Building forward better
Authors: Keith Martin, Zoë Mullan
Journal: The Lancet Global Health (2021)

The SARS-CoV-2 pandemic has challenged us all. It has tested every nation's public institutions and political leadership. Some countries, like Taiwan, New Zealand, and Vietnam, have shone. Others have been found wanting.1Leng A Lemahieu H Covid Performance Index: deconstructing pandemic responses.https://interactives.lowyinstitute.org/features/covid-performance/Date accessed: February 22, 2021Google Scholar But any crisis is an opportunity. For every country, this is a chance to build forward better; to not only become more effective at addressing future disease outbreaks, but vitally to strengthen the public institutions that underpin the effective delivery of a broader list of public goods: the rule of law, protection of human rights, a healthy environment, an effective tax system, infrastructure, housing, education, and—yes—health. Why is this important? If you examine development outcomes over time, the countries that achieved the greatest improvements strengthened these structures. For example, from the early 1960s, Botswana, Taiwan, and South Korea strengthened their administrative capabilities and exercised good governance and competent management. This enabled them to capitalise on their areas of competitive advantage. It has resulted in significantly improved socioeconomic outcomes for their citizens. Those that did not strengthen these structures chronically occupy the bottom of the UN's Human Development Index.2United Nations Development ProgrammeLatest Human Development Index ranking.http://hdr.undp.org/en/content/latest-human-development-index-rankingDate accessed: February 22, 2021Google Scholar Enhancing public administrative capabilities, not only in ministries of health, but also in finance, justice, public works, education, security, election oversight, and the environment will enhance the administrative foundation that girds any stable nation. One place to start would be to strengthen academic training programmes, including those that incorporate an element of international experiential learning. Most academic global health programmes in high-income countries (HICs) have partnerships with institutions in low-income and middle-income countries (LMICs). Via these arrangements, HIC students can gain short-term experiences in global health,3Lasker J Aldrink M Balasubramaniam R et al.Guidelines for responsible short-term global health activities: developing common principles.Globalization Health. 2018; 14: 18Crossref PubMed Scopus (38) Google Scholar and HIC researchers conducting studies in LMICs can acquire valuable skills and access to study populations. The often resource-constrained host institution often gets very little out of these "partnerships".4Kenworthy N Thomas LM Crane J Introduction: Critical perspectives on US global health partnerships in Africa and beyond.Med Anthropol Theory. 2018; 5: 2Google Scholar Herein lies an opportunity. Partnerships between HIC and LMIC academic programmes should be structured so that the LMIC institution gains substantial, long-term benefits from the collaboration. This could take many forms. HIC institutions could provide trainers, curricula, free access to their libraries and journals, funds to strengthen critical infrastructure (eg, access to broadband), assistance in grant writing, and reciprocal training opportunities as requested by the host institution. Durable, long-term benefits to the LMIC institution should be mandatory in any HIC–LMIC global health collaboration. It is important that these efforts include not only biomedical disciplines, but also public administration, management, finance, law, and engineering, which have too little presence in global health despite their importance to sustainable development.5Gostin LO Monahan JT Kaldor J The legal determinants of health: harnessing the power of law for global health and sustainable development.Lancet. 2019; 393: 1857-1910Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar Strengthening LMICs' training programmes will increase the pipeline of trained professionals needed to manage the delivery of public services.6United Nations Development ProgrammePublic administration reform practice note.https://www.undp.org/content/undp/en/home/librarypage/capacity-building/public-administration-reform-practice-note.htmlDate accessed: February 22, 2021Google Scholar, 7UNStrengthening the role of public institutions in poverty eradication and sustainable development.https://publicadministration.un.org/Portals/1/REPORT%20Poverty%20Eradication%20webinar_16%20Oct.pdfDate accessed: February 22, 2021Google Scholar, 8IMFRole of capacity building in poverty reduction.https://www.imf.org/external/np/exr/ib/2002/031402.htmDate accessed: February 22, 2021Google Scholar This will also address another key development challenge: generating the revenues needed to pay for these services. Discussions about who pays for development programmes usually gets mired in a shop-worn debate over how much HICs will contribute to these efforts. But aid does not emancipate nations from poverty and instability. It is certainly essential in funding humanitarian emergencies, multilateral organisations, and as partial support to LMICs, but it is no substitute for the power domestic revenue generation plays in creating financial independence. Official Development Assistance, which in 2019 amounted to US$152 billion,9Xu K Soucat A Kutzin J et al.Global spending on health: a world in transition.https://www.who.int/health_financing/documents/health-expenditure-report-2019/en/Date accessed: February 22, 2021Google Scholar, 10OECDOfficial Development Assistance.https://www.oecd.org/dac/financing-sustainable-development/development-finance-standards/official-development-assistance.htmDate: 2019Date accessed: February 22, 2021Google Scholar is vastly less than the $2·5–3·0 trillion per year the UN estimates is needed to fund the Sustainable Development Goals (SDGs) in LMICs.11Roadmap for Financing the 2030 Agenda for Sustainable Development: 2019 to 2021.www.UN.orgGoogle Scholar Training and retaining a cadre of professional public servants who can manage a transparent tax system will enable LMICs to capitalise on their often extraordinary national wealth and pay for the public goods their citizens are seeking. Across more than 40 breakout sessions, seven plenaries, 30 satellite sessions, and 700 posters, the Consortium of Universities for Global Health (CUGH) 2021 annual conference, Addressing Critical Gaps in Global Health and Development, held online on March 12–14, tackles multiple global health challenges. Naturally the SARS-CoV-2 pandemic is featured prominently in the programme, but so are other critical issues including: non-communicable diseases, the social determinants of health, gender inequity, existing and emerging infectious diseases, capacity building, racism and colonialism, climate change, pollution and biodiversity loss, one health, poverty, war, and conflict. The popular Pulitzer Center communications workshop and Global Film Festival continue. Multiple awards will be presented virtually, including the Lancet student poster awards. The SARS-CoV-2 crisis is an opportunity to reform how we practise global health; to focus on the countries and communities in greatest need; and to collaborate humbly, transparently, and respectfully to strengthen the public institutions essential for sustainable development and state stability. We have a chance to build forward better. It is one we must not miss. We declare no competing interests.