While July saw a crush of global pandemic-related meetings – some joint and some clashing – to accommodate tight schedules and northern summer holidays, achieving a pandemic-proof world is still a long way off. 

The two pandemic negotiations underway at the World Health Organization (WHO) have held individual and joint meetings over the past few weeks, with talks dominated by equity, early warnings for pandemics and financing.

The Working Group on amendments to the IHR (WGIHR) is strengthening the International Health Regulations (IHR), the only legally binding global rules governing health emergencies. 

Meanwhile, the Intergovernmental Negotiating Body (INB) is developing a pandemic accord to address other gaps that emerged during COVID-19 – particularly how to ensure equitable access to vaccines and medicines.

The United Nations General Assembly holds a High-Level Meeting on Pandemic Prevention, Preparedness and Response (PPPR) on 20 September to ensure political leadership for future pandemics, and the draft political declaration for this has also been finalised in the past two weeks.

However, the declaration is more aspirational than action-oriented – although there is an outside chance that it might be tightened up during the HLM.

In combination, these three processes are supposed to lay out a continuum of multilateral and country-based action to prepare for, identify and ward off future pathogens that threaten humanity. 

However, while there is unanimous agreement that equity must be at the heart of any future pandemic response, there is still substantial disagreement about how this can be achieved. 

Vaccine hoarding is unlikely to stop 

Gaps and weaknesses in the global response to pandemics have been well documented, particularly in a damning report from the Independent Panel on Pandemic Preparedness and Response (the Panel).

“An amended IHR that fails to address the gaps expressed by COVID-19 will not make the world safer. Likewise, a pandemic accord that fails to ensure equitable access to pandemic-related products, fails,” WHO Director-General Dr Tedros Adhanom Ghebreyesus warned the recent two-day joint meeting of the WGIHR and the INB.

The most glaring failure was the inability of many low and middle-income countries, particularly in Africa, to get early access to COVID vaccines as wealthy countries bought excessive doses when they were scarce.

While the three negotiation processes are unlikely to entirely prevent wealthy countries from buying hoards of scarce vaccines at a premium from pharmaceutical companies in future pandemics, they can reduce inequity by developing fair and rational global processes to govern the allocation and distribution of pandemic goods. The INB Bureau has proposed, for example, that 20% of vaccines produced in future pandemics are allocated to the WHO for distribution.

An important part of the negotiations is making explicit the roles and responsibilities of countries and international bodies, particularly identifying global structures that decide who gets access to medicine – rather than leaving this to politicians from wealthy nations who are beholden to their electorates.

‘Complementarity, coherence and continuum’

“Complementarity, coherence and continuum” is how New Zealand’s Dr Ashley Bloomfield, co-chair of the WGIHR characterised the themes emerging out of the two-day meeting between his group and the INB.

At the meeting, the Brunei delegate described the IHR as “emphasising the obligations of member states to the WHO, particularly in terms of reporting, surveillance and domestic implementation of standing recommendations of the Director General”.

Meanwhile, a pandemic accord should define the “multilateral system for ensuring global health security in the event of sustained and prolonged disease spread”, outlining “the obligation of member states to each other,” added the Brunei delegate.

Currently, the highest level of danger in the IHR is a “public health emergency of international concern” (PHEIC), but there is now wide support for the addition of a “pandemic” category, said Bloomfield. The two Bureaus co-ordinating the respective negotiations would work on a proposal for discussion, he added.

The WHO Secretariat has also recommended that this definition “be accompanied by a mechanism to determine a pandemic [and] the actions that such a declaration would trigger” as well as how to de-escalate these actions once the threat is over. 

Dr Mike Ryan, the WHO’s head of health emergencies, also suggested that the negotiators include an “intermediate stage” that would enable the WHO to say: “We’re very worried, but it’s not yet a PHEIC”. 

The Independent Panel was scathing in its assessment of the current IHR health emergency process, describing the “step-by-step confidentiality and verification requirements and threshold criteria” needed before the WHO Director-General (DG) can declare a PHEIC as constraining rather than facilitating rapid action. 

Under the amended IHR, the DG may need to be empowered to publish information about outbreaks with pandemic potential without the approval of implicated member states.

Tiered threat alerts for IHR?

Amid the many proposed amendments to the IHR, US wants a tiered alert system “to better define stages of public health threats, enable better reporting incentives and to prevent local or regional outbreaks from becoming large-scale global health emergencies, including pandemic emergencies”. 

It wants the IHR to include a “pandemic emergency declaration within this tiered alert system”. This would be linked to the pandemic accord “because of its ability to trigger activation of emergency response provisions within the accord”.

While the US proposal has widespread support it also faces opposition, including from Russia and China, who believe it could undermine their national sovereignty.

China’s refusal to grant WHO experts access to Wuhan, ground zero for COVID-19, after the pandemic had been declared also raises the question of whether the IHR should empower WHO-appointed experts to visit the sites of outbreaks.

Meanwhile, the African region and Bangladesh have proposed an amendment to Article 12 of the IHR dealing with equity, which would see the WHO DG making an “immediate assessment of availability and affordability of required health products” after the declaration of a PHEIC.

According to this proposal, the DG would also develop “an allocation mechanism or plan, based on public health need, to avoid any potential shortages and ensure that populations at risk have access to health products and technologies”.

Incentives for countries to share information 

The IHR do not set down member states’ obligations following the declaration of a PHEIC. In changing the system of alert to orient it towards speedy action, the incentive structures need to be addressed. 

At present, public health actors only see the downside of drawing attention to an outbreak in their country that has the potential to spread – which under COVID-19 triggered travel bans and other punitive actions. 

The Panel proposed that “incentives must be created to reward early response action and recognise that precautionary and containment efforts are invaluable protection which benefits all humanity”.

In addition, countries themselves need to jack up their capacity to identify and prepare for health emergencies.

One-third of member states do not have enabling legislation and financing for health emergency prevention, detection, and response capabilities, according to the reports countries are required to submit to the WHO in terms of the IHR.

When the WGIHR meets again in October, it will focus on equity provisions (Article 13 A) and financing mechanisms to achieve equity (Article 44), according to Bloomfield.

Equity in operation, not just in talk 

Given the triumph of nationalist self-interest during COVID, it is hardly surprising that the pandemic accord negotiations have focused on equity, in particular equal access to vaccines, as well as research and development (R&D), pathogen access and benefit-sharing, and global supply chains. 

However, the usually jovial INB co-chair Precious Matsoso recently expressed some frustration with member countries’ repetition of equity being a cornerstone of the accord “without saying how it shall be operationalised”.

The European Union is also concerned that talks have focused too much on pandemic response to the detriment of preparedness and prevention.

INB negotiations have splintered into a number of informal meetings on contested issues in the draft agreement – largely related to the draft’s Chapter Two on equity – for member states to gain a better understanding of each other’s views.

As the accord will be legally binding, this makes reaching agreement on controversial issues harder. Sticking points include intellectual property rights for pandemic-mitigating products, and whether member states should be “incentivised” for sharing information about pandemic-causing pathogens.

The access and benefit-sharing approach originates from the Convention on Biological Diversity, which states that countries have sovereign rights over their genetic resources and should be consulted before these resources are used in research and development (R&D). Some countries, primarily in Africa, want to have a share in profits derived from products that are developed from the genomic sequencing of pathogens that they share.

The pharmaceutical industry is dead set against genomic sequencing sharing being linked to rewards, warning that this will slow down the development of future vaccines.

“We do not have to choose between equitable access and innovation,” Tedros told the joint WGIHR/ INB meeting. “We do not have to choose between protecting public health and making a fair profit. We can strike a balance.”

Failure of international systems 

The Panel believes that system-level change is needed to overcome the failure of the international system to prevent, contain, and mitigate the impact of COVID-19.

It had pinned its hopes on the establishment of an independent Global Health Threats Council to elevate pandemic risk to the same level as war, terrorism and economic threats.

But the UN draft Political Declaration on Pandemic Preparedness and Response entrusts the WHO with managing pandemics. The UN’s only oversight is another HLM in 2026 to assess the declaration’s progress.

This puts even more pressure on the WHO negotiations to ensure that the processes and structures they decide on are fit for the challenge.

Other pandemic responses also pushing ahead

Outside of the pandemic negotiations, a number of key initiatives are underway to pandemic-proof the world. Post-pandemic, there is widespread political support for each WHO region to have the ability to manufacture its own vaccines. To assist with this, the global vaccine alliance, Gavi, and the African Union (AU) are spearheading building regional vaccine manufacturing, and in August, they are convening a regional vaccine manufacturing forum.

The aim of the forum is for African leaders, manufacturers and Gavi to “strategize around sustainable manufacturing”, according to Gavi’s Aurélia Nguyen. 

Meanwhile, the Pandemic Fund has awarded its first tranche of $338 million in grants to help 37 countries to build their pandemic resilience. The Pandemic Fund was initiated by the G20 and is housed at World Bank. The World Bank estimates that the world needs $10 billion a year for the next five years to address the gaps in countries’ pandemic responses.

As Tedros told the joint meeting of the two WHO negotiations: “All of these elements are essential but insufficient on their own. It’s only the combined strengths of all of them together that will truly keep the world safer.”

Image Credits: Aishwarya Tendolkar, CGTN.