There are only six negotiating days left to nail down the final piece of the Pandemic Agreement, but huge areas of disagreements still exist between World Health Organization (WHO) member states.

The talks, which start on Monday, are set to go until 11pm each night at the WHO headquarters in Geneva – but this may not be enough time to bridge the significant differences between member states on what the Pathogen Access and Benefit Sharing (PABS) system should look like.

The PABS system is the crucial operational annex to the Pandemic Agreement adopted by the World Health Assembly (WHA) last May, and is supposed to be adopted by this May’s WHA.

“Of course, there are differences between member states, but I can also see that they are closing the gaps. And we believe there will be landing zones on areas where there are still differences,” WHO Director-General Dr Tedros Adhanom Ghebreyesus told a media briefing on Wednesday.

“I’m confident that the PABS could be agreed, and the agreement on PABS will also help us to start the ratification process of the pandemic agreement that was approved by the member states last May,” Tedros added.

However, the latest PABS Annex text released by the Intergovernmental Working Group (IGWG) Bureau on 9 March, shows that there is little agreement so far. (Greened text shows agreement, while yellow shows significant consensus).

Balancing sharing and benefiting

The crux of the PABS system rests on how countries share data about pathogens with pandemic potential, the obligations on parties (including pharmaceutical manufacturers) that get access to this information, and how those who share their data benefit from any vaccines, diagnostics and therapeutics (VDTs) that are developed as a result.

Aggrey Aluso, executive director of the Resilience Action Network Africa (RANA), said the world needs a legally binding PABS agreement and the “highest level of political accountability”.

Without this, Aluso advocated for missing the May World Health Assemby deadline and “[taking] more time to get something that will really be transformative”.

Aluso was addressing a media briefing in Brussels on Wednesday, hosted by the AIDS Healthcare Foundation (AHF) shortly after it had held a protest at the European Parliament to demand that the European nations ratify a PABS system that ensures equitable access to medicines and vaccines during health emergencies.

AHF Europe head Daniel Reijer called on European countries to support a legally binding PABS system that “guarantees fair and timely access to vaccines, tests and treatments for all countries, and not only after a pandemic is officially declared, but during health emergencies as they are unfolding”.

Several powerful European countries, particularly Germany and Switzerland, have advocated for voluntary sharing of any VDTs. Protecting their powerful pharmaceutical industries, they have argued that the compulsory sharing of VDTs will stifle innovation and impinge on intellectual property rights.

New obligations in latest PABS draft

The latest PABS draft sets several obligations for member states sharing pathogens. PABS materials “shall” be shared “as soon as available, on a priority basis”, with one or more of the WHO Coordinated Lab Network (WCLN) laboratories of their choice. This includes uploading the pathogen sequencing information.

However, while pathogen sharing is mandatory and speedy, the draft adopts less prescriptive approach to benefit-sharing – the stickiest aspect of the entire talks.

Pharmaceutical manufacturers who participate in PABS are expected to donate at least 10& of their VDTs to the WHO and a further 10% “at an affordable price”.

During the less serious public health emergency of international concern (PHEIC) – such as the recent mpox outbreak –  manufacturers are to “implement benefit-sharing provisions, including options” regarding access to VDTs.

Participating manufacturers are expected to pay an annual fee to be part of PABS.

They are also expected to commit to at least two out of five options, namely: capacity-building and technical assistance; research and development cooperation;. facilitating rapid access to VDTs for public health risks; granting non-exclusive licenses to manufacturers in developing countries to produce VDTs; and finally, “other forms of technology transfer as mutually agreed”.

Several other loose ends remain. African countries and the Group for Equity, a large alliance of countries from different regions, want contracts with manufacturers to be included as part of PABS – something opposed by Europe.

Legally binding – or bust

Meanwhile, at the last meeting of the IGWG, the Group of Equity and the WHO’s Africa, Eastern Mediterranean and South-East Asia regions all stated that they wanted a legally binding PABS system – or bust.

“PABS is the heart of the Pandemic Agreement. If the heart is weak, the body cannot function, and the agreement will not deliver equity,” said Indonesia on behalf of the Group of Equity, and the three regions – collectively representing over 80% of the world’s population.

Zimbabwe, speaking for the Africa Group, said: “Equity and benefit-sharing must be operational, enforceable and central to Pandemic Agreement, including the PABS annex. These elements cannot be aspirational, deferred or left to voluntary implementation. Past experiences has shown the consequences of such approaches.”

Meanwhile, The Elders – an association of former world leaders – have urged member states to deliver a PABS Annex that is “equitable and operational from day one”. 

“Both access and benefit-sharing obligations must be predictable and guaranteed, not left to goodwill or last-minute negotiations once a crisis has hit. 

“Without binding arrangements, countries with the least bargaining power will be left without access again. The system should also include firm commitments which generate trust and incentivise broad participation.”

The Elders also called on member states to “include additional negotiating days if needed to reach consensus by the current deadline”.

Running alongside the PABS negotiations, the United States is pursuing bilateral agreements with developing countries that make its health aid contingent on recipient countries agreeing to provide the US with rapid access to information about dangerous pathogens.

To date, the US has signed 24 bilateral health agreements in terms of the Trump administration’s America First Global Health Strategy – their somewhat chaotic alternative challenge to the Pandemic Agreement.

As further impetus for the PABS talks to succeed, The Elders called for “The multilateral architecture for pandemic preparedness and response” to be  “protected as a collective endeavour”.

They noted: “Bilateral arrangements are not a substitute for a shared mechanism supported by all countries which can be counted on in an emergency.”