The coronavirus COVID-19 outbreak has brought into focus the need for a global health system. Infectious disease outbreaks are a global problem that nation states alone cannot tackle. To minimise the damage and effectively contain an outbreak a unified global response is needed.

At present, the lack of effective coordination and oversight at a global level, means that each country’s response is a reflection of its own political and health system, which differs enormously across countries and depends to a large extent on the level of available economic and health care resources. This can result in the implementation of ineffective strategies which are at odds with international cooperation. For example, numerous countries, including the United States, have imposed travel restrictions, temporary border closures and flight bans which do not work in this case.

Pandemic preparedness is a global public good

The key issue is that health systems are currently in the domain of national governments. Yet, as becomes clear when we consider measures to curtail the spread of the COVID-19 outbreak, this means that there is a sovereignty problem because pandemic preparedness represents a global public good and aspects of its response need to happen transnationally. Examples of activities that arguably need to happen at the global level include the development of global guidelines and norms, research and development into vaccines and treatment, outbreak surveillance and early warning systems, and the management of disease transmission across borders. All these activities ideally also need to be funded and managed at the global level.

In practice, however, it has been reported that these types of activities are underfunded, and although international financing for such activities increased somewhat after the Ebola outbreak, this increase was not sustained. There is an underinvestment in these areas because these are public goods, which suffer from what we call in economics the ‘free rider’ problem: people can benefit without paying. For example, they can benefit from outbreak containment activities carried out by one country, without supporting the cost of that containment.

Global financing is necessary

Contributions from countries are also voluntary, and it was pointed out that in 2017, 78% of funding for global public goods came from just five international funders (including two country governments). To avoid this problem, we need to move towards compulsory financing of global public health, with all countries being encouraged to contribute according to their income, through innovative financing mechanisms at the global level such as global taxation, and/or a financial transaction tax.

There has been a growth in recent years of financing mechanisms to support the global response to outbreaks. For example, the Coalition for Epidemic Preparedness Innovations (CEPI), a partnership between public, private, philanthropic, and civil society organisations was established after the Ebola outbreak, to develop vaccines, and is supporting vaccine development for COVID-19. The World Bank also set up a Pandemic Emergency Financing Facility to help the world’s poorest countries respond to outbreaks. However, there are now a plethora of global financing initiatives for single health issues, resulting in fragmentation of financing. Ideally funds need to be combined into a single pool to finance the global health system efficiently as a whole.

The case for a unified global health system

There are also challenges facing current management and governance arrangements for global health. While the World Health Organisation (WHO) is mandated to provide a number of health system functions at a global level, it is not sufficiently funded to do so.

Furthermore, the WHO budget is highly dependent on contributions from individual countries, and funding levels can be volatile, responding to changes in leadership and shifting political priorities. For example, the United States recently announced their plan to reduce their global health spending by three billion US dollar and reduce their funding of WHO by half.

The power of WHO is further challenged by the absence of a global enforcement mechanism to tackle countries that do not comply with the International Health Regulations, a global treaty to prevent and protect against the spread of health risks including infectious disease.

If we are to effectively tackle global health challenges such as disease outbreaks, which promise to become more prevalent, we need a global, unified, health system.

A world parliament

An important element of this global health system would be a world parliament that determines the budget for global health activities and ensures they are properly funded through compulsory global contributions and financial mechanisms, and that the regulatory framework exists to ensure consistent responses across countries, and their compliance with evidence based global health policy. Finally, a world parliament would also provide the level of legitimacy, accountability and oversight needed for this system to be generally accepted. The development of a unified global health system can start now, and would be an important step towards a world parliament.