The need for regional cooperation in addressing health threats and supporting preparedness is clear. Regional cooperation around COVID-19 has varied, reflecting disparities in political support, resources and health governance across regions, while highlighting the urgency for strengthening efforts to address the current pandemic and future crises.
We recommend that G20 countries support regional organizations to foster a coordinated regional health response; reaffirm their support for the World Health Organization (WHO) and other regional organizations; promote regional needs in discussions around pandemics; invest in scaling-up capacity for data sharing and for the production of supplies, vaccines and medicines; and foster inter-regional cooperation.
Challenge
The COVID-19 pandemic has revealed how most countries are unprepared to fight a cross-border health challenge on their own. While attempting to address the spread of the disease, countries generally sought to do so within their own borders, many times with little understanding or knowledge of what was proving to be successful in other countries and failing to coordinate actions internationally to make best use of regional and national resources. Part of the challenge stemmed from already weak health systems that were unable to cope or from lack of preparedness, despite country commitments to the International Health Regulations (IHR).
In 2019 the Global Preparedness Monitoring Board, a group convened by the World Health Organization and the World Bank, published a report showing that countries were significantly underprepared, as exemplified by their lack of prioritization of their binding obligations under the IHR (GPMB, 2019). In particular, the board commissioned a study to understand the global impact of a “high-impact respiratory pathogen pandemic” and called on the G7, G20 and G77 members to follow through with political commitments, funding for preparedness plans within their countries and supporting efforts in the Global South by contributing to multilateral organizations (Johns Hopkins Center for Health Security, 2019). It has been known for some time that preparedness is not costly when compared with the costs of health emergencies, but countries tend to take action and invest only once crises strike.
A crucial part of preparedness is to develop partnerships and initiatives, not only to monitor health threats and strengthen capacity, but also to collaborate on responses once a pandemic is identified. It is clear that countries have a vested interest in ensuring that neighbouring countries can address their health threats. Countries in the same region frequently share similar histories, population characteristics and topology, resulting in shared problems and grounds for infectious spread, as well as the need for similar facilitation and forms of cooperation. This is even more crucial for lowand middle-resourced settings and smaller countries that would greatly benefit from sharing of resources, knowledge and advocacy at the regional and global level. However, given that the primary responsibilities regarding health policies still lie with the nation states, it is important to understand how collective action can be encouraged and the areas where cooperation will be most effective to address and prepare for future unexpected health threats.
Proposal
This policy brief considers regional cooperation, whether through formalized institutions such as regional organizations or ad hoc groups, as being essential to address health threats and support health preparedness within their member states. While some were quick to act, the initial response to the pandemic from many regional organizations was insufficient. The European Union (EU), for example, recognized that its own response as inadequate in the early stages of the fight against COVID-19 (Banks, 2020). As the pandemic progressed, positive examples of regional cooperation emerged, drawing from the need of countries to collaborate, especially regarding vaccines. The African Union (AU), for example, successfully obtained donations of supplies for its member states (African Union, 2020) and subsequently negotiated with pharmaceutical companies and other actors to obtain much needed PPE and vaccines. It is now clear that some regional organizations were unable to act, despite their intentions to do so, due to lack of political support, lack of established plans and in many cases, lack of resources. These variations in regional health crisis responses reflect broader disparities in the strength of regional health governance systems. It has been shown, using empirical evidence from Latin America’s subregions, that the capacity to collectively deal with public health challenges is the outcome of the interplay between state capacity, regional leadership and external actors (Agostinis and Parthenay, 2021).
We argue that mechanisms for regional cooperation in health should be capitalized upon and strengthened immediately to address the current pandemic, to prevent the next outbreak from becoming a pandemic and to better address a pandemic if it were to occur.
Regional cooperation has already shown several areas for potential involvement during pandemics. An article by Amaya and De Lombaerde (2021) found that regional organizations can serve several roles. They can:
– Serve as a bridge between the global and national level;
– Facilitate cross-border mobilization of goods and services;
– Regulate cross-border mobility of persons;
– Pool resources for the production and procurement of medicines, vaccines and supplies; and
– Coordinate actions with donors and external partners.
We explain how each of these roles can be applied to address the current COVID-19 pandemic and prepare for future pandemics below.
Regional organizations can and should act as intermediaries between the global and national levels, helping their member states in a vertical manner, for instance by translating agreements and guidelines from the global level (e.g. treatment guidelines for COVID-19 or wider agreements such as the SDGs) to national policies and targets appropriate to their specific settings and mobilizing resources to reach these goals; as well as horizontally with the countries by facilitating the sharing of data and support to address cross-border policy challenges and evidence-based coordination of these goals.
Given the nature of pandemics, a coordinated effort is necessary first at the regional level, which can then inform the global level, to monitor developments, generate a better cross-border response, pool resources and allocate supplies to areas of most need, as well as minimize the negative economic effects of the pandemic. Regional organizations rely on technical support from the WHO and its regional offices on all health issues, but support of the institution is particularly important to enhance epidemiological surveillance and case identification by sharing data across countries, as well as encouraging and strengthening research capacity and safe data sharing within and across national institutions and regions. Regional organizations thereby have the potential to play an important role in steering and promoting health-related data flows, both vertically (as intermediaries between the global and national levels) and horizontally (among regional actors and member states) (Amaya, Kingah and De Lombaerde, 2019). This data-sharing should also involve public and private universities, think tanks within the countries and global initiatives such as existing, relevant trustworthy health research infrastructures, such as the International COVID-19 Data Alliance 2020 (ICODA, 2020). Regional organizations have also made use of the World Health Assembly, the forum through which the WHO is governed and where countries state their positions, to advance their health goals at the global level (Amaya, Rollet and Kingah, 2015). This forum has in the past also fostered inter-regional collaboration on health issues (for example, between the EU and AU), which would be crucially important if another health crisis were to occur.
Outside these mechanisms, regional organizations can and, as discussed previously, have already proposed direct solutions to address pressing health issues such as pandemics and long-standing health inequities. For this, they can learn from past regional efforts developed by the EU, for example, as well as from inter-regional partnerships with other groupings. While they already partner with other regions, the role of the EU in strengthening growing regional efforts, especially from the Global South, will continue to be important.
The importance of generating high-quality data and sharing this data with other countries has been highlighted in the current crisis. Public health data sharing was one of the reasons Severe Acute Respiratory Syndrome (SARS) did not become an established disease following its emergence in 2002 (Curley and Thomas, 2004) and we have seen ample examples of data sharing between countries in the COVID-19 response. Sharing information is crucial in the response to diseases, especially when these are new diseases and there are still many unknowns in terms of their incubation period and how they are transmitted, among other issues.
Expertise exists in all regions; however, efforts to scale up capacity, especially in the Global South, are hampered by lack of investment. For example, while the African continent bears 27% of the global burden of disease, it only has 1.7% of the world’s physicians (WHO, 2006) and less than 2% of research. Forecasts of a recession due to the COVID-19 pandemic in the African region, as well as in Latin America, will have further detrimental effects on existing inequities and access to health, with some countries probably reversing the gains they had made in the past two decades (Ossai and Ogbuoji, 2021; ECLAC, 2021). As previously discussed, universities, research institutes and government ministries need further support to better identify emerging health threats, rapidly generate responses to stop outbreaks from becoming epidemics and share data. This support should be in the form of financial investments to enhance existing initiatives for cross-country collaboration as well as to develop new ones, in addition to technical support to establish regional laboratories, disease surveillance mechanisms and scale up the training of healthcare professionals.
Moreover, even if it may not be realistic, or even desirable, to regionally centralize or pool strategic medical supplies, regional management mechanisms should be created that can ensure that a temporary overcapacity in one member state can be matched with lower capacity in another member state or another region. This will result in regional economic added value. During the COVID-19 pandemic, we saw some instances of cross-border mobilization of patients from countries with acute under-capacity of health resources in their intensive care units to neighbouring country hospitals with spare capacity, but the challenge lies in identifying these opportunities and in bringing patients back home. Regional organizations can play a role in finding structural governance mechanisms for such cross-border mobilization in crisis situations.
The COVID-19 crisis has also shown that cross-border mobility of persons can be problematic in crisis situations in the presence of nationally differentiated policies, including lockdowns. This is particularly the case in densely populated border areas and border (twin) cities, with closely intertwined economies. Regional organizations can play a role in the orderly management of such situations and the orderly use of restrictions on cross-border mobility.
Regional organizations can also facilitate the joint procurement of essential medicines, medical supplies and other equipment through pooled purchasing and joint advocacy for increased production. This not only ensures a lower price through bulk purchasing but also equalizes the negotiating power of countries, especially lower-income countries, which are otherwise not competitive. In addition, regional organizations can also play a role in promoting regional pharmaceutical production capacity to reduce extra-regional dependence and vulnerability. We have already seen first steps towards this through the development of licensing agreements between AstraZeneca and Sinovac Life Sciences with laboratories in India and Brazil (respectively), producing vaccines that can then be distributed to their neighbouring countries. While capacity to produce pharmaceuticals and vaccines exists on every continent, this capacity needs to be strengthened and expanded so that more countries are able to contribute to these efforts. In addition to capacity, it is also an issue that requires political will to ensure greater technology transfer in some cases through the use of TRIPS flexibilities or other mechanisms to use and enhance the manufacturing of vaccines and supplies. Synergies can be sought with national and regional higher education and research institutions.
Finally, as previously mentioned, regional organizations can coordinate, and have been coordinating in the case of the AU, the work of donors and partners to support lowand middle-income countries already facing capacity constraints to address their own domestic issue. Regional organizations can also support countries in setting the foundation for their recovery by generating mechanisms to reduce the economic and social effects of the pandemic, by jointly negotiating debt forgiveness from multilateral banks and partner with donors for regional growth (see also recommendations of T20 Task Force 9 International Finance). Likewise, these organizations can also support countries in mobilizing resources for other existing health concerns or concurrent health emergencies that may have been neglected due to the focus on COVID-19 in the past year.
RECOMMENDATIONS
COVID-19 has affected all corners of the globe. The G20, as one of the premier international forums, has members from each of these corners, representing the very brand of cross-border cooperation needed to tackle a challenge such as COVID-19. The G20 also comprises many key players in the regional organizations that this policy brief addresses, which means they can take the lead on these issues in those forums as well. The implementation of the recommendations provided to regional organizations requires buy-in and support from their most powerful members, almost all of whom are present at G20 Italy. Specifically, we recommend that G20 members:
–Demonstrate regional leadership and empower regional organizations so that they can play a more active and proactive role in designing and rolling out coordinated action in the health sector, with special emphasis on mechanisms that foster readiness of the overall health systems vis-à-vis epidemics and pandemics. Leadership implies taking political initiative, launching visionary ideas, providing financial resources to the regional level and/or pooling national resources, mobilizing knowledge centres, among other initiatives. These regional mechanisms should be technically solid, and they should be designed in such a way that their continuity should not depend on political cycles and changes in political leadership at the country level.
–Reaffirm their support to the WHO, as well as established and nascent regional efforts to address health issues. The WHO provides crucial technical support to regional organizations and their member states, so furthering its activities will be important. At the same time, regional organizations have also shown their ability to directly develop health projects during the COVID-19 pandemic. Supporting different types of regional efforts will be crucial, particularly during health crises.
–Promote the consideration of regional needs and action in upcoming discussions and negotiations around pandemics. The added value of the regional dimension around health issues is clear. Therefore, we recommend promoting the regional dimension in negotiations around pandemics, including discussions for a new international treaty for pandemic preparedness and response, as called for by health ministers in the World Health Assembly in 2021, while actively involving regional organizations in these negotiations.
–Invest in scaling-up capacity for data sharing within regions and the regional capacity to produce supplies, vaccines and medicines. Strengthening research capacity for data sharing should not be reserved to regional institutes but also public and private universities and think tanks within the countries.
–Foster and provide venues for South-South and North-South sharing of lessons learned and cooperation. This also entails leading and promoting inter-regional cooperation, and ensuring support from the EU and G20 grouping for various regional efforts.
REFERENCES
Agostinis G, Parthenay K (2021). Exploring the determinants of regional health governance modes in the Global South: A comparative analysis of Central and South America. Review of International Studies, 1-23. doi: 10.1017/S0260210521000206
Amaya AB, De Lombaerde P (2021). Regional cooperation is essential to combatting health emergencies in the Global South. Globalization and Health, 17(9). doi: 10.1186/s12992-021-00659-7
Amaya AB, Kingah S, De Lombaerde P (2019). The role of regional health diplomacy on data sharing. The SADC and UNAS UR cases. Regions & Cohesion, 9(1):93132. doi: 10.3167/reco.2019.090108
Amaya AB, Rollet V, Kingah S (2015). What’s in a word? The framing of health at the regional level: ASEAN, EU, SADC and UNASUR. Global Social Policy, 5(3):229260. doi: 10.1177/1468018115599816
African Union (2020). African Union to distribute more COVID19 supplies to its member states after receiving the third consignment from the Jack Ma Foundation. https://au.int/en/pressreleases/20200429/african-union-distribute-more-covid19-supplies-its-member-states-after accessed 22 July 2021
Banks M (2020). EU response to coronavirus pandemic was ‘inadequate’, says EU Commissioner. The Parliament Magazine (April). https://www.theparliamentmagazine.eu/news/article/eu-response-to-coronaviruspandemic-was-inadequate-says-eu-commissioner accessed 22 July 2021
Curley M, Thomas N (2004). Human security and public health in Southeast Asia:
The SARS outbreak. Australian Journal of International Affairs, 58(1):17-32
ECLAC (Economic Commission for Latin America and the Caribbean) (2021). Fiscal panorama of Latin America and the Caribbean 2021: Fiscal policy challenges for transformative recovery post COVID-19. <ahref=”https://www.cepal.org/en/publications/46809-fiscal-panorama-latin-america-and-caribbean-2021-fiscal-policy-challenges”>https://www.cepal.org/en/publications/46809-fiscal-panorama-latin-americaand-caribbean-2021-fiscal-policy-challenges , accessed 22 July 2021
GPMB (Global Preparedness Monitoring Board) (2019). A world at risk: annual report on global preparedness for health emergencies.Geneva, WorldHealthOrganization. https://apps.who.int/gpmb/assets/annual_report/GPMB_Annual_Report_English.pdf accessed 22 July 2021
Johns Hopkins Center for Health Security (2019). Preparedness for a high-impact respiratory pathogen pandemic. Baltimore, Center of Health Security. https://apps.who.int/gpmb/assets/thematic_papers/tr-6.pdf accessed 22 July 2021
ICODA (International COVID-19 Data Alliance) (2020). About Us. London, Health Data Research UK. https://icoda-research.org/about/about-us/#visionandmission accessed 22 July 2021
Ndudi Ossai E, Ogbuoji O (2021). Redressing the impact of COVID-19 on medical education in Africa: the need for collective action. BJM Global Health, 6(e005067). doi: 10.1136/bmjgh-2021-005067, accessed 22 July 2021
WHO (World Health Organization) (2006). Working Together for Health: The World Health Report. Geneva, World Health Organization
