Multilateral health: Developing a habit of pandemic preparedness

In May 2023, the World Health Organization (WHO) declared that covid-19 was no longer “a public health emergency of international concern”. Since the virus was first identified early in 2020, it has killed an estimated 20 million people worldwide and wreaked economic damage predicted to top $13 trillion by the end of 2024. The toll of excess mortality around the world suggests that the virus continues to cause the deaths of several thousand people a day. Nevertheless, as the crisis phase of covid passes, international efforts are gaining steam to put in place a more effective system to prepare for future pandemics.

The European Union has committed to play a central role in those efforts by supporting a more robust form of global health governance. The EU has strongly promoted the negotiation of a new treaty under the auspices of the WHO that would shape the world’s response to health emergencies. But the project for a new treaty is only one of a plethora of initiatives to improve pandemic preparedness, leading to a risk of overlap and confusion between different structures. And the conflicting agendas of the countries and institutions involved are likely to stand in the way of any far-reaching changes.

Moreover, while there is broad recognition that global health preparedness needs more funding, countries are facing many other demands on their resources. The trade-offs and coordination to improve the global health system require high-level political engagement. But health is at risk of slipping down the list of political priorities as leaders focus on other crises. Finally, any revisions to global health systems will require that the developed world address the calls for greater equity from leaders in lower-income countries and emerging economies – who are likely to demand measures that go beyond anything the EU and other wealthy countries have been willing to consider to date.

All this means that the road to a better global defence against health emergencies will be arduous. The EU and member states may have more short-term impact if they complement their efforts in these forums with ad hoc initiatives to improve pandemic preparedness in countries in the global south.

Obstacles to global coordination

Covid-19 laid bare several weaknesses in the world’s systems to prevent, detect, and respond to health emergencies. States were too slow to share information about the emerging threat and failed to coordinate their responses; the WHO faced criticism for not warning governments quickly enough about the likely spread of the virus; many countries were unable to sufficiently track the virus’s spread; and there were marked inequalities in countries’ access to countermeasures, above all vaccines. Some of these shortfalls were due to a lack of funding or capacity constraints, but more stemmed from political factors – including countries’ resistance to international scrutiny, as well as their reluctance to cede greater powers to the WHO while prioritising the needs of their own populations.

The biggest unknown hanging over the various initiatives to strengthen global preparedness for future pandemics is whether the world’s leaders can be persuaded to agree to measures that will limit their ability to act in a similarly political manner next time around.

The experience of covid-19 highlighted the costs of disunity. And the glaring inequalities in access to countermeasures have made it impossible for rich countries not to take some actions to ensure fairer distribution in response to a future pandemic. But, in other respects, the world is more divided on global health than it was before the pandemic. Covid-19 led to an upsurge in tensions between China and the West. It also increased suspicion of and hostility to the WHO among some parts of the populations in several countries, particularly the United States. Now, the failure of coordination that was evident in the response to covid-19 is repeating itself in the process of trying to improve global health structures.

Initiatives in pandemic prevention and response

In pushing for the creation of a new legal instrument, the EU is seeking to defy a global context that in the past years has become markedly more competitive and less conducive to international treaty making. WHO member states have set up an intergovernmental negotiating body that is due to submit a draft treaty for consideration at the World Health Assembly in May 2024. But discussions are proving contentious.

There has been particular dispute about suggestions from global south countries that pharmaceutical companies in receipt of government funding should incur a range of obligations on licensing, technology transfer, and pricing

The EU’s health commissioner, Stella Kyriakides, warned recently that the process was at risk of being derailed by current dynamics. A couple of drafts have been circulated that include a range of options in the areas where disagreement is strongest. There has been particular dispute about suggestions from global south countries that pharmaceutical companies in receipt of government funding should incur a range of obligations on licensing, technology transfer, and pricing – and that the release of information on pathogens should be linked to the sharing of countermeasures produced with this information. Among the proposed measures is a requirement for producer countries to set aside 20 per cent of their stocks of pharmaceutical products relevant to pandemic response, such as vaccines and antivirals, for global distribution by the WHO.

This demonstrates the gulf between the claims of many low- and middle-income countries and the positions of the most developed economies, where advanced medical research on vaccines is concentrated, suggesting that it may be difficult to reach a compromise. The ‘red lines’ that European countries have maintained on these positions up to now suggests that any treaty European countries are prepared to sign will disappoint the expectations of developing countries and emerging economies.

There is also disagreement about the nature of the treaty. After some initial reluctance, the US has thrown its weight behind the negotiating process. But it is pushing for an agreement that contains some non-binding elements, due to the likely difficulty of winning consent in the US Senate for the ratification of a full treaty, especially one that gives a central role to the WHO. The pandemic treaty would then take the form of a framework agreement that set overall goals but relied on sub-agreements or non-binding pledges for detailed commitments – and any treaty would only affect the obligations of countries that signed up to it. The process could therefore create a patchwork of different binding and voluntary commitments across the global health landscape.

The US, for its part, has prioritised reforms to the International Health Regulations (IHR), a body of law that applies to all WHO members and that includes provisions on pandemic preparedness and response. The working group that is considering amendments to the IHR has received hundreds of proposals, with many focusing on equity and the strengthening of processes to support and monitor countries’ implementation of IHR obligations. In principle, IHR amendments could be passed by a two-thirds majority of the World Health Assembly, but the WHO has traditionally operated by consensus. Since several countries emphasised the importance of sovereignty in speeches at this year’s assembly, there will be a tension between seeking strong oversight powers and winning broad backing for the amendments. Moreover, the relationship between the revisions to the IHR and the proposed new treaty remains unclear, despite efforts by the different working groups to coordinate their efforts.

Funding and political leadership

A third major initiative following covid-19 is the launch of a dedicated fund, housed in the World Bank, to help strengthen countries’ capacity to prepare for and respond to future pandemics. The Pandemic Fund has received support and initial donations from a range of countries, with the US and European countries at the fore.

Still, its funding remains comparatively limited. A G20 panel on pandemic finance estimated that it would take $10 billion a year to improve the world’s readiness for a similar health emergency to covid. To date, the fund has received pledges of $1.9 billion. In addition, the fund would not address the clear need for a separate pot of money that would be available for surge financing once a pandemic was under way. The way the fund will set its priorities for preparedness spending, as well as its relationship with the proposed pandemic treaty – as with the IHR amendments – remain unclear.

As covid-19 has waned, health has receded as an issue in international politics. An international high-level meeting on pandemic preparedness at the United Nations in September 2023 offers a chance to renew the political momentum and bring more coherence to the reform of the global system. But some analysts have criticised the first draft of the declaration to be issued at the meeting for its lack of focus and ambition.

Behind the scenes, a debate is under way among policymakers and analysts about whether international political leadership independent of the WHO will be necessary to coordinate the world’s response to pandemics. The independent panel set up to review the world’s response to covid-19 has recommended the formation of a “global health threats council” to provide leadership; the WHO’s director-general has proposed instead that the organisation should host a high-level forum such as this, to avoid further complicating the global health landscape.

The WHO has also launched an initiative to create a standing platform to enable the distribution of vaccines and other medical products in the event of a future pandemic. This aims to build on the lessons of the Access to Covid-19 Tools-Accelerator platform during covid, including the need to scale up more quickly and offer a greater role to regional organisations and developing countries. A fairer system to distribute countermeasures will be an essential part of an improved global response to pandemics. However, a recent assessment from the independent panel seemed to question whether it was right for the WHO to lead this effort, suggesting that the organisation should concentrate on its core functions of providing technical support, information, and guidance.

The range of efforts underway, the apparent lack of political coordination, disagreements over the proper role and authority of the WHO, and the limited resources that have been made available all suggest that a comprehensive new settlement for pandemic preparedness may be elusive. The EU should continue to do what it can to help solve these problems. But, in the meantime, it may be able to do more to improve the world’s capacity to prevent and respond to health emergencies through more ad hoc initiatives – above all, by working with developing countries to strengthen their health care and surveillance systems, help them develop the capacity to manufacture vaccines, and encourage European pharmaceutical companies to go further in sharing knowledge and expertise with producers in the global south.