The world has been shaken at its economic, political, and social core by the COVID-19 pandemic. The impact of the pandemic has led to calls for re-thinking the future of human societies in ways that will result in a fairer, healthier, and more sustainable world. Recognizing that the pandemic is not the only crisis facing humankind, other mega trends equally as important to consider in any rethinking of future directions are:
Together these mega-trends have created an unstable world which is more open to health and other crises.
The world has also adopted seventeen goals - The Sustainable Development Goals (SDGs) – which have given us a vision of where the world should be by 2030. The 17 SDGs are: 1) No poverty 2) Zero Hunger 3) Good Health and wellbeing 4) Quality Education 5) Gender Equality 6) Clean Water and Sanitation 7) Affordable and Clean Energy 8) Decent work and Economic Growth 9) Industry Innovation and Infrastructure 10) Reducing Inequality 11) Sustainable Cities and Communities 12) Responsible consumption 13) Climate Action 14) Life Below Water 15) Life on Land 16) Peace, Justice and Strong Institutions 17) Partnerships for the Goals.
Further to these goals the United Nations has also endorsed the goal of Universal Health Coverage (UHC) which include
Many also envisage that UHC will only be achieved through the provision of public services based on comprehensive primary health care1. In addition, there is some agreement (the Paris Accord) that global warming must be kept below two degrees Celsius compared to pre-industrial levels. While there is some denialism regarding climate change there is primarily a strong and growing consensus on the target and the need for strong action to achieve it.
This section summarizes the relevance of sub-themes 2 & 3 as they are an important backdrops to envisaging the world we want in the future.
While in May 2021 some rich countries have had access to vaccines with robust immunization programs and are near to achieving herd immunity (Israel, Canada, UK, US) the story is completely different in many LMIC. In India, Brazil and the Philippines in May 2021 the pandemic was raging and new variants emerging. The issue of equitable access to COVID-19 vaccines and treatment technologies is crucial and poses massive questions for the global community about equitable provision of access to health care. The role of political leadership has emerged as vital in determining pandemic responses. There is also evidence that the pandemic has led to an increase in gender-based violence. The pandemic has underlined the importance of strong public health systems which are free at the point of use.
A trend that underpins all the others is the human-created and destructive impacts on many of the environmental systems on which human health and life depend. This is characterized by ecological ‘overshoot’, in which population demand on ecosystem resources exceeds the capacity for resource regeneration, with climate change posing the most immediately critical health-related issue. As one example, particulate air pollution (associated with fossil fuel consumption and greenhouse gas emissions) is responsible for three times as many deaths annually as HIV, malaria, and tuberculosis combined. Despite 25 years of efforts to implement the United Nations Framework Convention on Climate Change (UNFCCC), through its two agreements and one protocol, CO2 emissions continue to increase rather stabilize or decline. The commitment of the European Union and election of US President Biden has given a boost to efforts to establish more ambitious carbon reduction targets, but a secure climate future is far from assured. Given the urgency of action on climate change, a quarter century of slow or no substantial prevention or mitigation attests to crises in effective global governance, with concern that the slow decline in multilateralism will worsen the situation. The recent G7 meeting in the UK did make some commitments to climate action but commentators2 have seen the commitments as not going far enough. Other multilateral meetings happening in 2021 are G20 (Saudi Arabia, November 2021), and OECD (tax reform) and the COP26 in Glasgow (November 2021). While Climate change is the focus of sub-theme 2 addressing this crisis is critical to the ability to achieve the vison in this sub-theme.
The first mega trend we will examine is the continued rise in economic and wealth inequities, first noted in the 1980s and early 1990s and which has accelerated since. Not only are such inequities associated with slowing, stagnating, or inequitably distributed health risks; their impact on social stability and potential to create national and regional conflict is now widely accepted as one of the major concerns facing humanity. The issue of rising inequity is a cross-cutting issue and relevant to mos of the other issues PMAC 2022 will be considering including climate change, income security, working conditions and health. World Bank data indicate that in most countries in the world wealth distribution as measured by the Gini co-efficient are becoming less equal3.
There are many reasons for this dramatic rise in wealth/income inequities but most of them pertain to policy decisions governments have made over the past four decades in which neoliberal economic theory predominated. Since the 1980s the share of global economic product going to labour has declined substantially while the share to capital (investors, TNCs, etc.) has increased so contributing to the widening inequities. A further reason has been the declining share of GNI within countries being captured by taxation for redistribution through cash transfers and/or investment in public programs, including health and social protection. Some countries, notably in LMICs, are now increasing taxation (measured as a portion of GNI) that could sustain or improve financing for health and other social protection programs. Their low levels of economic output (GNI), however, means that even with improved and progressive taxation many LMICs will be unable to finance adequate social safety nets in keeping with the SDG targets without external forms of financial assistance. Moreover, the impacts of the pandemic on the global economy will reduce considerably growth and taxation potential for many of these countries.
At the same time, countries’ tax/transfer capacities remain constrained by the hypermobility of capital, continued international tax competition, and a growth rather than reduction in offshore financial centres (‘tax havens’). Huge amounts of wealth and income continue to avoid or evade taxation and redistribution or public investment for public good purposes. There have, however, been considerable efforts to reduce these practices in recent years since the publication of the Panama Papers which revealed the extent of tax evasion.
During the COVID-19 pandemic the wealth of the world’s richest individuals increased dramatically. The wealth of the richest people in the world have boosted their already vast wealth by more than $400bn (£296bn) since the coronavirus pandemic began as their businesses benefited from lockdowns and financial crises across the globe. –Some transnational pharmaceutical companies are making large profits from the sale of vaccines. Pfizer announced that it expects $26 billion in COVID vaccine sales this year while also refusing to share any significant vaccines with low and middle incomes countries4,5.Reversing the trend towards increasing inequities is vital to a healthy and fairer future.
The rise in non-communicable disease in all countries regardless of income has reached the proportions of a pandemic 6. WHO reports that 71% of all deaths are a result of NCDs. The vectors of NCDs concern social and commercial determinants of health. NCDs have increased as the marketing of products such as high sugar content drinks and the design of cities which encourage low exercise. This means we have car dominated cities, unwalkable neighborhoods, marketing and consumption of fast foods and weak social ties. While NCDs have been called “lifestyle” diseases, putting the onus for change on individuals, these “lifestyle’ choices” have deep roots in unhealthy systems. Thus, reducing their impact will require system change. These changes would include the on-going struggle to establish effective public health systems which are based in comprehensive primary health care. Such community-based care would be able to work to reduce NCDs in communities including by identifying and advocating for change to the social and commercial determinants. These systems would also be helpful in handling future epidemics of infectious diseases.
The cost-effective health promotions and disease prevention should be addressed in the future plan to tackle NCDs. Effective health promotion and disease prevention interventions should also address both proximal and distal determinants of ill health of the population in terms of both issue based and setting based determinants (such as, for issue based, sedentary life style, unhealthy eating, tobacco and alcohol uses 7, along with setting based, such as, aging society and vulnerable population).
Global life expectancy has risen by more than a decade over the last 40 years to reach 73.2 years. It is also projected to increase in every country over the next 40 years, according to the United Nations, as mortality improvements shift from childhood to later ages. However, in some high income countries including the US and UK life expectancy is stalling and has declined for some low socio-economic groups8,9. Population ageing and fertility decline are key trends when considering how to make the world sustainable in the context of COVID-19. Older people constitute the large majority of deaths due to COVID-19. The pandemic has also powerfully revealed the importance of public health and the value of preventive medicine. It has dramatically exposed the social determinants of health and the stark inequities of those most impacted by disease, from health, social, and financial perspectives. Highlighting the importance and urgency of investing in healthy ageing. The pandemic has also had significant and substantial impacts on fertility behaviours including substantial fertility decline in high-income settings, and increased numbers of unwanted pregnancies in low-income settings. Planetary overpopulation continues to threaten ecological sustainability.
More people are on the move than at any previous point in human history. Much of this movement is internal migration, often rural to urban or internal displacement. Some is facilitated international migration, but an increasing amount is forced migration (in response to conflict, environmental degradation, and threats to livelihoods), while some involves asylum seeking or refugee claimants as defined under international law10. The rise in forced (informal) migration has increased its criminalization and dangers, the erection of border barriers (including armed walls), the creation of huge settlement camps (particularly in LICs where most forced migrants are located), and politically motivated racist rhetoric by some of the world’s most powerful leaders fomenting increased xenophobia and hate crimes. There are a declining number of countries willing to take refugees. Some countries cautiously accept refugee claimants and asylum seekers. But over 65 nations are taking measures to exclude refugees, those 66 million international migrants whose flights from their homelands are considered to be ‘forced’ by immiseration, drought, conflict, or all three. Tens of millions more become internally displaced, housed in massive refugee camps located in LMICs that lack the resources to provide for them. The conditions in these camps makes the pandemic spread more likely: crowded conditions, limited water or sanitation facilities, and no intensive care for those with severe COVID. With wealthier donor countries are reducing foreign aid budgets to cope with their own domestic pandemic bailouts or recoveries, cuts to food aid are leading to extreme hunger for those trapped within refugee camps11. The threats to the health of these migrants are clear.
HICs with an aging population are sometimes urged to accept more migrants from LICs with a youthful population based on a ‘win/win’ argument: reduced population pressures and poverty in LICs and a replenished working age portion of the demographic pyramid in HICs. This argument is based on conventional economic modelling of dependency ratios (the number of older people [aged > 60 or > 65]/ the number of working-age adults [aged 15–64]). The WHO Global Report on Ageing 12notes this conventional modeling is ageist as it assumes that all older people are dependent. In low-income countries, for instance, approximately 50% of those aged 65 years and over are in the labour force. In the G7 countries, in the decade before COVID-19, people aged 50 years and over drove 100% of employment growth.
Declining employment options and the requirement for a continuous growth in working age population to sustain an expanding older population question its longer-term relevance or ecological sustainability. UN-led efforts to seek agreement on a ‘managed migration’ compact remain tenuous13. Post-COVID-19, when growth will be needed, a focus on healthy ageing to achieve a longevity dividend needs to be a priority. The UN has declared the decade from 2021- 2030 The Decade of Healthy Ageing14.
Challenges to the dominant ‘growth’ oriented global economy are not new but are gaining a new urgency in the face of unsustainable patterns of growth. Some of the alternative models that have been proposed include: steady state economics15 ‘doughnut’ economics’16, in which financial policies and practices should be assessed for their human socio-health and ecological ‘overshoot’ impacts (similar to a Health in All Policies approach); policies to promote circular economies17, in which waste is reduced and resources continually reused to minimize environmental impacts; and ‘glocalization’, a concept that emphasizes forms of local production/consumption, local exchange currencies, and producer cooperatives to improve democratic accountabilities and lessen environmental damages. Modern Monetary Theory has also challenged the idea that government debt is necessarily bad and in fact is important to nation-building activities. Collectively, such ideas are sometimes referred to as ‘degrowth’ economics, and often include incorporation of new national account measures based on human wellbeing, ‘prosperity’, and/or a sustainability development index rather than on GNI growth per se. The health impacts of different economic systems need to be assessed as a part of their value18.
Shifts in the distributions of political and economic powers amongst countries and regions are outcomes of post-1980s globalization. Enabled by trade and investment liberalization agreements originally led by the World Trade Organization (WTO), economic interdependencies between countries increased. The 1990s through the early 2000s were characterized by the creation of global production chains, increasing employment and economic growth in many low- and middle-income countries (albeit unequally distributed) while decreasing manufacturing and services employment in many high-income countries. Increased liberalized financial flows and under-regulated derivative investments and banking rules increased macroeconomic instabilities, culminating in the 2008 global financial crisis. Concerns with rising government debt partly consequent to the 2008 crisis led to widespread fiscal austerity that replicated many of the requirements of earlier IMF/World Bank structural adjustment programs. Past and present fiscal austerity measures, either as conditions on new IMF loans to governments or undertaken voluntarily, have negative health impacts, particularly in low- and middle-income countries (LMICs), but also in high-income countries (HICs), and for poorer populations within countries. Economic growth globally, and in most countries, has slowed considerably since 2008, creating economic and political uncertainties. The COVID-19 pandemic has created new threats to prosperity and threatens to see countries going backwards in terms of meeting the SDGs by 2030.
The rate and direction of economic change has led to a rapidly growing area of enquiry – the commercial determinants of health which examines the ways in which business interest, especially trans-national corporations have a negative impact on health. The size and power of transnational corporations also continues to increase; 78 of the top 100 economic entities are now TNCs.
The first, and most notable, outcome of geopolitical shifts in economic and political power and influence has been a slow erosion in the multilateralism that has characterized global governance. In the face of sluggish economic growth and increasing competition for consumer markets, multilateral trade rules are being supplanted by bilateral and regional trade and investment agreements in which more powerful states are able to negotiate rules that favour their economic or political interests. Regional agreements, such as the new African Continental Free Trade Agreement (AfCFTA), could lead to more equitable development outcomes, although much will depend on the extent to which such agreements emphasize social and political development and not just commercial/economic growth. A further issue is extent to which the asymmetries in power and size between countries in regional agreements are explicitly managed in the texts of such agreements. An on-again/off-again trade war between the USA and China is becoming a defining geopolitical feature with implications for the economic stability (or instability) of many of the world’s countries, and how this might ‘trickle down’ to affect health and health systems.
Past history shows that global disasters on the scale of the COVID-19 pandemic bring a huge imperative for innovation19. This pandemic was the first where the rapid deployment of technology, and specifically digital technology, became a core component of the race to understand, contain and deliver a potential solution.
It was an artificial intelligence (AI) algorithm that first alerted much of the world to COVID-19 on 31 December 2019 and went on to successfully predict 10 of the first 12 cities to be impacted.20 Primary care and outpatient hospital care had long held the promise that they could largely be delivered digitally but COVID-19 precipitated this with many countries forced to adopt a digital-first approach. The vaccine industry underwent a paradigm shift in technology delivering a viable mRNA vaccine within one year when previously timelines had been closer to one decade.
Some of these technologies are likely to evolve to play a permanent role in health beyond COVID-19. New vaccine technologies have the potential to revolutionise how humans fight infectious disease and offer potential solutions for other huge killers, such as malaria, which have so far eluded us. Telehealth can make care more efficient and coordinated and has the potential to bring expert care to underserved areas of the world. AI can help us prevent the next pandemic and develop new and more effective treatments.
Despite the progress, almost most half of WHO member countries do not have a health technology policy and lack of standards for data protection, privacy and security as well as the conditions for data sharing risk slowing or reversing progress.21Whether the technology trend from COVID continues depends on the role of governments in leading, empowering and regulating technologies.
Ultimately, these technologies have the potential to accelerate the achievement of the SDGs and the world we want for many but also risk driving further health inequity by excluding those who don’t have access to them, either due to cost, access or knowledge.
Increasing the ability for a health system to withstand and effectively respond to shocks and stressors is critical to achieving a position from which to address effectively to future pandemics and to maintaining progress to date on the world’s global health goals. To be resilient, health systems must be flexible enough to adjust resources, policy, and focus in response to constantly emerging challenges. USAID22 recognizes the need to build resilience to acute, time-bound events such as disease outbreaks, as well as to longer-term dynamics such as protracted population displacements, weak government authority or legitimacy, population pressure, social exclusion, and climate variability. The type, intensity, and number of overlapping shocks and stressors cannot always be predicted, but the fact that there will be shocks and stressors can. In many countries, health systems are unprepared for these inevitable events, whether unexpected external crises or internal governance challenges such as shortages, or payment delays.
Primary Health Care (PHC) is vital to the task of building strong health systems. The exact nature of PHC is a matter of debate. WHO has recently revitalized its support for PHC23 and while this was widely welcomed some flaws have been highlighted 24as the Astana Declaration does not see PHC as an organizing principle for a health system and as having a role in supporting and advocating for intersectoral action. Further the critique noted that the positioning of PHC as part of Universal Health Coverage it supported private sector activity which was often likely to be too the detriment of a strong public health system. The importance of strong public health systems has been shown in many ways during the COVID-19 pandemic25.
UNAID’s recent paper on health systems in 2030 has describing them as having to be absorptive, adaptive, and transformative in order to cope with times of crisis Absorptive capacity relates to the existing ability of a health system to take intentional protective action and to maintain stability in the face of known shocks and stressors to prevent or limit negative impacts. Adaptive capacity is the capacity of the health system to make incremental and flexible adjustments in order to better manage a changing environment while improving overall system performance. Finally, transformative capacity refers to the ability of the health system to make fundamental functional and structural changes that address underlying challenges and contextual dynamics which impact performance and progress toward health outcomes. Other work has stressed the importance of effective community participation in the design of health systems26 and the need to build strong public systems that are most effective at ensuring equitable access and outcomes. The importance of community health workers27,28 is also evident.
Nearly everyone and most organisations agree with the SDGs and the Paris targets on global warming. They offer a comprehensive vision for the world. However, there is considerable disagreement about how these goals are to be achieved. These disagreements are likely to have shifted over the course of the COVID-19 pandemic. The pandemic has opened up a bigger space in which to envision different ways of achieving the SDG and climate goals. Broadly speaking there are three categories of responses to the question of how to achieve the SDGs which are evident in national and global debates. These can be represented on a continuum.