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Germany might be on its way to filling the void left by the U.S. in global health. But it’s not going to admit it.
In the wake of U.S. President Donald Trump’s confirmation that the U.S. will exit the World Health Organization — leaving a gaping financial and political hole in global health — Germany is trying to step up to the plate.
Weeks after the Trump administration formally notified the United Nations of its withdrawal from the WHO, German Health Minister Jens Spahn took to the stage in Geneva, flanked by French Health Minister Olivier Véran, and announced a €200 million increase in German funding. The cash injection would put Germany’s contributions at around €500 million — an amount exceeded in the last two years by only the U.S.
Although the U.S. is an important partner to the WHO, it can be replaced, said David Heymann, an epidemiologist who headed the WHO’s response to SARS in 2003. “Germany has become a very important partner in global health recently and other countries are stepping up as well,” he said shortly after Trump’s announcement.
It’s not just cash that Germany is funneling into global health. It's also determined to be the voice of reason in shaking up the WHO post-pandemic. A case in point: While Germany and France abandoned talks over an American proposal for reforms at the WHO, they penned their own plan to strengthen the organization.
Pitching for 'more WHO'
The two nations recently made the pitch for a beefed-up WHO in a blueprint, reported by Reuters last week, that would give the global body more legal powers while boosting mandatory payments from member countries.
Spahn, who has continued on the path forged by the similarly-minded Hermann Gröhe (as POLITICO predicted Germany would do in 2017), isn’t afraid of claiming at least some of the credit for the WHO’s recent decision to launch an independent review to evaluate the pandemic response performance. The Council of the EU presidency under Berlin has been an important vehicle through which Spahn can amplify his message that the WHO could “only be as good as member states let it be.”
Back at home, Germany’s new global health strategy is also being drawn up and set to be published later this year. Progress on the domestic front is already being made, argues a 2019 BMJ editorial, with Germany establishing a sub-committee on global health in the German parliament; increasing the budget for global health in several ministries; and establishing new centers for global health at some universities.
More broadly, Germany is trying to lead by example, said Anna Holzscheiter, professor of political science at the Technical University of Dresden and head of the research group on global health policy at the Berlin Social Science Center. She points to its increased contributions to the WHO and its willingness “to finance hugely unpopular areas [in the WHO] such as health system strengthening, monitoring and evaluation.”
At the same time, Germany has managed to walk the tightrope between swearing its allegiance to the WHO and criticizing it. Spahn even admitted that Trump “does have a point” on the need for reforms at the WHO. In a similar vein, what his predecessor Gröhe wants to see is the strengthening of the WHO's core capacities, including an evaluation of the 2005 international health regulations and whether there is enough progress in the implementation of this legal framework.
“You need to spend money for the fire brigade in peacetime, not only when the house is burning,” said Gröhe.
Calling for change is also in line with Germany’s calls for the WHO to be strengthened, say some WHO watchers.
“Strengthening ... also means that you look at the weak parts of the organization, how this can be improved,” said Detlev Ganten, founding president of the World Health Summit and former CEO of Berlin’s Charité university hospital.
A long time coming
As Ganten sees it, Germany has the opportunity under its Council presidency to work with the rest of Europe to exert some influence on global health. “Before the pandemic situation, global health was not considered as important as it is now,” he said.
But well before the pandemic, Germany was shoring up its clout in global health under the leadership of Chancellor Angela Merkel, with Gröhe, Merkel's close confidant, being instrumental.
"Germany has a long tradition in respecting its international responsibility," explained Gröhe on why global health became so important. "After World War II, the whole comeback of German international reputation or responsibility was in a very non-military way."
What kickstarted Gröhe's focus on global health was antimicrobial resistance and Ebola. In 2015, when the G-7 met in Bavaria in Germany, the Ebola outbreak in West Africa was fresh in their minds, prompting leaders to promise support for health systems. The G-7 also endorsed the WHO's action plan on antimicrobial resistance.
“It was a lot of lobbying,” he admitted, when speaking of Germany’s efforts to get global health on the agenda of the G-7 and G-20.
Perhaps most significant was Germany's decision to put health policy on the G-20 agenda in 2017. That year, Germany hosted a fundraiser for antimicrobial resistance research and helped draft a declaration from the G-20 health ministers that put the issue center-stage, with the ministers pledging that the G-20 was "well-placed to contribute to joint commitment and action in close cooperation with the WHO."
“It had never happened in that forum before 2017,” said Caroline Schmutte, the lead of the Wellcome Trust’s office in Germany. Since then, Germany has been “really continuing down the path funding and advocating for global health from the very top,” she added.
Ilona Kickbusch, an external WHO adviser and founder of the Global Health Centre at the Graduate Institute of Geneva, describes this shift as a "big reshuffle," with the pandemic creating a space for "middle powers," such as Germany, to move in.
All the same, experts are wary of asserting that it could be an outright replacement.
“It will be difficult to fill [the gap] ... both in terms of the financial contribution and then, of course, in geopolitical terms,” said Holzscheiter.” Unlike the U.S., she argues, Germany doesn't have aspirations to be a global superpower even though it's “on the best way to become” a top global health leader.
Gröhe is also cautious. Germany is a strong power and has clear global responsibility, Gröhe said, but he doesn’t see it replacing the U.S. “We need an international approach,” is Gröhe's assessment.
‘Germany hates doing things alone’
What perhaps best explains Germany’s reluctance to take the reins on its own is its commitment to multilateralism, which is vital for these “middle powers,” explained Kickbusch.
The country’s federal system, where power is distributed to states, has meant that multilateralism is in the “DNA of Germany,” said Kayvan Bozorgmehr, head of the department of population medicine and health services research at Bielefeld University. But he worries that this multilateral world is “increasingly under attack.”
“The question is — to which direction does this trend go? Towards stronger nationalism?" asks Bozorgmehr. "Or can we actually manage to revive the multilateral system and keep it alive and strengthen it?"
A telling recent example was the chaotic start of the pandemic, when tensions in Europe over access to limited personal protective equipment reached fever pitch. Germany banned exports of face masks and other protective equipment; Italy stopped any exports of personal protective equipment without prior authorization; and the Czech Republic asked local producers to keep their masks in the country.
Europe was hardly alone in this respect. Across the Atlantic, the U.S. was accused of alleged “modern piracy” of face masks; it attempted to buy German vaccine maker CureVac and it hoarded the world’s stock of remdesivir.
But Germany then changed course and admitted that the export ban had backfired. Sick patients from Italy and France were also brought to Germany for treatment.
The way Wellcome’s Schmutte sees it, two trends emerged from the pandemic: The “my country first” approach and the collaborative one.
“The COVID-19 pandemic has clearly caused some nations to look more and more inside to think about global health in a much more nationalistic way,” she said. But other countries, including Germany, are working hard to ensure that "multilateralism actually really stays at the core of how we approach global health." As examples, she pointed to countries working to finance solutions to the pandemic together and researching with openness and dialogue.
Germany also isn’t alone in its efforts to increase its standing on global health.
“It's also states like China that have aspirations to step in,” warned Holzscheiter. And private foundations such as the Bill and Melinda Gates Foundation and the Wellcome Trust are “already knocking on the door,” she said.
Kickbusch points to the EU and the Commission in particular as entities that also show ambitions in this area. India, Australia and France are other “middle powers” that have become more active in the global health fronts, she said.
“There is a shift happening. And we'll have to watch that," said Kickbusch.
So far, in the face of the rise of nationalism, as countries assert that development funding would be better spent at home, Germany has shown a broad political consensus at home over the importance of global health funding.
"There's been a lot of agreement in both the governing parties, but also opposition parties, that this is a global challenge, that it needs a global approach to it," said Schmutte. "The belief in multilateralism cuts across many parties and members of the government."
All the major political parties in Germany agree that this is “not a national question, it’s an international question,” echoed the World Health Summit’s Ganten. “And there's a very strong feeling in politics, in business in the private sector, civil society. There's no real opposition.”
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