Editors’ Note

The COVID-19 pandemic has demonstrated the importance of investing in strong health systems for countries to be able to respond to the myriad health issues that continue to confront the world—from climate change, antimicrobial resistance, and the threat of future pandemics, to chronic diseases that account for seven of every 10 deaths worldwide. G20 member states are in a unique position to tackle these urgent issues at the G20 Summit in New Delhi in September 2023. These countries account for 85 percent of global GDP, over 75 percent of global trade, and approximately two-thirds of the world’s total population. Given that sustainable development and good health and well-being for all (SDG 3) are deeply intertwined, addressing global health inequity should be at the centrestage of the G20’s primary objectives of promoting financial stability and economic growth.

The state of public health in G20 nations is complex and multifaceted, with a range of interrelated challenges in need of sustainable solutions. A few of the G20 nations have well-developed healthcare systems, and yet, there continue to be significant disparities in health outcomes and access to healthcare. For instance, the United States (US) spends far more on health than other high-income countries, yet life expectancy in the country is not only significantly lower than those of its counterparts, but it has also declined since 2014.^[i] Avoidable mortality in the US in the past 10 years has dropped by only 5 percent per capita—lower than the reductions of 25 percent in Switzerland or 19 percent in the United Kingdom.^[ii] Addressing these disparities and improving access to quality healthcare for all, as well as tackling emerging threats are a few of the key public health challenges facing the G20 nations.

India assumed the year-long presidency of G20 in December 2022. Under its leadership, the G20 has accorded particular emphasis on various health priorities. These tasks are aimed at addressing the critical challenges faced by the global community and advancing the well-being of populations.

One area of emphasis is pandemic prevention, preparedness and response, with a focus on international cooperation. India’s Presidency recognises the importance of strengthening global health security to prevent outbreaks and pandemics; and if they do occur, to respond effectively to them. This requires enhancing early warning systems, improving ‘One Health’ surveillance and data sharing, and promoting collaboration among countries to tackle health emergencies. Scaling up laboratory capacity for genomic testing and expediting data-sharing are also important priorities. This multi-pronged approach aims to reduce the risk of future zoonotic outbreaks that have the potential to become pandemics.

The mounting threat of antimicrobial resistance is another subject on the G20 agenda. Without urgent action, AMR could claim more lives every year (10 million) than the COVID-19 pandemic did in the past three years (nearly 7 million at the time of writing). Indeed, AMR is one of the most significant challenges in global health, food security and global development. In the long-haul, AMR not only threatens our capacity to treat infections like pneumonia and tuberculosis, but it also risks rendering basic medical procedures ineffective—from organ transplants to chemotherapy and hip replacements. Addressing this issue is crucial, and involves encouraging the prudent use of antimicrobials, strengthening surveillance systems, promoting research and development for new antibiotics, and enhancing infection prevention and control measures.

Ensuring easy access to affordable essential vaccines, therapeutics, and diagnostics (VTDs) is another crucial G20 priority under the Indian Presidency. In high-income countries, three of every four people have received at least one vaccine dose as of mid-July this year, compared to a far less one in every three in low-income countries.^[iii] These products need to meet high standards of effectiveness, safety, and quality assurance. Supporting the development of scientific and technological capabilities worldwide requires knowledge-sharing and financial co-investment, particularly from high-income countries, to allow the intellectual and entrepreneurial potential in low- and middle-income countries (LMICs) to flourish. The Presidency is committed to promoting equitable access to vaccines, particularly for LMICs. It supports efforts to enhance vaccine production and distribution, facilitate technology transfer, and address barriers to vaccine access and affordability.

Another priority for the Indian Presidency is enhancing the capacities of health systems in all countries to effectively address both pandemic threats and essential healthcare needs. This necessitates co-investments in building a diverse and skilled health workforce that can serve the global population, and strengthening health systems so that they are capable of effectively responding to health crises and meeting the healthcare needs of populations. Without urgent global action, the World Health Organization (WHO) estimates, there could be a shortfall of 10 million healthcare workers by 2030, largely in the developing world.^[iv]

Leveraging innovative digital technologies to advance primary-care-led universal health coverage (UHC) is an additional priority being pursued. Today, more people have access to mobile phones (6 billion) than toilets (4.5 billion). While this is not a cause for celebration, it only means that digital health could reach a huge proportion of the global population.^[v] The G20 recognises the potential of digital health technologies in improving healthcare delivery and accessibility. It seeks to harness digital innovations to enhance health systems, facilitate remote healthcare services, strengthen health information systems, and promote interoperability of health data. This is key to providing equitable and affordable healthcare, especially for vulnerable populations.

While the G7 has given impetus to global health from a sense of shared vulnerability, the G20 under India’s Presidency aims to contribute to global health governance, foster international cooperation, and drive tangible actions that can improve public health outcomes in the G20 and beyond.

In this spirit of global solidarity and health equity, this compendium offers itself as a platform for debate around key issues in public health. It is a “thinking and doing” monograph for readers seeking to understand how we can transform society by addressing today's complex and interconnected public health challenges. The featured essays not only highlight the ongoing battles but also offer ideas and positive examples of how public health can be transformed in creative and practical ways.

The curated essays in the volume discuss the state of public health in G20 countries and explore current initiatives that are being taken to promote health equity. It consists of country-specific studies and also regional and global perspectives that can enlighten readers about the issues pertaining to public health challenges, including emerging infectious diseases, access to vaccines and drugs, and environmental pollution. To this end, we have brought together scholars, policymakers, members of civil society organisations, and domain experts across the field of public health to provide insightful analyses of the many facets of the current public health agenda.

The compendium has three parts.

Part One concerns itself with the conceptual terrain and framework around strengthening health emergency preparedness, prevention and response through global cooperation in public health.

The first essay, authored by Richard Hatchett and Kate Kelland, makes a compelling case for the creation of a global ‘vaccine library’ to counter future inevitable viral pandemic threats. The authors argue that such a repository of knowledge will allow the scientific and medical community to deliver new vaccines against a novel pathogen in as little as 100 days, and harness the prospect of a future free from the deadly threat of pandemics.

The second chapter, by Aurélia Nguyen, offers a comprehensive assessment of the global response to COVID-19, focusing on life-saving vaccines. It outlines crucial measures taken to curb global vaccine disparities and save more lives: flexible funding, robust health systems, and stronger vaccine manufacturing in the Global South. The essay showcases mechanisms like Gavi's COVID-19 Vaccine Delivery Support Program in countries like Somalia, and closes with a hopeful call to fortify global defenses against infectious outbreaks that loom over the horizon.

In their essay, Ranga Reddy Burri, Robert Skov, B.E. Pradeep and Ralf Sudbrak provide a nuanced overview of the emerging crisis of Antimicrobial Resistance (AMR) that poses challenges to healthcare systems and patient outcomes across the world. The essay explores the multifaceted nature of AMR and emphasises the importance of collaboration, low-cost interventions, alternative diagnostics, and therapeutics in containing AMR. The analysis highlights the need for a comprehensive, multi-pronged approach and a whole-of-society approach to combat AMR.

The fourth chapter, contributed by Barbara Stocking, critically examines how stronger international frameworks can help the world better prepare for the next pandemic, with a focus on the Pandemic Accord as well as a revision of the International Health Regulations. The chapter underscores the need to bolster financing to ensure that the Instrument is effective, particularly for low-income countries.

The succeeding essay by Soumya Swaminathan and Priyadarshini Rajamani discusses the transdisciplinary concept of ‘One Health’ as an integrative approach that considers all the determinants of health, designed for disease prevention and control. This approach allows multisectoral collaboration across a range of connecting factors including antimicrobial resistance, and prevention and control of zoonoses, vector-, food- and water-borne diseases. The chapter makes the case that One Health implementation would help in pandemic prevention, preparedness and response and enable the strengthening of the Indian health system.

Janice Tan and Jeremy Lim round up this section with an essay that highlights the persistent challenges on the journey to universal health care and health equity. The chapter notes how high out-of-pocket expenses continue to burden vulnerable populations even in highly developed countries, highlighting the need for targeted interventions and policies to achieve health equity. The inclusion of case studies on Indonesia and Singapore, representing a developing and developed nation respectively, elucidates the applicability of solutions in government funding, health and social insurance, public-private partnerships and procurement in distinct national contexts and over different time frames.

Part Two of the monograph delves into the critical role of digital health as an enabler for health equity and Universal Health Coverage.

Sumit Sharma opens this section with a discussion of the challenges posed by a growing disease burden particularly in LMICs, and the parallel opportunities for public and private players to execute innovative solutions through public-private partnerships (PPPs). The authors examine how PPPs can drive collaborative research, enable infrastructure and capacity build-up, and promote new execution capabilities and skills to improve services.

The eighth essay, by Lav Agarwal, explores the country-level experience of adopting digital technologies to implement health goals. Using the case of India, the article argues that digital health is propelling the world towards more integrated health systems that are focused on delivering patient-centred care, improving health outcomes, and making the best use of healthcare resources.

Sameer Kanwar and Varun Kumar, in their case study on India, underline the country’s success in establishing a robust digital public infrastructure (DPI) by leveraging technology for inclusive growth, economic development, and improved governance. They observe that India’s efforts in building its digital public infrastructure (DPI) incorporates the principles of scalability and inclusion, balancing regulation and innovation, and the need for continuous adaptation in regulatory frameworks. The chapter offers India's DPI transformation as a lesson for other countries to emulate to leverage technology for inclusive growth.

In the tenth essay, Shoko Noda outlines how India's digital infrastructure, driven by transformative platforms like Co-WIN, U-WIN, and e-VIN, has ushered in a new era of digital health for all citizens. They describe the continuing evolution of India’s digital landscape and technology’s role in revolutionising healthcare delivery as it can transcend barriers of geography and socio-economic status and help foster a healthier nation.

Part Three of the compendium opens up a discussion on emerging themes in Public Health transformation, underscoring the direction for policy and praxis in the context of public health.

Chapter Eleven, authored by Robin Fears, Volker ter Meulen and Andy Haines, discusses how human activity-driven climate change is contributing to a growing global health crisis.  The authors call on the G20 to mobilise its resources and reach to: capitalise on regional policy initiatives, bridging between national and global levels of governance; address current biases in generation and use of research worldwide; and support the Planetary Health approach to understand and manage changes to natural systems affecting human health, equity and well-being at multiple scales.

In the twelfth essay, Mansi Chopra, Tina Rawal and Monika Arora discuss the significant burden of non-communicable diseases (NCDs) on health, development, and economies particularly in LMICs where over 75 percent of NCD-related deaths occur. Health promotion approaches, supported by evidence-based policies, play a crucial role in NCD prevention and management. The chapter draws attention to the urgent need for comprehensive and collaborative approaches to prevent and manage NCDs and improve population health outcomes.

In their piece, Pratima Murthy, K.P. Muliyala and C. Naveen Kumar describe the systemic response in mental health care service delivery. Using India as a case study, the chapter outlines the legislations, policies and programmes in place and the challenges for their implementation to ensure equity in mental health care.

In Chapter Fourteen, Wenzhen Zuo, Huan Xu, Lizzie Tecson, Bettina Borisch, Sadaf Lynnes, Laura Magaña, Priscilla Robinson, Duncan Selbie and Jim Campbell discuss the ways that COVID-19 pandemic tested our core public health capacities and exposed the weaknesses in health systems around the world. As countries build their public health capacities and fill the health systems gaps exposed during the pandemic, a key way forward is to strengthen national health systems by investing more on the public health workforce.

Naveen Rao, in his chapter, notes how the rapid development and equitable distribution of COVID-19 vaccines highlighted the transformative power of public health partnerships. Drawing lessons from these partnerships, the author emphasises the need to replicate their success in tackling the existential threat that is climate change.

The last chapter, authored by Patrick Webb, Sandy Thomas and Derek Flynn discusses the failures of contemporary food systems in providing diets that are healthy, affordable, and sustainable for three billion people; and why their transformation is key to resolving such challenges. The authors recommend specific actions to reverse this profound failure of policy through priorities to enable change and address systemic inhibitors to progress.

Accelerating Global Health: Pathways to Health Equity for the G20 is not just a compendium of essays but a collective call to action. The chapters in the monograph address a raft of intersecting issues around public health, from global, regional and local perspectives. The aim is to initiate dialogue that furthers research methodologies, conceptual frameworks and the larger policy agenda in G20 member states. Finding solutions to some of the questions identified in this volume will help countries effectively respond to global health security challenges and pave the way for a healthier, more equitable, and sustainable future.

Read the volume here.

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^[i] Max Roser, "Why is Life Expectancy in the US Lower Than in Other Rich Countries?". Our World In Data, 2023.

^[ii] Commonwealthfund.Org, 2023.

^[iii] Global Dashboard for vaccine equity (2022) UNDP Data Futures Platform.

^[iv] "Health Workforce," Who.Int, 2023.

^[v] "It's Official: More People Have Access To A Mobile Phone Than Toilets In The World". Vocalcom, 2014.

• Healthcare
• Sustainable Development
• India
• Antimicrobial Resistance
• Climate change
• Digital Health
• Food Systems
• Global Partnerships
• Mental Health
• Non-communicable Diseases
• Pandemic Preparedness
• Public Health Workforce
• Vaccine Access

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