This blog is part of a series by CGD and partnering institutions from Germany focused on presenting specific policy proposals for the next German government’s leadership on global development issues.
Germany has stepped up as an important player in global health in recent years, rising to become the third largest government donor to health in 2019. Notably, Germany has played a key role in WHO reform efforts; it is the largest donor to WHO for the 2020-21 budget period, and one of the largest WHO emergency fund donors. Germany has also played a leading role politically, placing health on the agenda of the G-20 for the first time in 2017 and trying to tackle increasing global health fragmentation as co-initiator of the Global Action Plan.
All eyes are on Germany’s upcoming September 26 federal election as COVID-19 and its fallout are likely to constrain future global health financing. Some donors, such as the UK, are drastically slashing aid budgets while others, like the US, are considering shifting a greater share of financing towards health security. At the same time, the crisis is stretching already-constrained health budgets in low- and middle-income countries.
While health security is rightly a top priority in the current context, it is critical that global health donors also focus on longer-term support to partner country health systems to deliver quality, equitable services, and build national capacity to prevent and respond to the next outbreak. (Stay tuned for a complementary blog on how Germany can lead the way on revamping the governance and financing of pandemic preparedness.)
As Germany looks to its upcoming federal elections in September 2021 and assumes the G-7 presidency in 2022, we propose three ideas for how the next government can protect—and even raise the ambitions of—its commitments to global health, especially by strengthening health systems in low- and middle-income countries.
Three opportunities for the next German government
1. Assure greater policy coherence in Germany’s global health engagement
Germany’s global health engagement remains highly fragmented across different arms of the government. While the ministry of health (BMG) recently led the development of a cross-ministerial global health strategy (October 2020) and is responsible for WHO engagement, the ministry of economic cooperation and development (BMZ) leads engagement with the World Bank (alongside the ministry of finance, BMF), the Global Fund, Gavi, and on broader health systems efforts in partner countries. And global health research and development is managed primarily by the education and research ministry (BMBF). A consequence of this fragmentation was that, at the start of the COVID-19 pandemic, Germany did not develop—nor lead on—a comprehensive, global response plan.
Looking ahead, Germany should consider creating a global health ambassador position (akin to the appointment in several Nordic countries) within the Chancellery to help reduce fragmentation and drive greater coherence in Germany’s policymaking on global health. Further, the newly created parliamentary sub-committee on global health (under the Health Committee) should move ahead as a whole-of-government cross-issue committee given its cross-sectoral drivers and implications. The government should also establish clear milestones and actions to anchor the implementation of its cross-ministerial global health strategy (for example, on strengthening the WHO, reducing global health fragmentation, and providing a timeline to increase its own global health funding).
2. Prioritize health systems strengthening in financing
Germany should step up its global health financing commitments, in turn spurring the added benefit of more political leverage to drive reforms within the broader global health system.
To complement efforts to strengthen and ensure adequate and flexible financing for WHO, Germany should provide predictable contributions to other global health multilateral institutions that advance cross-cutting global health goals, including health systems strengthening (for areas such as surveillance systems, procurement and supply chains, and the health workforce).
For example, increased support to UNFPA, particularly in the face of the UK government’s cuts, would help assure continued access to essential sexual and reproductive health services for women and girls during, but also beyond, the pandemic. Another priority should be continuing to support the Global Financing Facility (GFF), including through its current resource mobilization campaign for essential services for reproductive maternal newborn child and adolescent health. The Global Fund’s next replenishment that will kick off in 2022 also offers an opportunity for Germany to prevent setbacks to hard-won global health gains posed by COVID-19.
3. Increase effectiveness and accountability of global health investments
Around 40 percent of Germany’s global health ODA is channelled through multilateral entities (e.g., the Global Fund, EU institutions, Gavi, IDA, WHO, and UNFPA). Alongside increasing multilateral commitments, Germany should structure its funding to improve effectiveness and accountability, and to reduce fragmentation and the burden this places on countries. Germany should continue to push for multilateral entities to jointly work towards shared outcomes, based on country priorities, where possible through integrated health systems strengthening approaches, along with ensuring its own health systems funding can be tracked more transparently.
One option would be to explore setting up a multi-year performance agreement between Germany and a global health multilateral institution where contributions are tied to achievement of specific pre-agreed benchmarks, modelled on DFID’s previous performance frameworks with UNFPA and the Global Fund. Another is to test different innovative financing and results-based models to foster evidence and learning, including via impact evaluations. For example, Germany’s technical cooperation agency (GIZ) could (jointly) fund an evaluation window focused on programming strategies for health systems strengthening, in collaboration with the German institute for development evaluation (DEval) and other partners.
Going forward, the next German government should place a sharper focus on providing support for core, cross-cutting health systems strengthening - and increase funding for multilateral health organizations that can support low- and middle-income countries to deliver on this goal.
While COVID-19 will remain a top priority globally after the election and should also be central to the German G-7 Presidency, Germany can help ensure that other global health gains are not lost by elevating systems strengthening and sustainability on the political and financing agenda.