and health-foolish members: By Mariana Mazzucato & Ilona Kickbusch. Project Syndicate. Retrieved May 25, 2022, from https://www.project-syndicate.org/commentary/world-health-organization-needs-adequate-financing-by-mariana-mazzucato-and-ilona-kickbusch-1-2021-12?barrier=accesspaylog

McInnes, C., Lee, K., & Youde, J. R. (2020). The Human Right to Health and Global Health Politics. In The Oxford Handbook of Global Health Politics (pp. 493–505). chapter, Oxford University Press.

Meier, B. M., Bueno de Mesquita, J., & Williams, C. (2021). Global obligations to ensure the right to health: Strengthening Global Health Governance to realise human rights in Global Health. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.3915846

Millar, L. (2020, July 21). Can International Law Improve Compliance with G7 and G20 Health Commitments? G7 Research Group. Retrieved April 25, 2022, from http://www.g7.utoronto.ca/evaluations/millar-health-hard-law

Moon, S., & Kickbusch, I. (2021). A pandemic treaty for a fragmented global polity. The Lancet Public Health, 6(6). https://doi.org/10.1016/s2468-2667(21)00103-1

Ooms,G.etal. (2017). Anchoringuniversalhealthcoverageintherighttohealth.1–28.OKONJO-IWEALA , N. G. O. Z. I., SHANMUGARATNAM, T. H. A. R. M. A. N., & SUMMERS , L. A. W. R. E. N. C. E. H. (2021, December). Rethinking multilateralism for a pandemic era. IMF. Retrieved May 25, 2022, from https://www.imf.org/en/Publications/fandd/issues/2021/12/Multilateralism-Pandemic-Era-Okonjo-Iweala-Shanmugaratnam-Summers

Sirleaf, E. J., & Clark, H. (2021, November 1). G20 Summit covid-19 outcome deeply disappointing. The Independent Panel for Pandemic Preparedness and Response. Retrieved May 25, 2022, from https://theindependentpanel.org/g20-summit-covid-19-outcome-deeply-disappointing/

Shah,R (2021). Rich countries saved themselves during the pandemic. Poorer countries are reeling.The Washington Post. Washington Post Available at https://www.washingtonpost.com/outlook/development-global-covid-poverty-inequality/2021/10/21/2231a9c2-32b1-11ec-9241-aad8e48f01ff_story.html.Shanmugaratnam, T. (2021, October 25).

Investing in future health security. The Global Governance Project. Retrieved May 28, 2022, from https://www.globalgovernanceproject.org/investing-in-future-health-security

The Independent Panel, Clark, H., & Sirleaf, E. J. (2022, May). Transforming or Tinkering Inaction lays the groundwork for another pandemic. The Independent Panel for Pandemic Preparedness and Response. https://live-the-independent-panel.pantheonsite.io/wp-content/uploads/2022/05/Transforming-or-tinkering_Exec-Summ_Final_May17-1250EST.pdf

Wenham, C., Eccleston-Turner, M., & Voss, M. (2022). The futility of the pandemic treaty: Caught between globalism and statism. International Affairs, 98(3), 837–852. https://doi.org/10.1093/ia/iiac023

WHO. (2022, April 19). Delivering on the G20 leaders’ commitment to build an equitable and effective Financial Intermediary Fund (FIF) for Pandemic Preparedness and Response (PPR). https://www.who.int/news/item/19-04-2022-delivering-on-the-g20-leaders-commitment-to-build-an-equitable-and-effective-financial-intermediary-fund-(fif)-for-pandemic-preparedness-and-response-(ppr)


Latest Policy Briefs

Register for Updates

Would you like to receive updates on the Global Solutions Initiative, upcoming events, G7 and G20-related developments and the future of multilateralism? Then subscribe here!

1 You hereby agree that the personal data provided may be used for the purpose of updates on the Global Solutions Initiative by the Global Solutions Initiative Foundation gemeinnützige GmbH. Your consent is revocable at any time (by e-mail to [email protected] or to the contact data given in the imprint). The update is sent in accordance with the privacy policy and to advertise the Global Solutions Initiative’s own products and services.