Covid-19 prompts the EU and the Netherlands to rethink global health

Policy Brief

Covid-19 prompts the EU and

theNetherlands to rethink

globalhealth

NOVEMBER 2021

Never waste a good crisis?

Global health revisited

In the wake of the Covid-19 pandemic,

global health policy has re-emerged on

the global political agenda. The European

Union (EU) and its member states have

increased their budgets, reﬂecting the

need for collective action to address the

pandemic. However, it is less clear to what

1 The authors are grateful for various review

comments by colleagues and external experts.

Funding for this publication was made available

by Cordaid, KNCVTBC and Aidsfonds. The content

falls under the responsibility of the authors only.

The Covid-19 pandemic prompted a strong re-engagement in global health.

Because the pandemic coincided with geopolitical rifts between the US and China,

but required a global response, the EU and its member states took responsibility to

safeguard the World Health Organization (WHO) and initiated global arrangements

for vaccine sharing for developing countries. Within the EU, mandates and global

health functions have traditionally been underdeveloped and divided between the

development and health sectors. For the Netherlands, this is perhaps the case to

an even larger extent. Development funding has focused primarily on sexual and

reproductive health and rights, and the health ministry has had limited interest and

capacity on international health issues, with the exception of certain speciﬁc issues

such as Anti-Microbial Resistance (AMR) and medicine prices. Spending on global

health by both the EU and the Netherlands has been fragmented, with mainly ad hoc

budgets being made available for the international pandemic response. This policy

brief calls for a structural response and more coherent outlook on global health.

extent the crisis has prompted structural

changes linked to a revision of global health

priorities and related ﬁnancial investments

by the European Commission (EC) and the

Netherlands. For health ministries, the added

value of looking at health as a European and

international issue is not automatic. At the

same time, development actors seemed less

focused on public health security interests,

such as improving the early detection of

infectious diseases outbreaks or zoonotic

risks. Rather they focused more on other

issues such as universal health coverage.

This raises the question of what drives this

incoherent and weak proﬁle of the EU and an

EU member state like the Netherlands in the

global health domain, and whether this will

be different now that the EU has experienced

Louise van Schaik, Martijn Haas and Remco van de Pas

Clingendael Policy Brief

the tremendous impacts of a pandemic.

What could be done to make the EU’s global

health efforts more coherent? And what

could the Netherlands contribute to a more

integrated EU approach?

Although the EU and its member states

are, in general, the largest provider of

development aid, the ﬁnancial contributions

to global health have been relatively low

in comparison to other sectors.

From EU

member states, it is mainly Germany that is

a signiﬁcant contributor in this ﬁeld. This is

also apparent in funding for certain Covid-

related initiatives. For example, the European

Commission’s and EU member states’

collective pledge of over 2.5 billion USD to

the COVAX Advanced Market Commitment

(COVAX-AMC) was lower than the 3.3 billion

USD pledged by the US.

Moreover, the

funding is fragmented across many initiatives

targeting different aspects of the global

health agenda. This hinders the WHO’s role

as central coordination organisation in the

ﬁeld of global health policy, even though

the funding from global health initiatives,

such as the Global Fund to Fight AIDS,

Tuberculosis and Malaria and the Global

Alliance for Vaccines and Immunization

2 Pauline Veron and Mariella Di Ciommo, Fit for

Purpose: The EU’s Role in Global Health in the Era

of COVID-19, 2020.

3 GAVI, Key Outcomes One World Protected - COVAX

AMC Summit: Assured Resources for the Gavi

COVAX AMC, 2021.

(GAVI), also pays for some WHO services

for implementing speciﬁc programmes.

Tensions over the initial handling by the

WHO of China’s response to the outbreak

of coronavirus exposed its vulnerability.

European countries and the EU stood up

to safeguard the WHO in response to the

US withdrawing its funding for the WHO.

The EU, moreover, initiated new global

responses, notably the COVAX facility

for joint purchases of vaccines.

Later on,

it proposed a pandemic treaty to prompt

a more coherent approach to pandemics

and prevent new outbreaks. It is not yet

clear how this new instrument links to the

International Health Regulations (2005),

which fall under the auspices of the

WHO and are meant to prompt pandemic

preparedness and responses.

Where is global health on

Europe’s agenda?

Health is perhaps one of the ﬁelds which

is least Europeanised, compared to, for

instance, economic, agricultural, trade and

environmental policies, where member

states are sharing more policy-making

4 Louise van Schaik, Knud Erik Jørgensen and

Remco van de Pas, ‘Loyal at once? The EU’s

global health awakening in the COVID-19

pandemic’, Journal of European Integration 42, no. 8

(16 November 2020): 1145–60.

Table 1 EU global health contributions in comparison

WHO (2018-2019) GAVI (2016-2020) Global Fund (2017-2019)

European Commission USD 131 million (2.33%) USD 243 million (3%) USD 532 million (4.7%)

US USD 893 million (15.88%) USD 1,400 million (15%) USD 3,718 million (32.6%)

UK USD 435 million (7.73%) USD 2,159 million (23%) USD 1,569 million (13.8%)

Germany USD 292 million (5.19%) USD 668 million (7%) USD 814 million (7.1%)

Netherlands USD 55 million (0.98%) USD 304 million (3%) USD 180 million (1.58%)

Sweden USD 77 million (1.37%) USD 198 million (2%) USD 293 million (2.57%)

Denmark USD 14 million (0.26%) USD 11 million (0%) USD 45 million (0.4%)

Source: WHO, Contributors (2018-2019), 2021; GAVI, Annual Contributions and Proceeds 30 June 2021, 2021;

the Global Fund, Data Explorer, 2021.

Note: The % ﬁgure relates to the states’ total share in the organisation’s budget

Clingendael Policy Brief

competences at EU level. This is also

reﬂected in the EU’s international outlook,

where (global) health has not featured

prominently in the past. In the European

Commission (EC) the Directorate-General for

International Partnerships (INTPA) and to a

lesser extent the Directorate-General (DG)

for Health and Food Safety (SANTE)

are in the lead for different aspects of

global health. Other DGs, including the

Research (RTD) and European External

Action Service (EEAS), are contributing to

speciﬁc aspects, such as funding global

health research and diplomacy efforts.

INTPA has just entered a new era after

the introduction of the Neighbourhood,

Development and International Cooperation

Instrument (NDICI) as main ﬁnancial

instrument for development cooperation,

worth about 80 billion Euros in the period

2021-2027. Health is included under the

Social Inclusion heading and is traditionally

not a big item; nevertheless ofﬁcers involved

in programming development funding

fear that budgets for health programmes

in partner countries are under pressure

because of the many competing demands for

NDICI funding. A limited amount of funding

for health is also available under the Global

Challenges heading of NDICI.

Within DG INTPA high hopes are on the

new ‘Team Europe’ approach, which would

encourage matched funding by the European

Commission and EU member states, thus

giving EU health programmatic support

and initiatives greater impact and visibility.

However, it remains to be seen whether this

approach will materialise in the ﬁeld of global

health. Previous efforts to make EU efforts

more visible or to coordinate funding from

the EC and EU member states suffered from

a lack of interest by member states that had

their own development priorities. Moreover,

if national agendas or self-interest dominate

in Team Europe initiatives, the result might

be a development agenda that is less needs

based and coherent than is desirable.

INTPA is also in the lead regarding EU

support to the Global Fund, GAVI, COVAX,

the Global Financing Facility, etc. Here,

numbers have increased in recent years and

in response to the Covid-19 pandemic.

DG SANTE saw its budget for health security

increase by tenfold because of the pandemic,

but most of the funding will be spent within

the EU to new and revamped institutions

to address pandemics, develop treatment for

emerging infectious diseases and respond

adequately to epidemics early on. Together

with the European External Action Service

(EEAS) DG SANTE coordinates the EU’s

position in WHO. The direct budget from

the EU to WHO is limited, with the European

5 Examples are the European Centre for Disease

Prevention and Control (ECDC), European

Health Emergency Preparedness and Response

Authority (HERA), and the European Medicines

Agency (EMA).

Table 2 European Commission funding to global health initiatives

Current funding

(pledgesandcontributions)

Change since last funding period

CEPI (2020) USD 102 million (7,01%) + USD 5,8 million (2019)

COVAX AMC USD 489 million (4,98%) -

GAVI (2021-2025) USD 357 million (5,9%)* + USD 114 million (2016-2020)

Global Fund (2020-2022) USD 606 million (3,6%) + USD 73 million (2017-2019)

WHO (2020-Q2 2021) USD 576 million (6,36%) + USD 445 million (2018-2019)

Source: CEPI, 2020 Annual Progress Report, 2021; CEPI, 2019 Annual Progress Report, 2020; GAVI, Annual

Contributions and Proceeds 30 June 2021; the Global Fund, Data Explorer; WHO, Contributors (2018-

2019); WHO, Contributors (2020-2021), 2021; GAVI, Key Outcomes One World Protected - COVAX AMC

Summit: Assured Resources for the Gavi COVAX AMC.

* Excluding contributions and pledges to COVAX AMC, % ﬁgure relates only to total direct contributions

to GAVI.

Clingendael Policy Brief

Commission having contributed 131 million

USD to the WHO in the 2018/2019 biennium.

The contributions of the UK, US, Germany

and Japan surpassed the Commission’s

contribution to the WHO in recent years.

DG SANTE was also in the lead with regard

to the joint purchasing of vaccines for

the EU. A national focus in EU member

states at the start of the pandemic made

this vaccine sharing a difﬁcult task, with

initiatives such as the ‘Inclusive Vaccine

Alliance’ initially undermining DG SANTE’s

efforts.

But eventually the EC, together

with negotiators from EU member states,

negotiated vaccine deals on behalf of the EU,

and this may be replicated in the future

for other disease outbreaks, including for

zoonotic diseases.

The efforts of DG INTPA and SANTE seem

only loosely connected and coordinated, and

this is also the case for the EU Council bodies

for which they develop legislative proposals

and common viewpoints. EU Council

Conclusions on global health of 2010 that

were adopted by development ministers of

EU members states quickly lost momentum.

This lack of coordination is related to the

absences of a common deﬁnition of global

health and EU objectives for global health.

Whereas DG INTPA focuses on health

from a development angle, emphasising

universal health coverage (UHC) and health

systems strengthening (HSS), DG SANTE

looks at health security requirements and

public health protection within the EU.

The compartmentalisation of different

aspects of global health and lack of joint

vision leads to a disconnect between the

EU’s internal and external approaches

to health, whereas pathogens, diseases,

medical products and services, and health

labour migrants travel across borders

transnationally.

6 Louise van Schaik and Remco Van de Pas,

Europeanising Health Policy in Times of

Coronationalism, Clingendael Policy Brief, 2020;

Jillian Deutsch and Sarah Wheaton, How Europe

Fell behind on Vaccines, Politico, 2021.

Dutch leadership on global

health narrowed down to sexual

and reproductive health rights

and AMR

The Dutch situation is somewhat similar to

that of the European Commission. In the

Netherlands global health policy is mainly

in the hands of the Ministry of Foreign

Affairs (MFA), or more speciﬁcally its DG on

International Cooperation (DGIS), and the

Ministry of Health (MoH).

With regard to development cooperation,

since the early 2010s a political choice has

been made in the Netherlands to focus

health spending on sexual and reproductive

health and rights (SRHR), as one of four

development spearheads.

It was considered

that on this issue a difference could be

made with programmes and political

and diplomatic efforts large enough to

have an impact in developing countries.

The policy includes combating maternal

mortality, treating HIV and AIDS and helping

LGBTI minorities.

It was soon realised that strengthening

health systems was a prerequisite for an

effective SRHR policy, and therefore some

support aimed to combine these two

ﬁelds. That choice has meant that very

little funding, capacity and expertise in

government and programmes is available

for other health topics. There is a clear

preference to fund efforts undertaken by

speciﬁc global health initiatives such as

the GAVI and the Global Fund. Parliament

generally favours these investments as they

are deemed to provide good value for money

on clearly deﬁned objectives and indicators

for reporting on results.

Within the MoH, the international department

is a relatively small team with dedicated

staff focusing on WHO, EU health policy

and other international health policies.

The Netherlands has been an active

contributor to the Global Health Security

Agenda (GHSA), a US-initiated international

7 The others are food security, water and rule of law.

Clingendael Policy Brief

partnership to strengthen capabilities in the

ﬁeld of health security. Dutch engagement in

the GHSA has focused on the risks of AMR

and supported a ‘One Health’ approach,

including mitigating the risks of zoonotic

diseases. In implementing the One Health

approach, the MoH also works with other

relevant ministries, for example the Ministry

of Agriculture. Another MoH priority has

been cooperation in seeking a reduction of

the price for (rare) medicines and recently

to promote local production of medicines.

Before and at the start of the Covid

pandemic, the higher echelons in the ministry

were focusing predominantly on national

health efforts. The EU’s joint purchasing of

vaccines was actively supported, but little

attention remained for other international

health questions.

The Dutch position in the WHO and

its contribution to health security in

countries outside the EU received little

attention in parliament either, except from

vaccine donations to speciﬁc countries,

for example Suriname and Indonesia.

In 2020, the International Advisory

Council on International Affairs (AIV)

was asked to quickly develop guidance

on how the Netherlands should respond

to the Covid - 19 pandemic internationally.

The resulting document recommended a

leading role for the EU in the pandemic

response and a bolstering of the WHO.

It pointed to the potentially devastating

impacts of the pandemic in developing

countries. In early 2021, the Dutch parliament

asked the AIV to prepare guidance on a

framework for the future Dutch Global Health

Strategy aimed at creating a more coherent

global health policy.

This advice might aid

a new government in formulating a new

approach to global health.

8 De Jonge, H M, Kamerbrief over Vaccindonatie,

2021.

9 Advisory Council on International Affairs,

Nederland En de Wereldwijde Aanpak van

COVID - 19, 2020.

10 Advisory Council on International Affairs,

Adviestraject Kaders Voor Een Nederlandse Global

Health Strategy, 2021.

Policy mandates and related networks

from the development and health side are

not well aligned when it comes to global

health. The focus on SRHR, including HIV

and AIDS, has resulted in a lack of attention

for supporting global health more generally

and has hampered a needs-based and

coherent global health approach, especially

in the context of the Covid-19 pandemic.

This is exempliﬁed by the Inclusive Vaccine

Alliance (IVA) launched on 3 June 2020

and coordinated by the Netherlands MoH.

The IVA and its four member states aimed

to support Covid-19 vaccine research and

procurement. One day later, however, COVAX

was launched. COVAX has a similar aim to

the IVA but is a global effort launched by the

Coalition for Epidemic Preparedness (CEPI),

GAVI and the WHO. The Netherlands MFA

participated in the launch of COVAX but had

not communicated the launch of this ﬂagship

global health project, which completely

overshadowed the IVA, to the MoH. This was

a surprising turn of events, since one of the

key roles of the MFA is to coordinate Dutch

contributions to international initiatives and

organisations such as the WHO and EU with

the respective experts of the international

department of the MoH.

Moreover, in 2020 the Netherlands

barely increased its funding to the WHO,

despite the latter being under pressure

by the US withdrawing its funds and

membership. It moreover became the

epicentre of Covid-19 surveillance, and

played a central role in sharing knowledge

and policy advice on how to handle the

Covid-19 pandemic.

Clingendael Policy Brief

Table 3 Dutch contribution to global health entities

(total share in organisation budget in brackets)*

COVAX AMC USD 83 million (0,84%)

GAVI (2021-2025)** USD 243 million (3%)

Global Fund (2020-2022) USD 114 million (2,14%)

WHO (2020-2021)*** USD 72 million (0,8%)

Source: WHO, Contributors (2020-2021); GAVI, Key Outcomes One World Protected - COVAX AMC

Summit: Assured Resources for the Gavi COVAX AMC; GAVI, Annual Contributions and

Proceeds 30 June 2021; the Global Fund, Data Explorer.

* Figures in brackets refer to the Dutch relative share in the organisation’s total budget.

** Excluding contribution to COVAX AMC. Includes period through 30 June 2021.

*** Data available up to Q2 2021.

Table 4 Netherlands Ministry of Foreign Affairs global health spending

(in thousands)*

 2019 2020

UN organisations

WHO 21.985 17.597

UNFPA 55.074 45.510

UNAIDS 10.000 30.000

UNICEF 12.000 7.000

Global health funds

GFF 14.859 16.114

G FATM 64.158 42.000

Gavi (incl. IFFIM) 52.121 44.467

Health Insurance Fund 10.090 10.030

Covid response 

COVAX 0 5.000

GFF 0 10.000

FIND 0 5.000

Health Insurance Fund 0 7.500

* Data provided on request by the Netherlands Ministry of Foreign Affairs.

The MoH reduced its funding to the WHO

by €900.000 compared to 2019, and only

12.5 million euros were made available from

the MFA budget for the WHO’s role in the

Covid response. This is ad-hoc funding, and

on a structural basis the Dutch contribution

to WHO stayed at the same level, whereas

its contribution to global health initiatives

has been increasing (see overview). Only in

the autumn of 2021 was a new pledge made

of 95 million extra funding for Covid-related

global health investments, of which 30 million

will go to the WHO.

Another example of a global health initiative

falling out of the scope of the budgets of

both the MFA and the MoH is the European

and Developing Countries Clinical Trials

Partnership (EDCTP), which is an EU-African

global health research partnership based in

The Hague. The EDCTP played a key role in

the Covid-19 vaccine development process,

freeing up capacity for clinical trials of

Covid-19 vaccines with support from several

Dutch universities and non-governmental

organisations (NGOs). The Netherlands,

however, is reluctant to contribute to the next

Clingendael Policy Brief

funding cycle. The MoH considers the EDCTP

to be a development instrument, despite its

clear connection to health security, and the

MFA believes funding to EDCTP would fall

outside its mandate as it is not related to

SRHR. Although the Netherlands lobbied

hard to host the European Medicines Agency

in Amsterdam, it appears to have little

interest in funding the EDCTP.

The Dutch advocating for global

health in the EU?

With regard to the Dutch position in the

EU, the focus is on highlighting SRHR,

including HIV and AIDS, in EU policies

and programmes. Advocating for SRHR

has become more difﬁcult because of

opposition by other EU member states to

SRHR policies that they consider inconsistent

with their socio-cultural values or religious

beliefs. SRHR is, however, Chefsache for the

Netherlands, and it is even prepared to block

EU Council decisions when SRHR language

is at risk of being deleted in relevant policies

and programmes. The Netherlands is also a

strong advocate of a Team Europe approach

to SRHR.

The focus on SRHR is, moreover, very

speciﬁc. For the Netherlands, SRHR is not

linked to demographic and population policy,

whereas it is linked in EC policy documents.

Population policy and reproductive health

for instance share a single category in EU

reports on external action ﬁnancing. For the

EU, population growth is a recognised, albeit

contested, problem – with promotion of

women’s right to birth control being part of

the policy options for addressing it; but for

the Netherlands these two issues should not

be connected.

Apart from SRHR, the Netherlands is

not taking much interest in other health

spending in EU development programmes.

The Netherlands is also not overly active in

EU coordination with the WHO. This has to

do with its more general reluctance to the

Europeanisation of health policy, which is a

ﬁeld where the EU only has a complementary

competence. The Netherlands is proud of

its relatively cost-effective national health

system and fears European interference

might compromise aspects of this system,

such as the mandatory social insurance

scheme that underpins it. There is a strong

reliance on national health institutions and

expertise. The WHO is considered one of

the sources of advice, but this has at times

been openly ignored, for instance on the use

of facemasks to prevent airborne infections.

Prime Minister Rutte signed a call pleading

for a pandemic treaty that was published

in major newspapers around the world, but

the issue has never been discussed in the

Dutch parliament.

Towards a more coherent Dutch

and EU policy on global health

Focus and generating impact seem to be

leading when it comes to choices made in

the ﬁeld of global health by both the EU

and the Netherlands. This has been to the

detriment of placing policy choices in a

wider context and seeking alignment with

other priorities, such as strategic autonomy

or the European interests in addressing the

pandemic not only at home but also abroad.

The ‘rescue’ of the WHO, the initiation

of COVAX and current efforts to agree a

pandemic treaty are laudable, but a strategic

and coherent outlook on global health

governance is lacking. It is not clear if a

pandemic treaty would eventually fall under

the WHO’s institutional normative powers.

11 Bainimarama, J V et al., ‘COVID-19 Shows Why

United Action Is Needed for More Robust

International Health Architecture’ - Op-Ed Article

by President Charles Michel, WHO Director General

Dr Tedros Adhanom Ghebreyesus and More than

20 World Leaders, European Council, 2021.

12 Sridhar, D and Woods, N (2013). ‘Trojan

multilateralism: global cooperation in health’, Global

Policy, 4(4), 325-335.

Clingendael Policy Brief

In conclusion, a number of recommendations

can be made to global health policymakers.

European Commission:

• Consider the development of a new

global health strategy co-shaped by

development and health constituencies

in which a connection to global health

research and other related topics would

also be established. Organise a joint

meeting with health and development

ministers to adopt Council Conclusions

on the issue and set up a monitoring

mechanism and enhanced capacities

for following up on global health

commitments.

• Consider setting up a Team Europe

approach for global health, or subsets

such as pandemic response capabilities

or health-system strengthening in third

countries, to better align funding from

the European Commission and EU

member states. In this ﬁeld, an effort led

by the European Commission is less likely

to bear fruit, as some EU member states

have a stronger signature in this ﬁeld.

The Netherlands:

• Support the drafting and adoption of a

solid and integrated Dutch as well as

European global health strategy and

reconsider a more balanced Dutch

contribution, with increased attention

given to global public goods and needs-

driven global health issues.

• Further boost the capacity of the MoH

international department to improve its

handling of global health issues on EU

and WHO agendas. There has already

been an increase in the number of

staff, and it would be good if this was a

structural feature, rather than simply an

ad-hoc expansion of capacity related to

the Covid-19 pandemic.

Both the EU and the Netherlands have done

global health with a rather narrow mandate,

and it would be good if they become a

little less ‘Dutch’ on this policy challenge

and considered it in a more coherent and

structural way. A ﬁrst step was made in

September 2021, when the Netherlands

MoH announced the donation of 27 million

vaccines to COVAX, matching the number of

vaccines already used in the Netherlands.

The MFA also announced new funding worth

€95 million euros to help ﬁght the pandemic

in developing countries.

But most of the

Covid-related spending remains incidental,

and structural changes in funding priorities

in the wake of the pandemic are yet to be

discussed. If anything, the pandemic has

taught us that on this issue a more coherent

approach might be able to bring us more.

13 Rijksoverheid, Nederland Doneert 27 Miljoen

Vaccins Aan Covax, 2021.

14 Rijksoverheid, 95 Miljoen Euro Extra Voor

Coronabestrijding in Ontwikkelingslanden, 2021.

About the authors

Louise van Schaik is Head of Unit EU & Global Affairs at the

Clingendael Institute. Her research focuses on EU external action, global

health, climate change policy and a range of related topics.

Remco van de Pas is a public health doctor and a global health

researcher. He is a Senior Research Associate at the Clingendael

Institute, Senior Research Fellow Global Health Policy at the Institute of

Tropical Medicine, Antwerp and a lecturer in Global health at Maastricht

University.

Martijn Haas is a Research Assistant in the EU & Global Affairs Unit of

the Clingendael Institute.

About the Clingendael Institute

Clingendael – the Netherlands Institute of International Relations –

is a leading think tank and academy on international affairs.

Through our analyses, training and public debate we aim to inspire

and equip governments, businesses, and civil society in order to

contribute to a secure, sustainable and just world.

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