Executive Summary

The domain of pandemic preparedness and response is best analyzed through a “polycentric” lens, whereby multiple actors participate in global policy-making. Yet, despite the prevalence of nonstate actors and cooperative partnerships in global health governance, policy-making in the early phases of the pandemic seemed to revert to a more traditional, state-centric model. States engaged in forms of global policy competition, racing after scarce resources and following “beggar-thy-neighbor” strategies. Where state interaction did occur, it largely took the form of ad hoc “policy borrowing,” or emulation of jurisdictions that seemed to be succeeding in addressing the pandemic, rather than a conscious effort to coordinate.

As the pandemic unfolded, forms of coordination did develop—including over the sharing of treatment results and the synchronization of fiscal action to address the economic effects of the crisis. In addition, the transnational scientific community—in collaboration with the private sector—saw spectacular success in its efforts to develop a vaccine to treat COVID-19. However, more substantive political cooperation—which requires repeated and structured interactions, harmonized policies, and reciprocal commitments to reach a common goal—remained elusive. Key intergovernmental bodies, such as the United Nations (UN) Security Council, served primarily to showcase deep division within the international community. National action, particularly on the mobilization of financial resources, continued to dwarf efforts in global cooperation, and states exhibited a range of reactions to scientific advice—including, in some cases, defiant rejections of effective countermeasures.
 

The evolving “regime complex” for pandemic preparedness and response has been shaped by two main policy approaches: a security framework, which emphasizes the need to contain the threats posed to prosperity and stability from uncontrolled pandemics; and a solidarity framework, which stresses the importance of equity in achieving broader global health outcomes. The former approach was manifest in several public-private and institutional partnerships prioritized by the developed world in the 1990s and 2000s; the latter approach was reflected in a series of health initiatives in the 1970s and early 1980s, including the World Health Organization’s (WHO) Global Strategy for Health for All. But a tension between these two frames has persisted, constituting a leading challenge for policy-makers in efforts to sustainably address the challenge of infectious diseases with pandemic potential.

The core element of the current architecture for governing pandemics—the WHO’s International Health Regulations (IHR, 2005)—is built on the twin imperatives of developing states’ “core capacities” to prevent and respond to pandemics and the duty of states to report “early and often” on disease events. Yet these regulations suffer from the same weaknesses as many other contemporary international agreements, including the right of states to either apply national health measures going beyond the WHO’s recommendations (for example, on trade and travel restrictions) or to breach some obligations through invocation of the “necessity principle”; limitations on the WHO’s authority and right of independent initiative; and ample space for states to exercise political influence.

Despite reforms designed to improve pandemic preparedness and response, key deficiencies in the WHO-led system thus remained, which hampered the chances for a timely and effective response to COVID-19. Aside from ongoing compliance problems with the “core capacity” requirements of the IHR (2005), the pandemic highlighted the limits of what the WHO, created and financed by states, can do in the face of a global pandemic. First, while it does have processes and procedures for information gathering, its resources and operational capacity were never designed to be a comprehensive system of global surveillance that would extend even to high-income and high-capability countries that might be located in the initial epicenter of an outbreak. Second, although the 2005 reforms to the IHR give the WHO’s director-general authority to signal that a member state is not cooperating effectively or to declare a “public health emergency of international concern” (PHEIC) over a state’s objections, the exercise of that discretionary authority is ultimately dependent upon the individual occupying this role.

Beyond the WHO, additional elements of the “regime complex” for pandemic preparedness and response have developed over recent decades to enhance compliance with the IHR—such as the Global Health Security Agenda. Moreover, states and other actors have attempted to deliver critical “global public goods,” such as higher-quality surveillance and timely alerts and the sharing of leading-edge research and development on pathogens. These efforts have nonetheless encountered difficulties that constrain the supply of all global public goods: the unwillingness of states to incur the material and political costs to realize the public good; and the need to engage in cooperative action both “at the border” and “behind the border” (i.e., passing and implementing domestic legislation).

Responses to both H5N1 and COVID-19 illustrate that states have not always perceived global health goods to be truly “public” and have thus competed over what they believe to be scarce resources. These underlying political realities are exacerbated by differences in states’ capacities and vulnerabilities, which shape their responses to health risks. There is thus a disjuncture between what high-income countries think is a global public good and thus are willing to pay for (e.g., rapid sharing of information about disease outbreaks from around the world) and what low-income countries most want to improve their provision of health-related public goods domestically (i.e., material resources from high-income countries).
 

Academic research points to several factors that can affect the likelihood and ease of cooperation, including the number of participants involved in a collective action problem, the scope of a cooperative endeavor, the time horizon for cooperation, the frequency of interactions, and the quality of information actors have about the performance of others. Cooperation in the field of pandemic preparedness and response is particularly complex because it entails many participants, takes place over a long period of time, and is multifaceted in scope. The need to base pandemic preparedness and response on a common scientific and epidemiological foundation intensifies this complexity, as well as the severity of key cooperation problems.

Regardless of the issue area, scholars have identified a set of recurrent cooperation problems that states face either in isolation or in combination when they attempt to solve common problems or realize joint gains. They have further demonstrated how formal institutions can facilitate cooperation among states by establishing focal points for coordinated action, reducing uncertainty about the behavior of others, and reducing the costs of making and enforcing agreements. Cooperative arrangements will emerge and succeed, however, only if states understand the type and structure of the cooperation problem they are facing, and if such arrangements incorporate the right “design features” to confront these underlying issues.

Much of the commentary on pandemic preparedness and response has framed the challenge through a “public good” lens and argued that enforcement mechanisms are needed to address problems of “free riding.” Our analysis questions that assumption and draws attention instead to the distribution problems that have shaped policy-making in this domain as a result of the differences in state capacities. First, while low-income countries benefit from the same disease outbreak information without expending the same financial resources as high-income countries—technically an instance of free riding—this situation does not deliver the former tangible benefits if they cannot improve their capacity to act on such information. Second, even in the face of a pathogen like COVID-19, high-income countries can take steps to protect themselves, regardless of what low-income countries do in their domestic policy. The mantra “no one is safe until everyone is safe” is a powerful moral imperative, but not all actors accept its validity, either epidemiologically or politically. Current deliberations on institutional reform must attend to distributional issues and address developing countries’ concerns about creating more obligations without corresponding financial mechanisms to enable their fulfillment.

Cooperation on pandemic preparedness and response has also been affected by states’ uncertainty over how other states will behave—most notably whether they will “defect” from negotiated provisions related to reporting and response. While the IHR (2005) are partly designed to address this temptation to defect, issues with information sharing around human-to-human transmission during the early months of COVID-19 reveal the persistence of this problem. The potential for defection is made more challenging by the fact that pandemics are both a transnational threat that requires some level of international cooperation (and thus the minimization of incentives to defect), as well as a national threat that requires the exercise of extensive sovereign powers—which increases incentives to defect if compliance is perceived to pose excessive limits on sovereignty.
 

The ideal institutional arrangements would include norms and systems through which states could share the burdens and benefits of effective pandemic preparedness and response; make space for nongovernmental actors as sources of information and assessment; and establish the right balance between ensuring accountability and responsiveness to member states while at the same time maintaining sufficient insulation from political pressures. As diplomats and policy-makers grapple with what is achievable in a nonideal context, the research on international cooperation and institutional design offers a series of lessons.

• While the global distribution of power matters, power functions in a variety of ways within institutional arrangements, and strong states do not always get their way. COVID-19’s clear demonstration of international interdependence presents opportunities for low-income countries to bargain for the assistance they have long demanded. Past instances in which great-power rivals have jointly addressed a common threat also indicate that the escalating competition between China and the United States does not necessarily foreclose cooperative arrangements in pandemic preparedness and response. However, it does suggest that alternative and more informal mechanisms for dialogue will be critical prior to (or alongside) any broader multilateral process.
• Universal membership is not always essential. Since greater numbers and heterogeneity may make compromises and compliance harder to achieve, some schemes might call for a smaller initial membership and a gradual expansion of the boundaries of feasible cooperation.
• Monitoring by nonstate actors works best as a complement to, rather than substitute for, more formal, treaty-based monitoring systems. Given that information sharing in the realm of infectious disease cannot operate without governments, additional efforts will be required to create space for public health “whistleblowers” to act on their professional ethics and leverage existing transnational networks.
• While the need for impartial verification and investigation continues to be highlighted in analyses of COVID-19, experience from other domains demonstrates that expert inspections can never be fully independent if they are connected to intergovernmental organizations and the states that create them.
• Domestic actors and interest groups can play a positive role in promoting deeper forms of international cooperation and in enhancing compliance through processes of “naming and shaming.” However, populist dynamics within states are increasingly acting as a break on multilateral cooperation.
• Inclusive structures and peer-to-peer dialogue can strengthen the normative power of a cooperative arrangement—thereby generating greater buy-in—as well as elicit more-productive engagement from reluctant states. Universal periodic review processes enable countries to assess capacities collectively and support one another as peers, thereby contributing to a common accountability framework.
   

Comparative studies of international cooperation and institutional design also raise questions about the viability of some of the key proposals for improvement in pandemic governance.

• Lack of incentives for strong enforcement. While recent commentary on global health security calls for stronger sanctions against states that fail to meet formal commitments, comparative research indicates that such punishment provisions exist in only a small minority of situations. In addition, analysts of cooperation on transnational threats such as climate change increasingly view the core challenge as one of addressing distributional conflict rather than achieving more-stringent forms of enforcement. In the case of infectious disease, enforcement has not been a central feature of either law or state practice. States’ reciprocal interests not to seek reparations for violating rules on trade and travel measures indicate that they are unlikely to agree to enforcement of infectious disease treaty provisions.
• Hard versus soft arrangements. Although binding agreements (such as treaty commitments) are frequently presented as the optimal solution to collective action problems, they often represent the lowest common denominator of agreement. As a result, some policy domains have embraced voluntary targets or “soft law” approaches as alternatives. Given noncompliance with existing legal commitments on global health security, the difficult distributional issues that affect cooperation in this policy domain, and the challenging political context that could undermine new treaty negotiations, nonbinding approaches to improve on pandemic preparedness and response are more likely to succeed.
• The challenge of transparency. Although the Nuclear Non-Proliferation Treaty and Chemical Weapons Convention offer models for encouraging states to consent to limitations on sovereignty, their relevance to pandemics may be limited both by states’ lack of agreement on the nature of the threat and by the intensity of today’s geopolitical competition between the United States and China, which makes new multilateral agreements on transparency and inspections unlikely.
   

The empirical record on international cooperation illustrates that optimal institutions or arrangements often fail to emerge even when there is a crisis or large potential gains to be captured. Three imperatives could help diplomats and policy-makers create the preconditions for more successful cooperation in meeting the challenge of pandemics.

The first main task is to understand and confront the incentives shaping state behavior in response to infectious diseases with pandemic potential. All states have an interest in rapid information exchange leading to timely and coherent recommendations to prevent further spread. At the same time, governments concerned that outside scrutiny could compromise their national security or social order have incentives to defect from transparency requirements. In addition, while pandemic preparedness and response is a concern for all states, it is not the primary health priority for all. Nor do all states perceive their vulnerability to pandemics in the same way.

Second, while some assessments emphasize the need to depoliticize cooperation in global health security, the academic literature suggests that such political forces can never be eliminated. Rather than wish politics away, initiatives for change need to understand and engage with political dynamics and potentially channel them in more productive ways. Areas of focus should include addressing the interests and “solidarity” concerns of low-income countries and how the United States and China can identify “islands of agreement” that will enable other, broader forms of multilateral negotiation to succeed.

Finally, efforts at strengthening cooperation must take the long view. Many prominent regimes that foster collective action took several years to be negotiated and often experienced ratification delays that impacted their entry into force. Cooperation itself takes time and often manifests not in perfectly designed institutions or agreements but in layers of collective action that may overlap to create a complex but evolutionary regime.
 

At the special session of the World Health Assembly in late November 2021, member states reached consensus on moving forward with a new “international instrument” to strengthen pandemic preparedness and response. Given the limitations of a treaty approach and the uncertainty surrounding the outcome of the negotiations, policy-makers should focus in the near term on enhancing compliance with existing state commitments and addressing the distribution challenges that lie at the heart of better pandemic governance. The analysis in this report suggests that the core functions of global pandemic governance include an effective system of surveillance and information sharing, the production and equitable provision of key public health interventions, and effective stewardship of the broader system itself. With these functions in mind, and considering the lessons from research on international cooperation, the following priorities for reform should be actively considered and supported:

• Targeted efforts to address the economic and political barriers to comply with the IHR (2005), including a new investment package for low- and middle-income countries; material rewards for improving domestic-level preparedness; a regularized peer-review process; additional resources for nongovernmental monitoring; and forms of financial compensation to incentivize transparent reporting.
• Limited reforms of the WHO that increase the predictability of its funding; strengthen its Health Emergencies Programme; improve its alert system; limit the politicization of staff appointments and reappointments; and mobilize a “Group of Friends” that can provide political support for cooperative solutions.
• Three new institutional arrangements that fill critical gaps in pandemic preparedness and response:
  • A stronger global surveillance network based on the proposals of the WHO’s Independent Panel for Pandemic Preparedness and Response and the G20’s High-Level Independent Panel;
  • A new head-of-state council that mobilizes resources and political will in emergency situations and that maintains a political commitment to pandemic preparedness in “normal times”; and
  • A permanent platform for equitable access to diagnostics, treatments, and vaccines that responds to the lessons learned from COVAX and creates a reliable stand-by production capacity.

In pursuing the reform proposals identified above, interested states and nonstate actors must remain cognizant of two realities: that in a multilateral framework, with near-universal membership, they are likely to make only modest progress; and that without movement on underlying incentives or specific efforts to manage the spillover effects of geopolitical competition on global health, material and political investments in cooperative arrangements and institutions such as the WHO are unlikely to yield positive results.