The Global Health Summit was held in Rome on 21 May 2021, co-hosted by the European Commission and Italy, as chair of the G20. Leaders, heads of regional and international organizations met to share lessons learned from the COVID-19 pandemic and to define the path ahead.
The present paper analyses the Rome Declaration as the first global health programme shared among the G20 Member States and based on the One-Health approach.
Documents such as preparatory work, official documents and observations from international organizations were analysed in order to provide a comprehensive review of the Rome Declaration.
Core principles of the Rome Declarations have emerged as well as the goal to improve cooperation among existing international organisations and national authorities.
Governments’ future decisions will be the key to determine the end of the pandemic. The interconnected impacts on health, the environment, and social and economic dimensions will be a central theme of the overall narrative aiming at bringing the G20 process towards achieving a more inclusive and sustainable society.
1.The origins of the G20 Health
The Group of Twenty (G20) was established in 1999 in Berlin, when the world’s leading industrialised and emerging economies met in an international forum; the goal was to further multilateral discussions on policy issues relating to the promotion of international financial stability, and since 2008 it has envisaged a final summit, with the participation of Heads of State and Government. The Presidency rotates every year and is responsible for proposing the topics that are included in the Summit agenda. Each year, the Presidency invites a number of other countries, which fully participate as guests in the work of the G20. Several international and regional organisations also take part in the G20, as well as engagement groups; the participation of the latter represents an important opportunity for the civil society to make recommendations to governments on the G20 Agenda’s issues.
In fact, the main characteristics are the intergovernmental nature of the preparatory process, its informality, and its ability to discuss and quickly find commonly agreed solutions to major global issues. In addition to the Summit, ministerial meetings, meetings of the Sherpas (responsible for conducting negotiations and facilitating consensus among the Leaders), also working group meetings and special events take place during the year of the Presidency.
In 2016 in Hangzhou, China, global health was reflected in the action plan for the 2030 Agenda.
Also, during the German Presidency in 2017, for the first time the G20 Health Ministers met in Berlin, affirming their role in strengthening the political support for existing initiatives and working to address the economic aspects of global health issues.
After that year, other states taking the Presidency have continued along this path, as confirmed by the subsequent Presidencies in Argentina (2018), Japan (2019) and Saudi Arabia (2020).
The growing awareness of the importance of discussing health issues at an international forum has been heightened by the experience of the pandemic. Health is essential for economic growth and development, and health crises, such as the current COVID-19 pandemic, cause economic instability in affected countries or entire regions of the world. Health threats are therefore directly connected to the G20’s scope of ensuring economic stability and prosperity.
The need for the creation of an interconnected world had already been highlighted by the German Presidency in 2017, through its pillars “Building Resilience, Improving Sustainability, Assuming Responsibility”. Calling on the States to build strong, sustainable and resilient health systems is even more urgent to face and overcome the pandemic.
2.The Italian Presidency’s Agenda and the adoption of the Rome Declaration
The global impact of the COVID-19 pandemic has been devastating, leading to heavy loss of human life and to an unprecedented disruption of public health, food systems, production and availability of consumer goods. As reported by the World Bank, in 2021 more than 100 million people have been in danger of falling into extreme poverty , while the number of malnourished people is growing exponentially .
Regardless of their organisational model and readiness level, healthcare systems all over the world have experienced massive pressure, as the pandemic made it difficult for hospitals to treat patients with COVID-19 and at the same time slowed down the treatment of other diseases. Therefore, health strategies must be focused on a new sustainability model: urgent action is needed to strengthen the social and health systems to promote the well-being of every person through a “transformative resilience” approach, achievable by implementing the principles of sustainability, circularity, holistic approach and “One Health”, and by fighting against social inequalities .
Since 1 December 2020, Italy has taken on the Presidency of the G20; the programme is structured around the trinomial People, Planet, Prosperity; it is based on the need to identify and implement the current global responsibilities, in order to provide equitable, worldwide access to diagnostics, therapeutics and vaccines – while building up resilience to future health-related shocks.
The Italian Presidency has also focused on the need to ensure a rapid recovery that addresses people’s needs, and at the same time to rebuild differently in the aftermath of the crisis, that is, through a better use of renewable energies and with a firm commitment to protecting our climate and our common environment.
A flourishing future also calls for a proper use of the main drivers of growth and innovation. This is why the Italian Presidency has also worked on bridging the digital divide and making digitalization an opportunity for all.
All of these goals cannot be reached without ensuring international cooperation. Therefore, the Italian government in collaboration with the WHO and other International Organisations, scientists, academic institutions, and global multilateral solidarity actors have discussed the lessons learnt from the pandemic and the steps to be taken in order to identify the way forward.
While building on the legacy of previous G20 presidencies, the Italian Presidency has proposed four areas of intervention:
monitoring the global health impact of the COVID-19 pandemic, with a detailed assessment of its consequences on the implementation of the SDGs;
defining preparedness plans, starting from the most vulnerable contexts and the less resilient countries;
planning a globally coordinated and collaborative response to health crises and emergencies;
defining common global strategies to support the development and the distribution of treatments and vaccines .
In early January 2021, the above-mentioned Health Issue Note was shared with the G20 health delegates and other members of the Health Working Group (HWG). These areas of intervention served as a starting point for the discussion and for identifying relevant issues, which were then reflected in the final declaration. In fact, starting from that moment, a number of meetings were held to exchange views on priorities, under the coordination of the Italian Presidency. The outcome was the adoption of the Rome Declaration as well as the following documents: the “Position Paper on Healthy and Sustainable Recovery” , the “Call to Action on Building One Health Resilience” , and the “Briefing Paper on Coordinated and Collaborative Response” .
With the adoption of the Rome Declaration, G20 Leaders have ``set out principles and guiding commitments [...]. These serve as voluntary orientation for current and future action for global health to support the financing, building, and sustaining of effective health system capabilities and capacities and Universal Health Coverage to improve preparedness, early warning of, prevention, detection, coordinated response, and resilience to, and recovery from, the current pandemic and future potential public health emergencies. These mutually reinforcing principles reconfirm our commitment to global solidarity, equity, and multilateral co-operation; to effective governance; to put people at the centre of preparedness and equip them to respond effectively; to build on science and evidence-based policies and create trust; and to promote sustained financing for global health'' .
2.1.Priority one: Monitoring the global health impact of the COVID-19 pandemic, with a detailed assessment of its consequences on the implementation of the Sustainable Development Goals
The first priority looked at the consequences that COVID-19 has had on societies, with a particular focus on the Sustainable Development Goals set in the 2030 Agenda. It has been highlighted that the pandemic has made the prospects of achieving several key SDGs remote, as inequalities increase between and within countries, leaving the poorest and most vulnerable further behind . In addition to SDG3 (ensure healthy lives and promote well-being for all at all ages), many other SDGs have a direct or indirect connection with health, determinants of health, and effective use of health services, such as SDG 2 (ending hunger, achieving food security and improved nutrition), SDG 4 (equitable and inclusive access to quality education), SDG 6 (access to water and sanitation), and SDG 11 (improving urban environments) . Moreover, in many countries the initial response to the pandemic did not pay adequate attention to the potential significant disruption of essential services, such as the provision of routine immunization, non-communicable diseases diagnosis and treatment, family planning and contraception, treatment for mental health conditions, and cancer diagnosis and treatment. Such gaps include an over-reliance on hospital care when the enhancement of primary care could have had the effect of reducing the pressure on hospitals, an under-investment in public health capacities, limited laboratory capacities, fragmentation in information systems and failure to address the needs of vulnerable populations.
These challenges need collective answers; the outcome of the discussion of the Health Working Group stressed the idea that expenditure on health should be regarded as an investment rather than a cost, and that equity and equality should be at the centre of a healthy and sustainable recovery in order to ensure that “no one is left behind ”.
Feasible and applicable emergency preparedness plans shall be pursued through supply chain security, a powerful, interoperable, integrated and real-time surveillance system with faster and transparent flow of information and data; empowered, and digitally literate, trained personnel; innovative digital infrastructure; multi-sectoral governance with effective vertical and horizontal communication; transparent and timely risk communication and effective international cooperation . Overall, two conclusions can be drawn from the G20 discussions on this topic, as highlighted in the Briefing Paper:
the importance of cooperation between states in order to share experiences and values;
the understanding that knowledge must lead to policy change and improvement to make health systems more resilient with a focus on public health .
2.2.Priority two: Defining preparedness plans, starting from the most vulnerable contexts and the less resilient countries
The second priority takes into consideration the fact that most known epidemics and pandemics have originated from animals, i.e. SARS in 2003, the H1N1 pandemic in 2009, the 2014 Ebola outbreak in West Africa, Zika in 2016, and now the COVID-19 pandemic . The developments brought by the last centuries have put significant stress on our ecosystems and societies. Firstly, changes in exploitation practices such as largescale deforestation, extraction of oil, gas and mineral resources, the intensification of agriculture and livestock production, and the overuse and misuse of antimicrobials have highlighted the interconnectedness of human, animal and environmental health.
Additionally, climate change as well as the degradation and impoverishment of our ecosystems are exacerbating biological risks, provoking the loss of habitats and biodiversity. The interconnected and fast-paced world in which we are living also makes it easier for outbreaks to spread rapidly.
Moreover, many of the Emerging Infectious Diseases (EIDs) are localized in low- and middle-income countries, with limited capacity to detect, prevent, and respond to such risks. In fact, this signal may remain unrecognized without strong healthcare, monitoring, and early warning systems, allowing the disease to proliferate.
The G20 have committed to build a strong holistic evidence-based One Health approach to prevent and address risks emerging from the human-animal-environment interface. These undertakings were also expressed in the “Call to Action on Building One Health Resilience ” adopted by the G20 Presidency in collaboration with WHO, FAO, OIE and UNEP, that have identified the following key actions:
Political commitment for long-term investment to build and strengthen resilient healthcare and agri-food systems, including full implementation of, monitoring of and compliance with the IHR;
Promoting a science-based holistic One Health approach, thereby preventing and addressing food safety risks, risks from zoonoses, and other health risks in the human-animal-environmental interface;
All-inclusive and operationalized cross-sectoral coordination and cooperation;
Concrete projects to be carried out that tangibly reduce the health risks at the human-animal-environment interface following evidence-based guidelines, such as investing in further development and enhancement of inter-operable early warning information, surveillance and trigger systems, as well as investing to reinforce surveillance and analyse early signal and data.
2.3.Priority three: Planning a globally coordinated and collaborative response to health crises and emergencies
With regard to the necessity of assessing a coordinated and collaborative response to health emergencies, it has been highlighted that there are three areas that deserve consideration for the potential outcomes in terms of both ability of health system to handle crises and potential returns on investment.
Firstly, a great opportunity is represented by digital technology; digital technologies foster continuous adaptation to the health needs of the population, with timely allocation of resources. Digital access and technologies are essential in the real-time training of frontline health personnel. In these uncertain times, it is essential to share the use of digital health tools to support countries’ response to the pandemic and be prepared for the post-pandemic phase and possible future emergencies.
Secondly, G20 Countries have recognised the importance of promoting mechanisms to strengthen the supply and equitable distribution of a global health workforce. In fact, the COVID-19 crisis has shown the importance of investing in this field; G20 Countries have also raised the chance to create a pool of cross-disciplinary groups, quickly deployable nationally, regionally and internationally .
Thirdly, and with reference to the shortage of essential health goods during the pandemic, the need has been discussed to create a supply chain network to prioritise critical supplies of essential medicines and equipment .
In the Briefing Paper on Governance in Health Emergency Situations , the “whole-of-government” and “whole-of-society” approaches to pandemic response have been emphasised. Overall, two main conclusions can be drawn from the G20 discussions on this topic:
the importance of continuous learning and sharing experiences;
the value of sharing the collective G20 experience as an engine for policy change .
2.4.Priority four: Defining common global strategies to support the development and the distribution of treatments and vaccines
During the G20 great attention has been paid to the need for common global strategies to support the equitable access to control tools (vaccines, therapeutics and diagnostics - VTD), with the goal of ending the COVID-19 pandemic, as well as being ready to face future potential public health emergencies . Coordinated efforts in research for developing and producing new medicines and vaccines will reduce the time needed for these processes to be carried out; it is important to give a rapid response to face the rapidity of the virus’s spread. One of the priorities is to provide frontline workers responding to COVID-19 with personal protective equipment as well as essential medical supplies, while continuing to invest in COVID-19 Tools-ACT and its pillars: diagnostics, treatment, vaccines, and health system strengthening .
Also, as was highlighted during the G20, research on vaccines must be accompanied by actions to ensure equitable and affordable access to diagnostics, therapeutics and vaccines for all, with a particular attention to vulnerable categories of people. In order to do so and to ensure vaccination acceptance, it is also necessary to rebuild trust in public institutions and experts, through the strengthening of research and guiding public health policies through evidence-based strategies at multiple levels of intervention .
Overall, the key message that has emerged is that universal, inclusive, quality primary health care is key to the prevention and response to health crises . Health systems which have focused more on primary health care (PHC) have demonstrated resilience, being more able to quickly adapt and maintain essential services by rebalancing clinical loads across levels of care, detecting cases early, managing simpler cases close to the community and employing triage to protect hospital capacity.
The most vulnerable communities, such as the ones in remote rural areas, in urban slums and those experiencing conflict and instability , should be at the heart of primary care efforts.
3.The Health Ministers’ meeting in Rome
Principles integrated into the Rome Declaration were taken over by the Health Ministers Meeting held in Rome on 5 and 6 September. During his speech, the Italian Health Minister Roberto Speranza has called on the extraordinary responsibility Ministers of Health are invested with at this particular time. He stressed that the current COVID-19 crisis should be regarded as an opportunity which will allow us to build a better future for the whole world. He recalled the powerful image of Pope Francis praying under the rain in Saint Peter’s Square in the spring of 2020, and his warning: “The only risk in this crisis is to let it go to waste”.
The structure of the meeting included three sessions: the first one dealt with the impact of COVID-19 on the sustainable development goals (SDG) of the 2030 Agenda. The achievement of the SDGs has been threatened by the pandemic, and this is why the G20 Health core message was “to build back better”. Improving health systems on a global, national and local scale, starting from primary care and community medicine, and investing a relevant amount of resources in health and wellbeing will be of capital importance in order to sustain long-term global socio-economic progress and achieve greater shared prosperity. It will therefore be necessary to pursue a recovery which takes into account the lessons learned during the pandemic, adapting them to the SDG context.
The second session aimed at providing specific guidance on these changes. The issues addressed included steps to be taken in order to prevent, be better prepared and respond to future pandemics. In the awareness that the latest health crises have had their main determinant factors in the human-animal-environment interface, one of the key answers provided by the G20 members was the necessity to strengthen the One Health approach, which encompasses in a holistic concept human, animal and environmental health as determinants of human wellbeing. In terms of response, the crisis has first of all brought to light the importance of having solid and efficient health systems, overcoming decades of inadequate investments.
The third session examined the tools which are allowing us to effectively counter the pandemic. G20 members will address identifying the best possible global strategies to support development and equitable access to vaccines, therapeutics and diagnostics. COVID-19 has taught us how scientific research, international cooperation and public-private partnership manage to produce extraordinary results, including safe and effective vaccines in a matter of months. The G20 Ministers will discuss how to ensure the widest possible access to vaccines worldwide, starting from existing collaboration mechanisms, including donation of doses to face the most immediate needs. It will furthermore be necessary to bridge the financing gap of the Access to COVID-19 Tools Accelerator (ACT-A), particularly in the pillars addressing health systems and diagnostics, which will continue to be relevant to the management of the pandemic together with vaccination programmes. The aim is for the G20 Health Ministers’ Meeting to send out a reinforced message of cooperation, solidarity and equity, in the belief that “no one should be left behind”.
4.The way forward
The Rome Declaration has gathered the principles which inspire the fight against COVID-19. While maintaining the WHO’s central role, the goal is to improve cooperation among existing international organisations and national authorities.
How leaders will decide to stimulate the economy in response to the COVID-19 crisis will either worsen global threats or reduce them. This is the moment for worldwide leaders to rise to the challenge of collaborative leadership and work together to find pathways to emerge from this pandemic with a global economic reset. People, animals and the planet must be at the core of this deep transformation for redistribution, regeneration and restoration. Prosperity for people and the planet is possible only if courageous decisions are taken today so that future generations can survive and thrive in a more prosperous world. In order to protect ourselves, and to recover, it is essential not to go back to the way we lived before, neglecting environmental protection and emergency preparedness.
When the COVID-19 pandemic began, national and international surveillance and response systems were not strong or prepared enough to contain the number of infections. As infection started to spread, a lack of universal health coverage left billions of people, including many in rich countries, without reliable and affordable access to medical treatment. Massive inequalities have meant that deaths and loss of livelihoods have been strongly driven by socio-economic status, often exacerbated by gender and minority status.
The “lockdown” measures adopted in order to control the spread of COVID-19 have slowed economic activity and disrupted lives, but have also increased the awareness of how the future should be. Preparation and coordination must encompass government effectiveness, workforce and equipment supply, interconnected platforms to improve research, equitable distribution of therapeutic and preventive counter-measures. Government effectiveness is a key determinant of pandemic outcomes. The intertwined impacts on health, the environment, and social and economic dimensions will be a central theme of the overall narrative aiming at bringing the G20 process towards achieving a more inclusive and sustainable society, supported by adequate investment in a sustainable future: “People, Planet, and Prosperity”.
Conflict of interest
None to report.
World Bank Group [homepage on the Internet]. Washington. COVID-19 to Add as Many as 150 Million Extreme Poor by 2021; 7 October 2020 [cited 2021 Nov. 6]. Available from: https://www.worldbank.org/en/news/press-release/2020/10/07/covid-19-to-add-as-many-as-150-million-extreme-poor-by-2021.
Italian Ministry of Health [homepage on the Internet]. Rome. Health Issue Note [cited 2021 Nov. 6]. Available from: https://www.salute.gov.it/imgs/C_17_pagineAree_5459_0_file.pdf. See, also, ASviS [homepage on the Internet]. Rome. Position Paper 2020 “Salute e non solo sanità” [cited 2021 Nov. 6]. Available from: https://asvis.it/public/asvis2/files/Approfondimenti/PositionPaperGdLGoal3.pdf.
Health Issue note, cit., p. 1.
Italian Ministry of Health [homepage on the Internet]. Rome. Position Paper on “Healthy and Sustainable Recovery” [cited 2021 Nov. 7]. Available from: https://www.salute.gov.it/imgs/C_17_pagineAree_5459_9_file.pdf.
Italian Ministry of Health [homepage on the Internet]. Rome. Call to Action on “Building One Health Resilience” [cited 2021 Nov. 7]. Available from: https://www.salute.gov.it/imgs/C_17_pagineAree_5459_10_file.pdf.
Italian Ministry of Health [homepage on the Internet]. Rome. Briefing Paper on “Coordinated and Collaborative Response” [cited 2021 Nov. 7]. Available from: https://www.salute.gov.it/imgs/C_17_pagineAree_5459_11_file.pdf.
G20. Rome Declaration [cited 2021 Nov. 7]. Available from: https://global-health-summit.europa.eu/rome-declaration_en.
Italian Ministry of Health [homepage on the Internet]. Rome. First Health Working Group Meeting January 26–27, 2021: Concept Note Priority One - Healthy and Sustainable Recovery [cited 2021 Nov. 7]. Available from: https://www.salute.gov.it/imgs/C_17_pagineAree_5459_1_file.pdf.
Ibid., p. 5 ss.
Rome Declaration, cit.
Briefing Paper, cit., p. 12.
Italian Ministry of Health [homepage on the Internet]. Rome. Second Health Working Group Meeting, March 25–26, 2021: Concept Note Priority Two - Building Transformative and Priority Three - Coordinated And Collaborative Response [cited 2021 Nov. 7]. Available from: https://www.salute.gov.it/imgs/C_17_pagineAree_5459_2_file.pdf.
Call to Action, cit. pp. 7–8.
Briefing Paper, cit., p. 7 ss.
Ibid., p. 8.
Ibid., p. 12 ss.
Italian Ministry of Health [homepage on the Internet]. Rome. Third Health Working Group Meeting, June 17–18, 2021: Concept Note Priority Four - Accessible Control Tools Defining Common Global Strategies to Support the Equitable Access to Control Tools (Vtd), including a Continuous Investment in Health Promotion and Disease Prevention to Achieve the Uhc [cited 2021 Nov. 7]. Available from: https://www.salute.gov.it/imgs/C_17_pagineAree_5459_3_file.pdf.
On the access to Covid-19 Tools: WHO | World Health Organization [homepage on the Internet]. Geneve. What is the ACT Accelerator [cited 2021 Nov. 7]. Available from: https://www.who.int/initiatives/act-accelerator/about.
Position Paper, cit. p. 6.
Ibid., p. 5.
Ibid., p. 16.