The EU Global Health Strategy: How to make it work

Summary

The European Commission has just released its new EU Global Health Strategy. Twelve years after the last, this strategy is meant to be the external dimension of the European Health Union. It could give renewed political weight to health in the EU’s external engagement and reiterate its importance in the policy agenda. 

This briefing note is a ‘how to’ guide to make the strategy a game changer for the EU’s role in global health. The strategy lays a solid foundation and provides sufficient direction as well as concrete lines of action. While  aiming to ‘go back to basics’ to achieve the health-related Sustainable Development Goals, it also clearly hopes to reassert the EU’s leadership in the global health space in a complex geopolitical environment.

The priorities of the strategy are widely welcome, but given the multiple crises the EU is facing, there is a high chance that global health will fall off the agenda again. The EU and its member states will need to tackle broader issues to ensure that the strategy leads to transformative change.

There is a need to invest in better coordination both between the EU and its member states but also between the different EU institutions. Furthermore, meaningful partnerships promoting co-ownership between the EU and partners will be crucial for the implementation. The EU and its member states need to nurture the momentum through sustained political leadership. It will also be particularly key in view of the change of political leadership in the EU institutions in 2024.

Introduction

The European Commission (EC) has just released a new EU Global Health Strategy (GHS) (jointly drafted by its traditionally internationally focussed Directorate General for International Partnerships DG INTPA and its more internally focussed DG SANTE). It is called ‘Better Health for All in a Changing World’ and thought of as an agenda leading up to 2030. The Strategy was announced in May 2022 and officially launched on 30 November 2022 following a wide public consultation. It recognises the central role of health and puts forward three key interrelated priorities in dealing with global health challenges: 1) deliver better health and well-being of people across the life course; 2) strengthen health systems and advance universal health coverage; and 3) prevent and combat health threats, including pandemics, applying a One Health approach. 

The last Communication on the EU’s role in global health and ensuing Council Conclusions date from 2010 (EC 2010; CoEU 2010). Calls for its renewal started before the emergence of COVID-19 but intensified during the pandemic. The 2010 Strategy had a lot of relevant elements, but the agenda quickly lost momentum and little progress was made in implementing its goals (EC 2010; Aluttis et al. 2014). This was due to the fragmentation of the European global health community, the EU’s limited mandate on health vis-a-vis member states, the member states’ resistance to forego to or share with the EU some of their competences on health, and the rise of other priorities and crises (Aluttis et al. 2014). Some of these aspects have seen progress since 2010, notably as a result of the COVID-19 pandemic, for example on the strengthened EU mandate on health. Yet, others, such as coordination and the urgency of other priorities (such as the energy and cost-of-living crisis, the war against Ukraine, the green and digital transitions), remain challenges that could potentially undermine the implementation of the new Strategy. 

The launch of this Strategy comes in a challenging geopolitical backdrop and is clearly guided by it. Yet it is a welcome development, given the limited focus on health in Ursula von der Leyen’s geopolitical Commission and in the programming of the EU’s €79.5 billion external financial instrument (Sergejeff et al. 2022). Meant to be the external dimension of the European Health Union, this new GHS could give renewed political weight to health in the EU’s external engagement and reiterate its importance in the policy agenda. Yet in some ways, it consolidates efforts that the European Commission and member states have been undertaking already. Could it be an opportunity for the EU to make use of its role and untapped potential in global health? Past ECDPM research has indeed shown that the EU does not sufficiently leverage its funding or its assets in a way that maximises its influence in global health (Veron and Di Ciommo 2020). The launch of this new Strategy is thus a timely opportunity to take stock of the lessons learned in the past twelve years (since the last GHS), and particularly during the pandemic. This would help formulate a broader agenda, building on the various tools that the EU has at its disposal. 

The new Strategy outlines twenty guiding principles and makes concrete lines of action that operationalise those principles. It also creates a new monitoring framework to assess the effectiveness and impact of EU policies and funding and lists some of the key projects which underpin this Strategy at global, regional and national levels. 

This briefing note aims to share some thoughts regarding the implementation of the Strategy and an effective way forward. We begin by unpacking the focus of the Strategy and then point to eight areas that in our view will be key for the effective implementation of the Strategy.

Building resilience beyond health security and pandemic preparedness

The Strategy’s aim is to “go back to basics” and achieve the health-related Sustainable Development Goals (SDGs). It refocuses the EU’s action on achieving universal health coverage (UHC), strengthening (access to) primary health care and tackling the root causes of ill health (like poverty and social inequalities, including strengthening education and social protection). 

Global health security (i.e. protecting citizens from threats by stepping up prevention, preparedness and response, and early detection) is one of the key components of the Strategy. The Strategy also emphasises the ‘One Health approach’ that tackles all the links between the environment, animal/plant health and human health. This is crucial for resilience building and to ensure that the root causes of pandemics can be addressed and prevent health emergencies (Veron 2021). The commitment to the One Health approach is further strengthened in the Strategy by reinstating the EU’s ambition to be climate neutral by 2050, and an overall strong acknowledgement of the link between climate and health ,although it could be detailed further. Yet, translating the One health approach into concrete actions on the ground is a challenge (Ribeiro et al. 2019). It requires a whole-of-government approach in partner countries (who are also increasingly adopting this approach), ‘whole-of-EU’ approach at HQ and delegation levels and close coordination between often siloed institutional structures (see example from Kenya – Munyua et al. 2019). In that regard, the TEI on Sustainable health security in Africa is promising, as it has a strong focus on coordination and an integrated approach.  

Effective and resilient health systems are critical to health security and disease control. If the EU wishes to play a bigger role in global health, a systemic approach ensuring an adequate balance between all the elements outlined above will be key. Without health systems strengthening and universal health coverage, low-income countries will hardly be prepared when the next pandemic hits (Veron and Di Ciommo 2020). Yet political attention and energy currently tend to go to a narrower approach that focuses on health security and pandemic preparedness. While these are core to global health, such a focus should not come at the expense of a broader, interconnected approach. Transnational health threats and infectious disease threats are only part of the picture on global health, and structural health risks stemming from poverty and food insecurity should not be overlooked (Clingendael 2022). 

What will it take to make this Strategy a success? 8 ways forward

While this updated communication clarifies the EU’s ambitions in global health and aligns them both with the SDGs and the EU’s geopolitical priorities, the EU institutions and member states will need to tackle broader issues to ensure that it leads to transformative change, including the EU’s mandate on health and coordination. Given the lack of clear leadership on (global) health in von der Leyen’s Commission, political energy is likely to be spent elsewhere. Crises are multiplying at EU level and global health tends to struggle to claim a priority spot. However, the Strategy does provide direction to facilitate implementation by identifying concrete lines of action, and placing an emphasis on coordination and the Team Europe approach. Below, we introduce eight key ways forward for the successful implementation of the Strategy.

1. Strengthening interlinkages between health and other policy areas

The GHS acknowledges the linkages between health and other policy areas, such as climate and digital, gender, R&I, trade, education, food security as well as peace and security and humanitarian assistance to a large extent. The EC commits to a “health in all policies” approach to ensure that a wide variety of EU policies genuinely contribute to health goals. While this ‘health in all policies’ governance is presented as a novelty of this Strategy, this approach was formally adopted by the EU already in 2006. However, its implementation has been a challenge (Koivusalo 2010; Bengtsson 2022) and the hope is that the new Strategy will improve delivery. The new Strategy also steps up this commitment, by promoting a reinforcement of internal EU coordination and a better division of labour and responsibilities to achieve the priorities of this Strategy. 

The new Strategy identifies three key enablers for better health, namely digitalisation, research, and a skilled labour force. Research and digitalisation are particularly seen as areas where new opportunities have arisen. The Strategy, for instance, commits to creating a conducive research environment and ensuring that innovative vaccines, treatments, and diagnostics for infectious and non-communicable diseases are developed and used, including through Horizon Europe. More broadly, the Strategy commits to supporting local health research and strengthening international collaboration with low and middle-income countries. The EU-Africa Global Health European and Developing Countries Clinical Trials Partnership (EDCTP3), a long-standing core partnership that supports health research, capacity building and strengthening of the regulatory environment in sub-Saharan Africa, is a central element to deliver on these commitments. The digital transition is also recognised as a key enabler to deliver global health outcomes, which was not the case in 2010. The Strategy clearly aims at displaying EU leadership in the area. The focus will be on addressing underinvestment in digital health and care in low- and middle-income countries, with a Team Europe initiative on digital health. 

The Strategy provides good opportunities for strengthening the EU’s work on gender equality and sexual and reproductive health and rights (SRHR). Before the publication of the Strategy, there were some fears that the new Strategy would take steps back on these politically sensitive issues to gather support from all EU member states (Interviews October and November 2022). Instead, the Strategy acknowledges the fundamental role of SRHR in global health and plans to strengthen the universal access to SRHR through a dedicated Team Europe Initiative (TEI) and support to UNFPA Supplies Partnership. Furthermore, the Strategy commits to paying particular attention to the needs and rights of women and vulnerable groups including LGBTIQ people and migrants. This is in line with the EU’s policies on gender mainstreaming and the principles and priorities set out in the Gender Action Plan III, and opens up avenues for strengthening the synergies between gender equality and global health. However, the commitments need to be followed up in practice. In the past, SRHR has not been prioritised in the EU’s and member states’ international spending, as it received only 2.04% of the total combined ODA spending of EU Institutions and Member States in 2020 (DSW and EPF 2022).

This Strategy is a real chance for the EU to show how it can bring together its unique capabilities and expertise across various policy areas. It should also ensure coherence between domestic and international EU action on health, given that domestic interests have tended to run counter to international solidarity during the COVID-19 pandemic. The artificial division between the EU’s internal and external policies must be addressed (Mosset 2022). The Strategy does so to some extent by recognising that health developments in the EU affect partners across the world and vice versa and committing to improving health preparedness and response at home as part of the European Health Union as well as to fighting root causes of ill health in the EU. 

However, it is also striking that the Strategy mentions the need to enhance the EU’s strategic resilience through diversifying and building EU capacity of supply chains for critical equipment and countermeasures, diagnostics and therapeutics. This is in principle supposed to help enhance access by partners to such goods and thus their health sovereignty, but the COVID-19 pandemic has clearly shown the tendency to focus on ensuring access to equipment and vaccines within the EU, and thus on domestic interests first. In this context, it remains to be seen whether the EU’s efforts towards health security will in time benefit partners as well.

Translating the health for all policies approach into practice, and ensuring multisectoral and interlinked interventions will require strengthening health expertise in the EU and improve the understanding of how health links to other priorities in DGs that do not have a direct health mandate. Effective coordination and attention to policy coherence will be crucial in that regard.

2. Ensuring a more strategic and effective engagement through internal coordination

The Strategy clearly aims to deepen the EU’s leadership and reassert its responsibility for tackling key global challenges and health inequalities “in the interest of the highest attainable standards of health, based on fundamental values, such as solidarity and equity, and the respect of human rights”. It also positions global health as an “essential pillar of EU external policy, a critical sector geopolitically and central to the EU’s open strategic autonomy”. 

Global health has increasingly taken a geopolitical dimension since the COVID-19 pandemic. On the one hand, the fact that health moved from a “soft power” and “development only” agenda to a critical economic and security issue opens the door to placing global health higher on the political agenda and offers an opportunity to strengthen the EU’s partnerships and push for more strategic international cooperation on health (Interview, November 2022). It is clear that the GHS intends to go beyond development and adopt a truly holistic health approach (Holmgaard Mersh 2022). On the other hand, this new framing should not overly securitise this agenda. Indeed, values such as solidarity and equity should not be lost in the implementation of this Strategy. For the EU, stepping up its role in global health should not just be out ‘winning the geopolitical fight’ and restoring its image after the damage done by vaccine inequity. While the EU’s credibility as a global health actor will also depend on its ability to act beyond development cooperation and provision of Overseas Development Assistance (ODA), the programming of EU external financial resources has a key role to play and transformative potential if used in a smart manner (particularly when it comes to health systems strengthening). Yet it is clear that in order to remain relevant in the global health landscape, the EU (particularly DG INTPA) will need to think critically about the role of development assistance for health as well as the role of global health organisations and how they fit with the overarching direction the EU is trying to provide with this new Strategy (Interview, November 2022).

The Commission’s commitment to shaping the new global health order through a more strategic and effective engagement is thus welcome. The EU’s added value in global health stems from its political expertise, the fact that it deals with multiple policy areas as well as its leading roles in trade and development aid (Veron and Di Ciommo 2020). It should leverage this political role as well as multidimensional policy-making and expertise to enhance its role as a global health actor. This could be done by more strongly linking policy areas for more impact, but also using its influence and tools such as political dialogue to advocate for (global) health. Yet the EC should also ensure that priorities are set and that the focus is placed on areas of key EU-added value to avoid spreading itself too thin. This will also entail clarifying the responsibilities, complementarity and added value of various EU institutions, not least the EEAS (for example, in terms of political dialogue and through the EU delegations) which has been rather absent in global health so far. 

The Strategy highlights the need for a more joined-up way of working within the Commission. Ownership and coordination across various parts of the EU institutions (not just in DG INTPA and SANTE) – including sharing the responsibility of implementing it – will be key for the credibility and legitimacy of the Strategy. This will be particularly important given the upcoming change of political leadership in 2024 (Interview, October 2022). Yet internal coordination between EU institutions has been a weak point in the EU’s health architecture so far (Veron and Di CIommo 2020), as responsibilities for the different components of the health agenda are segmented across DGs according to their mandates (such as DG INTPA, HERA, NEAR, SANTE, TRADE and CLIMA). While the Strategy goes to great lengths of discussing coordination between the EU and other actors, little attention is given to the coordination within the EU institutions. Going forward, it will be important for the EU to ensure that coordination around global health is also prioritised within and between the different DGs (particularly between the internally and internationally focused DGs), for instance through a working group, dedicated meetings and focal points. This will require sufficient (human) resources with the requisite expertise and capacity within the EU institutions (including in EU delegations) as well as in member states.  However, investing adequate resources and time in coordination will be a crucial component to facilitate the successful institutionalisation and implementation of the Strategy. While the EC may view this as its internal cuisine, not to be spelled out in a Communication, this is at the heart of effective action.

3. Clarifying responsibilities on health and enhancing coordination between the EU and member states 

Stronger global health leadership starts at home (Anderson 2022). Clarifying the roles and responsibilities of the EU and member states in health should be the first step towards better cooperation and coordination around global health. It would reduce the risks of fragmentation, and enable the EU to speak with one voice. 

In a narrow sense, health policy is member states’ competence, and the EU does not have a mandate to work on it, outside of supporting, coordinating and complementing national policies (OJEU 2012; Bengtsson 2022;  Veron and Di Ciommo 2020). The EU’s limited mandate on health has also been one of the factors behind the watered-down implementation of the EU’s 2010 GHS, as well as affecting the EU’s ability to respond to the COVID-19 pandemic (Veron and Di Ciommo 2020; Bengtsson 2022; Van Hecke et al. 2021). There have been some calls to update the respective competences of the EU and member states, but a revision of the treaty is highly unlikely and overall, member states have been reluctant to give the EU a broader mandate on health (for example, Kickbusch and Kökény 2022; Deutsch 2021; Bengtsson 2022; Interviews). The Strategy itself emphasises that both the EU and member states will act “strictly within their respective competences and institutional roles as provided for in the treaties”. 

The competences of the EU set some limits to what can reasonably be expected from the implementation of the Strategy, and make it even more important to coordinate efforts between the EU and member states. Through a strong emphasis on coordination, the EU wants to facilitate the effective implementation of the Strategy and overcome longstanding challenges. In the past, lack of coordination with member states, and struggles to agree on common positions has been a key barrier to the EU’s role in global health (Veron and Di Ciommo 2020). The document thus includes several ‘lines of action’ from the mapping of key measures and financing efforts by the EU and member states, to strengthening external communication around the EU’s work on global health. The EU also plans to establish a new coordination system between the EU and member states in 2023. 

The Team Europe approach and Team Europe Initiatives (TEIs) will have a crucial role to play in strengthening coordination. Pulling together EU institutions, member states and their development agencies as well as European Development Finance institutions, TEIs provide opportunities for better coordination of the collective efforts of European actors around global health, and to fully leverage the expertise of all Team Europe actors (Jones and Sergejeff 2022). While the Strategy does not launch new TEIs, it pulls together the existing ones on health under a common framework. However, there are still several outstanding questions that need to be addressed to ensure effective collaboration and complementarity between different pillars of the TEIs. Furthermore, significant and explicit efforts should be made to involve partner countries and other local stakeholders systematically and ensure that they have an active role in the implementation of the TEIs (Jones and Sergejeff 2022). Tackling the challenges in terms of the implementation of the TEIs will be a crucial step towards the successful implementation of the Strategy. 

To ensure participation and political buy-in to the TEIs in member states, the EC has aimed at keeping them as flexible as possible, while providing some overall guidance to facilitate the coordination and implementation (Jones and Sergejeff 2022). Therefore it is not surprising that in the GHS, the EU settles for ‘inviting’ member states to align with the priorities and action points of the Strategy, including in terms of coordination. This language stresses the voluntary nature of member states’ cooperation, which may be a strategic choice to get them on board, but also a necessity given the EU’s limited mandate on health. Going forward, ensuring the political buy-in in the member states and incentivising coordination beyond Team Europe Initiatives will be important. This will also help the EU’s plans to advocate for member states to increase financing for global health in line with the priorities in the Strategy. 

4. Ensuring adequate and effective funding for global health

The Strategy also places emphasis on effective funding and recognises that its implementation will require an important commitment of resources as well as a predictable and sustainable investment “commensurate with needs and ambitions”. The commitment to follow a new approach involving innovative finance, co-investment from partner countries and the private sector and pooling with other international actors is positive, as it shows a willingness to innovate and work differently as well as a focus on the ‘how’ rather than ‘how much’. The Strategy also expresses a willingness to make the EU’s financial contributions to global health even more impactful through closer mapping and monitoring of impact.

The commitment to prioritise global health across all relevant EU budget financing programmes (including the EU4Health programme, Horizon Europe, the NDICI-Global Europe) and fulfil its commitment on financing for global health within the framework of the multiannual financial framework is welcome, although it lacks specific financial targets and past ECDPM work has shown that funding for global health tends to remain rather low. For instance, while the EU committed to allocate at least 20% of its official development assistance to human development and social inclusion under the NDICI-Global Europe, education benefited from much stronger political sponsorship and energy (with a target of 10% for education in the programming of external resources in partner countries – an initiative of Commissioner for International Partnerships Urpilainen) (Sergejeff et al. 2022). Other targets exist in relation to climate, digital, gender or migration – all strong geopolitical priorities for the EU. While financial targets are far from being a panacea, the lack of a target for health so far demonstrates a lower level of political prioritisation that could be detrimental despite the commitments as set out in the Strategy. In view of the mid-term review of the Multiannual Financial Framework (2021-2027) and NDICI-GE in 2024 but also of the negotiation of the next MFF after 2027, it will be crucial to assess progress in terms of funding for (global) health and readjust targets if needed, both in the geographic programming of the NDICI, as well as in contributions to multilateral health initiatives financed through the thematic pillar of the NDICI.

Given the limits of aid, it is particularly positive that the Strategy encourages the use of new financing methods and innovative financial instruments and building on the European Fund for Sustainable Development Plus (EFSD+) that facilitates access to blended finance and budgetary guarantees. Together with the European Investment Bank and the European Bank for Reconstruction and Development, the Commission intends to develop a framework for global health financing, aligned with the EU’s priorities and those of partner countries. The private sector has a role in supporting public-private partnership hospitals, pharmaceutical manufacturing or financial services for health, but finding opportunities for investments in human development sectors that are attractive to investors can be challenging. Team Europe actors also still need to get accustomed to the use of innovative financing methods in the health sector, and strengthen the cooperation with DFIs under Team Europe (Sergejeff et al. 2022; Jones and Sergejeff 2022). 

5. Building health partnerships and strengthening health aspects in the EU-AU partnership 

Expanding and deepening existing partnerships with a wide range of stakeholders at the global, continental, regional, national and local levels is imperative to promote health sovereignty and autonomy and build resilient health systems. The GHS provides an opportunity for the EU to play a lead role and drive international cooperation in health towards achieving both the SDGs and UHC.

One of the GHS’ central elements is to support a strong and responsive multilateral system with the WHO at the centre, aimed at improving the global health architecture. In fact, on the day the GHS was unveiled, the EU committed to invest €125 million in extending UHC for the period 2023-2027, as part of a partnership programme with the WHO (Agence Europe 2022), a welcome pledge showing the EU’s political and financial commitment. In addition, the EU supports the negotiation and development of a legally binding pandemic agreement with a One Health approach and strengthened International Health Regulations necessary to empower the WHO to report and investigate pandemic threats rapidly. Lessons from the COVID-19 pandemic stress the importance of timely information to stem the spread of new diseases.

Aside from support to the WHO, the GHS provides an avenue for the EU to reshape global health governance to avoid the risk of the experiences during the COVID-19 pandemic where international responses to health threats were undermined in favour of national interests. 

Consensus should be built through deepened cooperation via the EU’s role in global governance groupings such as the G7, G20, as well as with other global, regional, bilateral and philanthropic partners, ensuring coherence of action to avoid duplication. Partnerships are at the core of the implementation of the new Strategy. This will increase the legitimacy and political buy-in of the Strategy. The consultation and inclusion of the views of stakeholders in low and middle-income countries in the drafting process was already seen as a positive development and key to the new Strategy’s legitimacy.

Stronger EU-AU partnership on health

The EU’s partnership with the AU on health will be particularly key for the Strategy to be meaningful internationally. Health was a paramount topic at the AU-EU Summit in February with African countries calling for vaccine equity. Tensions in the partnership revolved around the TRIPS waiver for restrictions on patents and other intellectual property barriers, in a bid to speed manufacturing and ease access to lifesaving products in the midst of a pandemic, with some seeing the EU’s stance on the protection of patents as placing the profitability of pharmaceutical companies above human lives. 

The support should build on the AU’s own initiatives and align with Africa's New Public Health Order which calls for strengthening African Institutions for Public Health, strengthening the Public Health workforce, expanding local manufacturing of health products, increasing domestic investment in health, and promoting an action-oriented and respectful partnership. A laudable aspect of the GHS is that it touches on the elements highlighted in Africa’s New Public Health Order, however, implementation of this multifaceted agenda requires comprehensive and coordinated support, which could potentially be supported by the range of TEIs in Africa, including support to local manufacturing, regulatory framework, health systems and public health capacity strengthening and digital health. 

A key priority for the AU going forward will be support for local manufacturing including transfer of knowledge and technology from European pharmaceutical companies. Africa imports more than 90% of the pharmaceutical products and 99% of the vaccines (Karaki and Ahairwe 2022). However, questions revolve around if the EU is willing to engage in the effective transfer of technology. Indeed, although the June WTO decision on the TRIPS waiver covers the production of COVID-19 vaccines, it does not extend to the production and supply of COVID-19 diagnostics and therapeutics critical in detecting new cases and new variants. ​​So far, TEIs have committed €1 billion towards supporting local production (EC 2021). At the November Commission-to-Commission meeting, an announcement of €15.5 million Team Europe Support Structure (TESS) by the European Commission, Belgium, Germany and France was made aimed at advancing the Partnership for African Vaccine Manufacturing (PAVM) hosted by the African Centre of Disease Prevention and Control. The new Strategy, rather than providing new elements, initiatives or measures, reiterates some of the commitments already made as part of the AU-EU Summit i.e. to “support regional and country efforts to strengthen pharmaceutical systems and manufacturing capacity for vaccines and other medical products and technologies to increase quality, safety, equitable access, and health sovereignty”. In doing so, it explicitly refers to and builds on ongoing initiatives such as the Team Europe initiative on Manufacturing and Access to Vaccines, Medicines and Health Technologies in Africa and the EU and Latin America and the Caribbean manufacturing and health partnership.

One area for strengthened cooperation is on the regulatory framework to enable equitable access to vaccines, diagnostics and therapeutics. The EU should help better define the regulatory role of the national regulatory agencies (NRAs), the regional regulatory authorities (RRAs) and the African Medicines Agency (AMA) and in turn the support they require to ensure that they fulfil their regulatory functions in an effective, efficient and timely manner (Karaki and Ahairwe 2022). Together with Team Europe and other development partners, such as the Bill and Melinda Gates Foundation, the EU committed to mobilising over €100 million to support the first implementation stages of the African Medicines Agency (AMA) over the next 5 years, and to strengthen other African medicines agencies initiatives at regional and national levels (Karaki et al. 2022; EC 2022). The EU, at the recent Commission-to-Commission meeting, signed an initial financial contribution of €5 million to support the operationalisation of AMA, a key institution mandated to improve access to quality, safe and efficacious medical products in Africa. 

The GHS also provides an avenue for the EU to focus on health systems strengthening both institutions as well as of health workforce capacity. Solutions for shortages across Africa and Europe should be evaluated in partnership and supported by systemic investments and African health policymakers should be included in discussions when European health workforce policies are being shaped (Mosset 2022). 

This new GHS thus offers an opportunity to re-energise the AU-EU partnership in a way that aligns with Africa’s objectives, particularly if it builds on existing African initiatives, institutions and mechanisms. Going forward, actors involved in the implementation of the Strategy should aim at supporting Africa’s ownership and strategic autonomy while reinforcing Europe’s values and interests.

6. Advocating for greater ownership of the health agenda by partner governments

Low-income countries invest roughly 5% of their GDP in health (ONE 2022). Partner country ownership is one of the key principles for development cooperation, and a crucial prerequisite for the successful implementation of the Strategy, which will require strengthening engagement at partner country level in order to incentivise national responsibility on health. Ultimately, this will in turn require ownership and political buy-in from the partner country, as well as accountability. 

The GHS recognises the importance of ownership and has included specific guiding principles on equal partnerships, co-ownership and advancing mutual interests. It notes that the relations with partners have to be based on ownership with shared responsibility, which is key to achieving health sovereignty. Furthermore, with the Strategy, the EU plans to engage with partner countries, to expand access to health services and encourage partners’ investment in health services. 

This is a welcome approach and development that ideally promotes the sustainability of health interventions and systems in partner countries. The Strategy also notes that the EU will encourage and help domestic resource mobilisation for health financing, which is essential for better global health outcomes and sustainability (GHA 2022a). In practice, promoting domestic investment in health systems in partner countries and ownership of the health agenda often requires a thorough analysis of the political context and factors that drive or block the strengthening of health systems or mobilising domestic financial resources in the country. Several factors, such as lack of capacity and expertise or systemic corruption, can hamper health system reforms. For instance, in the case of Zambia, widespread corruption in the health sector has been a crucial barrier to improving access to basic services (Nyambe 2021). Understanding the political economy in the health sector will also help the EU to ‘make the case’ for strengthening health systems, identifying champions around health, and building coalitions to boost political will and action. 

Similarly, many poor and highly indebted countries may have challenges in increasing domestic investments on health. Therefore, debt relief and access to Special Drawing Rights can both be potent tools to support African partners’ recovery from the pandemic (Sergejeff et al. 2022).

Going forward in the implementation of the Strategy, the EU should translate its promise to promote co-ownership into action. In practice, this would mean close involvement of partner governments and civil society during planning and implementation of interventions, tackling the issues in terms of partners’ involvement in TEIs and strengthened policy and political dialogue on health. Although internal and context-specific factors are key drivers of political interest and commitment, the EU can advocate for and assist in strengthening health systems in partner countries (see Sergejeff et al. 2022).  

7. Designing a proper implementation framework

A proper monitoring and evaluation framework is key to ensure the accountability and impact of the Strategy. The Commission has made a commitment to carry out a mid-term review and a final evaluation of the Strategy’s implementation in 2030. The Strategy also includes commitments to monitoring, with metrics and indicators that will be directly tied to actions and health outcomes. These reports will be published every two years. This is a significant improvement compared to the past. The 2010 Strategy indeed failed to shape broad, concerted action at EU level due to a lack of effective follow-up and operationalisation of clearly defined focus areas (EC 2010; Bengtsson 2022). These commitments are welcome and they need to be followed up on, but it remains to be seen which metrics and key indicators will be designed. Furthermore, the reporting cycle of two years may not be frequent enough to make the necessary adjustments over a period of eight years.

The Commission also commits to keep the European Parliament, the Council and civil society closely informed about financing and implementation progress by organising regular high-level exchanges, and hosting a structured dialogue with stakeholders as part of the annual Global Health Policy Forum process. This is a good way to involve actors and ensure ownership of the Strategy across the board, increase transparency as well as to allow civil society and other actors to hold the European Commission and member states accountable.

8. Keeping the momentum of the EU’s global health agenda in the short-, medium- and long-term 

The key priority going forward will be to maintain this momentum for global health in the midst of the war against Ukraine, the energy and cost-of-living crisis as well as the climate crisis. This will be no easy task and past experience has shown that strategies can quickly be forgotten on bookshelves. It will also be particularly key in view of the change of political leadership in 2024 which will lead to a discussion around new priorities.

As part of its upcoming Presidency of the Council of the EU (January – June 2023), the Swedish Government has indicated an ambition to negotiate and adopt related Council conclusions before the end of its term, building on the work done under the French and Czech Presidencies. This will be led by the Working Party on Development Cooperation and International Partnerships (CODEV-PI) in close cooperation with the Working Party on Public Health and other relevant Working Parties, mirroring the cross-sectoral ambition of the Strategy. The Swedish Presidency is well placed to achieve this, given the solid expertise on global health within its Government Offices as well as the comprehensive national Strategy adopted in 2018 as part of the implementation of Agenda 2030 (Government Offices of Sweden 2018). The Swedish approach to global health focuses on three pillars (echoing the WHO general programme of work as well as the GHS drafted by the EC): health security, health systems and healthy societies – a pillar that receives the least attention). The Swedish presidency will have an important role to play in terms of rebalancing the focus towards topics that tend to receive less political energy (such as the strengthening of health systems and how to make development cooperation impactful in that area, but also healthy societies). 

In the negotiations of Council conclusions, Sweden will however have to navigate the tricky issue of competences, given that member states have ample autonomy in health policy, regulation and implementation. Many aspects included in the Strategy might be watered down by the Council (such as topics like SRHR that are not consensual among member states). The Conclusions are also likely to highlight the need to ensure accountability and regular reporting, which will be important for the implementation and monitoring of the Strategy. Beyond the adoption of Council conclusions in the first half of 2023, it will be key for Sweden to closely engage with Spain and Belgium who will hold the EU presidency in the second half of 2023 and the first half of 2024 respectively. This will ensure continuity in the global health agenda.

Conclusion 

The EU’s new GHS lays a solid foundation to build a more coherent, effective and multisectoral approach to global health. It provides sufficient direction as well as guiding principles and concrete lines of action that will facilitate implementation. It also makes a welcome link to the EU’s geopolitical priorities, such as digitalisation and the green transition.

The EU will however need to tackle some key issues to be seen as a credible external actor in this field. The various actors involved in the implementation of this Strategy will need to strengthen internal coordination between EU institutions, coordination with member states (to achieve the ‘genuinely single and powerful voice’ that the Strategy aspires to) as well as flesh out the ‘spirit of partnership’ and ‘co-ownership’ that the Strategy promotes, particularly with regards to the AU-EU partnership.

Strong political leadership will also be needed to keep the focus on the fundamental issues (health systems strengthening, universal health coverage, primary health care, public health, health determinants) at a time when political energy tends to be spent on health security, pandemic preparedness and the fight against transnational health threats. 

More broadly, ownership of the Strategy will need to be institutionalised (including at EU delegations level) and sustained attention by top political leadership will be crucial for a topic that so far has been lagging behind. This will also include ensuring that global health gets the appropriate levels of funding at various levels (global, regional and national). In the current context of multiplying crises, the EU needs to align its short-term political objectives with the longer-term needs. Investment in health should be seen as a multiplier that will benefit the well-being of societies and the economy. The EU however cannot carry this agenda alone: it will need strong partners, but most importantly, in the long run, it will need to promote resilience, autonomy and buy-in in partner countries.

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Endnotes

(1)  The new Strategy should be read together with the first State of Health Preparedness Report, published in parallel with it, and considered together with the parallel communication on pandemic preparedness and response, which is also in preparation. 
(2) This includes a stronger European Centre for Disease Prevention and Control (ECDC), a new European Health Emergency Preparedness and Response Authority (HERA) and a reinforced role for the European Medicines Agency.
(3)  It is worth noting that Ursula von der Leyen did not attend the launch of the GHS on Wednesday 30 November. The Strategy was presented by Commissioners Kyriakides (for Health and Food Safety) and Urpilainen (for International Partnerships).
(4)  This is called the Neighbourhood, Development and International Cooperation Instrument - Global Europe (NDICI-GE).
(5)  As stated in the Strategy, "[t]he COVID-19 pandemic has been a litmus test of what is essential, what must change and what is missing to bring about effective global health governance."
(6)  In terms of service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance.
(7)  As attested by the State of Health Preparedness Report presented in parallel to the Strategy.
(8) Evidenced by the fact that health was absent from Ursula von der Leyen’s State of the Union speech on 14 September 2022. 
(9) This would focus on achieving a transformational impact for advancing universal health coverage, primary healthcare, pandemic preparedness and response, improved diagnosis and personalised medicine and continuum of care.