Brazil’s G20 leadership offers glimmers of hope for global health equity

On 31 October 2024, the G20 health ministers met in Rio de Janeiro, Brazil, following a series of preparatory meetings held throughout 2024. A recent series in The BMJ suggested priorities for Brazil’s G20 leadership.123 Brazil is taking this opportunity to advance global health diplomacy, but its leadership will need to go beyond formal declarations to address health inequity from a global south perspective.

The Rio meeting produced two unanimously adopted declarations. The main, more general, one4 revisits elements from the G20 health declaration issued in 2023.5 These goals include building “more resilient, equitable, sustainable, and inclusive health systems” and implementing universal health coverage in the short term, and reaffirming commitments to the sustainable development goals. The 2024 version introduces new sections on health workforce shortages inequities and the problem of post-covid syndrome, which are welcome additions to overcoming pandemic inequalities.

The declaration’s highlight is the launch of the Global Coalition for Local and Regional Production, Innovation, and Equitable Access, with Brazil serving as executive secretary and chair. Its goal is to overcome existing vaccine inequities by strengthening local manufacturing capacities to meet the need for access to technologies for neglected diseases and people “in vulnerable situations” and during health emergencies.4 However, state participation is voluntary, lacks enforceability, and broad funding is absent, limiting prospects for success.

This initiative nevertheless represents a noteworthy recovery for Brazil. It marks the revival of the country’s global health leadership after former president Jair Bolsonaro’s administration oversaw one of the world’s worst responses to covid-19.6 Seeking a prominent role in “vaccine diplomacy,” Brazil now aims to reduce the dependence of low and middle income countries on high income counterparts for vaccine manufacture and access to prevent repetition of the vaccine apartheid that occurred during the covid-19 pandemic.

The second declaration jointly focuses on climate change, health equity, and the One Health approach, with particular attention to antimicrobial resistance.7 This emphasis reflects a growing recognition by signatories of the importance of the interplay between environment and health.

The current G20 health meeting’s silence on war is a major shortfall. The 2023 G20 health document explicitly condemned Russia’s aggression against Ukraine, noting China’s and Russia’s dissent in a footnote.5 This year, however, the lack of consensus among G20 members regarding the situations in Ukraine and Gaza leaves these crises unacknowledged, mentioned only vaguely in a separate comment issued by Brazil.8 As such, the world’s largest economies reaffirm their shameful indifference to the massacres of civilian populations and the ongoing destruction of healthcare systems in these regions.

Although the effectiveness of high level declarations alone is often low, we recognise the value of the G20 health summit’s efforts to establish a common agenda among vastly heterogeneous countries. The reiteration of previous commitments to global health equity and climate action is all the more urgent given the results of the 2024 US presidential election, which saw the country move far right in its leadership. Under Donald Trump’s second presidency we are likely to see withdrawal of the US from the World Health Organization and the Paris Agreement on climate change, as well as funding reductions for global health programmes,9 amid a resurgence of anti-science and anti-public health ideology.10 In this context, the leadership of global south countries, including Brazil and South Africa, which will chair the G20 in 2025, is even more critical.

Global south leadership must advance the idea that geopolitical challenges are intertwined with, and can be informed by, local experience and innovations. These were evident in the crucial lessons learnt during covid-19 from local communities: the importance of local knowledge and practices of Indigenous, migrant, and favela communities, despite being largely excluded from international and national approaches to health emergencies.11 The pressing need to integrate food supply chains into healthcare systems must also be recognised.1 In light of this, it is disappointing that food justice and hunger are absent from the G20 health declarations; these issues should be central to future commitments and action plans.

Meanwhile, the G20’s focus on vaccines and other technologies, while serving an essential role, remains insufficient. Pharmaceuticals and epidemiological surveillance are not magic bullets; they must be grounded in social justice approaches to ensure that they do not reproduce inequalities, especially during pandemics. Health governance models that incorporate universal social protections and social participation, such as Brazil’s universal healthcare system (SUS), are thus crucial for effective health emergency responses; governments should certainly should not assume that community initiatives will fill the gaps. States must resume their responsibility for, and responsiveness to, meeting social needs of marginalised communities and throughout their jurisdictions. If these roles are left to philanthropic players, inequity will only deepen.

With next year’s G20 health summit again hosted in the global south, we are cautiously hopeful that its leadership can move beyond formal declarations to tackle global health inequities at their core.