Global Health Governance and Geopolitics

The US’s Health Strategy

With the exception of the Trump presidency, during which time it turned its back on the WHO, the US has always been a leading player in global health policy. The Biden administration’s National Security Strategy also demonstrates this through its references to global health policy. The Security Strategy emphasises cooperation with “like-minded partners” on health issues and criti­cises China’s behaviour during the Covid-19 pandemic. It also underlines the role of the US as a donor to the WHO and the World Bank’s Pandemic Fund, and notably as a sponsor of the US President’s Emergency Plan for AIDS Relief (PEPFAR) that was initiated in 2003. All of this can be seen an expression of the US’s pronounced will to shape global health.

This has been reinforced as various pre-existing offices were merged to create the Bureau of Global Health Security and Diplo­macy under the State Department in August 2023. The head of the Bureau describes global health security as a “key element” of US foreign policy, and health diplomacy is also the focus of two new divisions under the Bureau: the Office of Health Diplomacy and Capacity Development, and the Office of Regional and Multilateral Diplomacy. Diplomacy is therefore seen as necessary in forging new alliances in health governance.

With a budget of almost US$7 billion in 2023, PEPFAR is the Bureau’s largest pro­gram. During debates on extending the program, its advocates in congress emphasised, among other things, its “soft power” and ability to play an important role on the African continent, especially as China expands its influence there through health diplomacy.

Nonetheless, it is currently unclear whether the Bureau will receive the neces­sary financial resources in the coming years, especially considering that a Repub­lican presidency would likely change US global health policy. Many conservative Republicans are in favour of introducing conditionalities to funding PEPFAR and aim to exclude institutions that provide abor­tion counselling or services. Thus, the issue of global health is not only politicised due to systemic rivalries between countries, but also instrumentalised for domestic political purposes.

In conclusion, although the US’s global health efforts are increasingly characterised by domestic political conflict and the asso­ciated conditionalities, one thing is clear: The US is using global health policy to expand its geopolitical sphere of influence, especially in competition with China, and it is aiming to diplomatically forge new alli­ances to jointly combat health threats.

China’s Global Role

Even before Covid-19, China was already cooperating with countries in the Global South on health issues as part of the Belt and Road Initiative (BRI). This cooperation intensified during the pandemic as part of China’s so-called mask and vaccine diplo­macy. The Chinese government’s approach differs from that of the US in the sense that national sovereignty has been enshrined as a cornerstone of China’s Global Security Initiative. In effect, foreign governments that receive aid from China maintain con­trol over their own health policies, meaning that China’s Global Security Initiative and its health diplomacy don’t place explicit conditionalities on would-be recipient coun­tries.

Particularly when it comes to providing Covid-19 vaccinations, China filled a gap while other countries in the Global North reverted to “vaccine nationalism”. Further, China is establishing itself as an advocate for countries of the Global South in nego­tiations on the pandemic accord, particularly when it comes to intellectual property rights and access, and benefit-sharing. It can be assumed that China is hoping that these coun­tries will support its geopolitical aspi­rations in return.

Ultimately, China’s geopolitical ambitions are also expressed in its global health policies. On the one hand, China is expand­ing its sphere of influence through trade in medical goods, and on the other, it is enter­ing into new alliances in the Global South.

Germany’s Approach

The fact that the German National Security Strategy discusses preventing and combating pan­demics shows that the German gov­ernment has recognised the importance of global health policy as a matter of national secu­rity.

From a geopolitical perspective, however, the German Security Strategy only addresses import dependencies in the field of medical goods. The focus here is on the diversification of supply chains in the sense of “de-risking”. Beyond this, there are no further considerations of potential bilateral and multilateral diplomatic efforts which could strengthen Germany’s influence and im­prove cooperation and transparency in the early detection and prevention of health risks. The need for such approaches becomes all too clear when considering China’s lack of transparency throughout all phases of the Covid-19 pandemic.

The German government’s strategy towards China specifically addresses the latter’s lack of cooperation by emphasising that WHO member states have fundamental reporting obligations. This clearly refers to China’s lack of transparency in dealing with Covid-19. Once again, Germany’s strat­egy towards China also highlights economic interdependencies as a risk in the supply of medical goods.

Although the German government’s strategy towards China also sees it as a rival and contextualises health issues in this way, the multilateral approach of German foreign and security policy continues to dominate. The general bent of both the German Security Strategy and its strategy toward China are cooperation and coordination, even with “difficult” partners. How­ever, neither strategy addresses how the German government intends to deal with states such as China, India or Russia that unilaterally approach health issues or use the medical goods trade and global health policy to pursue their geopolitical interests.

Nonetheless, based on the experience of Covid-19 and in view of rising geopolitical tension, Germany should expect other countries to increasingly view global health policy as a field of geopolitical competition and as an instrument of foreign policy.

The Possible German Way

In view of shifting geopolitics, Germany should take on a stronger view of global health as a foreign and security policy issue. Yet in doing so, it should not “de-couple” from other countries, otherwise, the multilateral fight against health threats becomes considerably more difficult and the goal of creating a robust global health architecture is undermined.

Geopolitical rivalries are increasingly jeopardising the improvement of the global health architecture. While Germany strives for multilateral action, it will not be able to prevent some actors from using the supply of vaccines or other counter-measures as instruments of economic or foreign policy coercion. It won’t be able to prevent others from not cooperating transparently in the fight against outbreaks.

A possible German way could therefore be to transfer the “de-risking” strategy already applied to medical supply chains to other areas of global health policy. The German government should develop strat­egies in the event that countries are unco­operative in the fight against health threats or instrumentalise their global efforts for unilateral purposes or in advancement of their geopolitical interests. These strategic considerations must be spelled out and included in strategy documents.

Three approaches in particular should be emphasised in Germany’s multilateral strategy toward geopolitical spillover in the realm of global health governance: Firstly, the pandemic accord, IHR reform (both ambitiously set to conclude in 2024), and health diplomacy similar to that of the US should allow for the establishment of a broad alliance of states. This alliance should be based on a shared understanding of global health governance and include states from the Global South. Secondly, Germany should attach very few/minimal conditionalities on global health programs. In this vein, it should work towards waiving such conditionalities in the “Global Gateway” initiative of the European Union (EU). By giving preference to countries such as Ethiopia, Cambodia or Mozambique when exporting medical goods, Germany could counterbalance Chinese influence. Thirdly, when exporting medical goods or initiating programs, Germany should keep an eye on the geopolitical ambitions of other actors and offer practical alternatives that bring its partners more advantages than those of other actors. Nevertheless, it is important to keep geopolitical tensions away from efforts to build a new global health architecture – as was achieved in the past and, above all, during the early stages of negotiations on the pandemic accord. In doing so, Germany can carve out its role as a reliable partner that does not use global health policy as a tool to expand its geopolitical influence, but rather to improve the health of partner countries’ populations.

Last but not least, the EU, having formulated the Global Health Strategy, is of great importance. Still, the Strategy takes (too) little account of geopolitical affairs, albeit with the exception of pharmaceutical im­port dependencies. Here, the EU is attempt­ing to tackle these dependencies by relo­cating production to the EU and through stockpiling; but the aim should also be to diversify supply chains at the EU level in line with the German Security Strategy. Only by diversifying supply chains will the EU be able to overcome the current depend­encies that make it vulnerable to economic coercion through trade restriction.