How should the new government rebuild the UK’s reputation in global health?

Three critical challenges

The first is the long term challenge of domestic health expenditure by low and middle income countries being insufficient to meet health needs. The problem is now deteriorating because of low growth and high debt repayments, and stagnant aid budgets.5 Over three billion people now live in countries which spend more on debt interest payments than they do on health or education.6 This lack of finances makes the second challenge much harder—the increasing reality of truly global threats such as climate change, pandemics, antimicrobial resistance, and conflict. All are on the rise and require global cooperation, which is in short supply. Indeed, the third challenge is a breakdown in confidence in global health multilateral organisations, which was highlighted by the failure to achieve equitable covid-19 vaccine roll-out. This loss of confidence had longer term roots, stemming from the weakening role of the World Health Organization, with increasing presence of other better resourced and more agile actors, and concerns about current donor financing arrangements undermining national systems.7 Underpinning all three challenges are stark health inequalities and power imbalances in global heath.8

Delivering the manifesto

In its manifesto, the Labour government provided an outline of how it might approach these challenges.9 It will not increase spending or return to an aid budget of 0.7% of gross national income in the short term. It must therefore use limited resources better, focusing on fewer bilateral programmes in the poorest countries and allocating global resources to the most effective multilateral mechanisms. Effective action may be undermined by the low priority given to global health in Labour’s manifesto. But the manifesto’s focus on economic development, climate change, and security may open space for the UK to work on intersectoral action, such as the One Health agenda, or on substantial social and commercial determinants of health—for example, through taxes on tobacco, alcohol and sugar sweetened drinks.5

Development will remain under the Foreign, Commonwealth, and Development Office (FCDO) and, in partnership with the Department of Health and Social Care, it will aim to serve British interests and security. A broader understanding of enlightened self-interest is needed to make this a success.10 For example, the UK could invest in projects to strengthen health systems in low income countries, such as reforming priority setting mechanisms, which also form the cornerstone of global health security.1112

The manifesto commits to strengthening and reforming multilateralism and upholding international law. This means a commitment to the revised International Health Regulations and continuing to support the UK’s existing global health strategy, which calls for reform of global health aid architecture.113 The UK has some urgent decisions to make in this area since this autumn will see WHO, the World Bank, Gavi the Vaccine Alliance, and the Pandemic Fund all seeking funding pledges that would tie the UK’s hands for many years. In addition, the UK must contribute to ongoing negotiations on the global pandemic agreement. To make progress on reforming the global health architecture within this parliament, government will have to review these organisations and, in coordination with other countries, ensure that international pressure and funding moves towards constructive reform.

Finally, the manifesto commits to “genuine respect and partnership” with low and middle income countries. Processes must be developed and implemented to listen to governments and civil society in these countries about how this can be done. Options include reforming FCDO governance to include lower income country and civil society voices; adjusting bilateral programming to be longer term, taking greater risks through more direct budget support; backing multilateral mechanisms that empower low and middle income countries and providing them with core flexible resources, as the UK has done with WHO; and transforming the terms of UK global health aid, through providing flexible concessional loans rather than aid for predefined priorities, for example.8

Labour also commits to “empowering women and girls,” which is consistent with the previous Conservative administration. This must be delivered not just promised: reproductive and sexual health programmes were cut by a staggering 40% by the previous administration.314

The Labour Party takes over a UK global health agenda that is smaller in reputation and resources than it once was. To deliver on its manifesto and revive the UK’s reputation the new government will need to be decisive, prioritise its bilateral and multilateral expenditure, invest in health systems, and put money and political capital behind multilateral reform and equitable partnerships.