There are many advantages to using a global functions framework rather than just the narrow public goods framework
Photo: iStock The devastation caused by the COVID-19 pandemic has finally, and belatedly, forced the global health community to recognise that it has been neglecting an array of international collective action for health (ICAH) activities, including pandemic preparedness and response.
In 2020 and 2021, there were 14.83 million excess deaths globally associated with the pandemic, the WHO estimated. The pandemic will cause $13.8 trillion in economic losses by the end of 2024, according to the IMF.
These eye-watering numbers show the enormous costs of inaction when it comes to preparing for and tackling threats that transcend the boundaries of nation states, like pandemics, climate change and the global spread of antimicrobial resistance (AMR).
The world should have taken heed after the 2014-2016 Ebola epidemic in West Africa, which took a very long time to control. While it is true that weak national health systems in Guinea, Liberia and Sierra Leone made it harder to bring the epidemic to an end, another critical reason for the prolonged epidemic was the neglect of ICAH.
When the epidemic began, there was no Ebola vaccine, treatment or rapid diagnostic test, reflecting insufficient funding for and attention to research and development for emerging infections; regional surveillance systems performed poorly; and the WHO was criticised for its weak governance and leadership, which itself was due to a budget crisis.
It is clear that the world has largely been neglecting the need to finance, organise, govern and deliver a critical set of ICAH activities. Funding for such activities tends to rise after a crisis — as it did after the 2014-2016 epidemic — but then falls again once the crisis recedes, a pattern that is known as “cycles of panic and neglect”.
A key question for the future of global health is: How can these cycles be broken? How best can the case be made for sustained attention to ICAH activities?
One strategy that has emerged is advocacy for aid donors and all nations to invest more in global public goods (GPG). While this is a welcome strategy, it comes with an important limitation: The narrow definition of a public good.
The conventional definition of a public good is one that is non-rival (if one person consumes it, this does not reduce its availability to others) and non-excludable (no one can be denied access). Examples of GPGs for health include an open access research publication or a patent on a new antimicrobial drug, provided the patent is shared in the Medicines Patent Pool.
However, as my colleagues and I previously argued, the problem with using such a narrow definition is that it is “inadequate to capture the broad array of international collective actions needed to address supranational health challenges”.
Tackling AMR or climate change, improving the surveillance of infectious diseases and strengthening the WHO’s core functions are all ICAH activities that go far beyond GPGs alone.
The narrowness of the public goods definition is a key reason why the WHO came up with a new term, “common goods for health (CGH)”, which, they say is, “a new construct born out of the observed failures exposed by Ebola, SARS, Zika, and other communicable diseases as well as by other health and environmental risk factors.”
The term CGH includes GPGs but goes beyond them to also include goods or services that have “large social externalities, and thus will not arise through market forces alone”.
The Lancet Commission on Investing in Health went even further, coining the term “global functions”, which has three categories: GPGs; management of cross-border regional or global externalities (spillover harms and costs that are suffered by a third party and that go beyond nation state boundaries, such as AMR, pollution or pandemics); and fostering global health leadership and stewardship.
There are many advantages to using a global functions framework rather than just the narrow public goods framework. First, a global functions framework helps to clarify, define and classify essential ICAH activities. Second, when it comes to monitoring how much finance is being directed at ICAH, and how much additional funding is needed, a global functions framework helps the international health community to know what it is that we are prioritising, how much we are spending, what the price tag is, and the size of the funding gap (the gap between what we are spending and the amount needed).
Methods and tools are now available for tracking funding for ICAH activities. Finally, “global functions” capture the broad array of transnational activities that are critical in preparing for and responding to transnational challenges, including AMR.
| Lancet Commission on investing in health’s classification of global functions | |
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Global function |
Examples |
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Supplying global public goods |
activities |
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Managing cross-border externalities |
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Exercising leadership & stewardship |
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The World Antimicrobial Resistance Awareness Week takes place from November 18-24 every year.
Gavin Yamey is the director of the Center for Policy Impact in Global Health, Duke Global Health Institute, US.
Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth.
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