6. Conclusion: Recommendations for Improved Global Governance of Pandemic Preparedness and Response

WHO member states have consistently rejected formal sanctions or enforcement mechanisms—both generally and specifically in relation to compliance with the IHR. Instead, the designers of the IHR (2005) attempted to align incentives through multiple strategies that would cajole states into acting in ways that advance global public health. The first strategy is the power of the director-general to declare a PHEIC, even over the objections of the state or states affected. This authority was established, in large part, to incentivize governments to cooperate with the WHO early and often. The second strategy is the IHR’s reliance on the “market” and digital technology to encourage state compliance. Under this logic, member states will not be able to afford the stigma associated with a lack of transparency on infectious disease if they want the benefits associated with economic globalization, nor could they sustainably hide disease outbreaks given the many nongovernmental sources of information.

Reevaluation of whether these mechanisms for creating incentives are actually functioning as intended—particularly given the changing economic conditions within key states—will be central to the continued viability of institutionalized cooperation on pandemics through the IHR (2005). But more broadly, reform efforts should focus not on sanctions for lack of compliance, which are unlikely to gain traction, but on the economic and political barriers to improved national-level preparedness and the early sharing and processing of information on disease events. These could be addressed through the following kinds of proposals:

• A new investment package for lower- and middle-income countries, as recommended by the G20 report, based on: 1) costed national action plans for pandemic preparedness; and 2) pre-agreed and equitable contribution shares from advanced and developing countries.
• Further material rewards for improving domestic-level pandemic preparedness and information sharing (for example, through linkage to the funding of the International Monetary Fund and World Bank), based on a revised system of tracking country progress and identifying gaps in preparedness. Such a system could be co-led by the WHO and the World Bank, building on lessons from the IHR State-Party Self-Assessment Reports and the Joint External Evaluation peer-review process.142
• The issuing of regular opinions by global health lawyers on states’ interpretation and fulfillment of their obligations under the IHR (2005).143
• A formalized “universal periodic review” of national pandemic preparedness and response, as recommended by the WHA’s Independent Panel on Pandemic Preparedness and Response and the WHO’s Review Committee on the Functioning of the IHR.144 To strengthen this accountability mechanism, consideration could also be given to housing such a review process outside the WHO and within an intergovernmental arrangement that included a broader set of officials beyond health ministries.
• Regular “stress tests” to assess preparedness and resilience, administered nationally but including representatives of global bodies.
• Additional resources and support for nongovernmental forms of monitoring and reporting on preparedness (including through public indexes).
• A stronger and more systematic form of financial insurance to states that would assist in compensating them for any economic costs incurred from transparent reporting of disease events or from implementing interventions to address disease events. This insurance scheme should incorporate the lessons learned from the World Bank’s Pandemic Emergency Facility, improve the analytics required to forecast and price risk, and investigate options for risk pooling among countries.145
   

Endnotes

• 142The G20 expert report refers to this as a “Health Security Assessment Program” modeled on the Financial Sector Assessment Program. See ibid.
• 143Alvarez, “The WHO in the Age of the Coronavirus,” 583.
• 144See IPPPR, COVID-19, 51; and World Health Organization, Report of the Review Committee on the Functioning of the IHR (2005).
• 145G20 High Level Independent Panel, A Global Deal for Our Pandemic Age, 62.

When considering potential reforms of the WHO, member states of the WHA should focus their energies on mobilizing support for a limited set of reforms that will strengthen its functional and coordinating role and increase its insulation from political pressure. This task must be premised both on deep reflection on what actually went wrong in the early months of the COVID-19 pandemic, and on a clear understanding of what mechanisms currently exist.

The IHR (2005) already grant significant powers to the WHO to collect and share information, verify information, declare a PHEIC, and issue outbreak-specific guidance. They also articulate specific obligations for states to share information in a timely manner. The WHA’s independent panel report suggests that the core problem with COVID-19 was not information about the cases emerging in the Wuhan region but the slow pace with which information was transmitted and translated into effective public health guidelines by the WHO and the responses of individual national governments during the month of February 2020. In short, the primary problems were political rather than of institutional design. For example, the panel report finds that the WHO could have declared a PHEIC at least a week earlier than it did—raising questions about the current functioning of the organization’s Emergency Committee—and could have publicly voiced concerns earlier about the potential for human-to-human transmission. According to the panel’s report, the WHO operated with caution, weighing incomplete evidence, rather than on the basis of the “precautionary principle.” National governments also wasted crucial weeks, the report concludes, in which they could have acted both individually and collectively to stop the spread, relying instead on a “wait and see” approach.146

Nonetheless, specific proposals for reform of the WHO could make a tangible difference to its ability to play its functional role in future pandemic preparedness and response—assuming a disease event could occur in any country. Proposals that are worthy of support include:

• Promises from a “lead” set of countries to increase their contribution to the WHO’s budget, so that the proportion of voluntary contributions decreases to 50 percent of the WHO’s budget (with challenges to other countries to make proportionate increases). While the WHA meeting in May 2021 and preceding years of underfunding raise doubts about the feasibility of this proposal, it would represent an example of “catalytic” cooperation147 and could be a critical step to providing the WHO with more predictable funding.
• Dedicated funding from international financial institutions for the WHO’s Health Emergencies Programme, to give it “surge” capacity in pandemic crises, as well as the creation of a Standing Committee for Emergencies linked to the executive board.148
• Formalized links between the WHO and its independent collaborating centers to assist in articulating technical recommendations in fast-moving pandemic environments.
• Reforms to the alert system, including: 1) greater transparency in the composition and decision-making of the WHO’s Emergency Committees, including through the creation of a Standing Committee for Emergencies; 2) clearer categories for evaluating disease threats that will better differentiate among disease outbreaks and reduce ambiguity over the status of a PHEIC declaration; and 3) clearer action guidelines attached to different phases of outbreak alert and response.149
• A single, seven-year term for the director-general of the WHO, as proposed by the WHA’s independent panel, to limit the political dynamics around reappointment; and further professionalization of the recruitment of senior staff.150
• Regular mobilization of a “Group of Friends” of the WHO to explicitly coordinate ways to leverage political dynamics to improve upon collective action.
   

Endnotes

• 146IPPPR, COVID-19, 29.
• 147Hale, “Catalytic Cooperation.”
• 148IPPPR, COVID-19, 65.
• 149Any proposed scheme for graduated pandemic alerts will be met with objections. See, for example, Clare Wenham, Matthew Kavanagh, Alexandra Phelan, et al., “Problems with Traffic Light Approaches to Public Health Emergencies of International Concern,” The Lancet 397 (10287) (May 15,2021): 1856–1858. The WHO has already effectively engaged in issuing “amber alerts” by providing countries with information before formally invoking PHEIC authority.
• 150IPPPR, COVID-19, 65.

Beyond inspiring discussion on reform of existing institutions and mechanisms, the scale of the challenges posed by COVID-19 has prompted a variety of bold proposals for change in the global architecture for managing infectious disease. These recommendations need to be assessed against the reality of significant fragmentation of global health governance over the past two decades, during which the number of new international actors and initiatives has exploded. Within the context of this “dense institutional ecosystem,”151 a paramount concern is to avoid exacerbating coordination problems or the competition for scarce resources and political capital. Furthermore, without addressing the underlying political dynamics that are hampering effective cooperation—including geopolitical rivalry between the United States and China—any new schemes need to beware of reproducing the same problems in any new institutional scheme.
 

6.3.1 A Stronger Global Surveillance Network
 

COVID-19 has demonstrated that no country can expect to protect its population from pandemic threats solely through measures taken “at the border.”152 The need for a coordinated global surveillance network to prevent and detect emerging infectious diseases has thus been a consistent theme in recent expert panel reports and in the deliberations of bodies such as the G7. This global public good requires urgent capacity-building efforts at the national level and prioritization by international financial institutions as they consider the possibility of a dedicated pandemic financing facility153 or global health security fund.154 The following proposals could help support the realization of this goal:

• A global genomic and epidemiological surveillance network, with the WHO at its center, to prevent and detect cross-species spillover and to rapidly share data.155 As suggested by the G20 High Level Independent Panel, this network could build upon the model of the WHO’s Global Influenza Surveillance and Response system by increasing the availability of data on new pathogens, enabling just-in-time sharing of that data, and developing new analytic tools and predictive models. The newly created Hub for Pandemic and Epidemic Intelligence156 (linked to the WHO’s Health Emergencies Programme) should be explored as part of the solution to filling this key governance gap.
• A new global prototype pathogen agenda that helps to develop vaccines against representatives of the main viral families known to cause human disease.
• Stronger capacity in regional and national surveillance “spokes,” rooted in national public health institutes and centers for disease control but also linked to strengthened capacities in key “hubs” such as the WHO and the Food and Agricultural Organization of the United Nations. This hub-and-spoke system will require not only adequate infrastructure and training (particularly in molecular diagnostic capacity and data integration) but also agreement on the policies, principles, and underlying framework that will guide cooperation across the network.157
• Greater investment in “One Health”158 approaches to minimize possible spillovers from animals to human beings.
   

6.3.2 A Global Health Council
 

Various assessments and reviews of global cooperation on pandemics have concluded that the WHO should remain at the center of global health security governance, given its valuable technical competencies and important functional roles in infectious disease.159 But the same reports also stress the WHO’s lack of “political heft to mobilize and lead” multilateral responses to pandemics that pose wide-ranging threats and that it particularly struggles to “constructively partner” with the private sector.160

In response to this challenge, some have called for the creation of a Global Health Coordinator, reporting directly to the UN secretary-general, who could help to lead a coherent and unified response to pandemics and other global health emergencies across the UN system, while also providing “political cover” for the more technical work of the WHO.161 In this proposal, the coordinator would facilitate Security Council involvement in infectious disease crises and work in concert with the leadership of financial bodies such as the International Monetary Fund, World Bank, G20 and G7, as well as with relevant nongovernmental and humanitarian organizations. As an alternative, the WHA’s independent panel argued for a new Global Health Threats Council that would elevate pandemic management to the highest political level of decision-making (heads of state and government) and thus have the capacity not only to mobilize the resources and will to act decisively in emergencies but also to maintain a political commitment to pandemic preparedness in “normal times.” Such a body, the panel suggested, could also monitor progress toward the goals and targets set by the WHO and thus increase efforts to hold actors accountable for their pledges.162

Do these ideas address the core problems witnessed during current and previous pandemics? While a UN coordinator role was in place in earlier cases, such as during the Ebola outbreak in West Africa and the Democratic Republic of the Congo, such a position does not address underlying issues related to resources and political will. Moreover, operational coordination across the UN system was not the most pressing problem during the COVID-19 pandemic. The director-general of the WHO already engages regularly with core parts of the UN system and has established a practice of cooperating with Bretton Woods institutions such as the World Bank and the International Monetary Fund. Coordination with particular regimes has been more problematic; for example, World Bank funding was not initially available for early vaccine orders under the COVAX scheme. In addition, the provisions for pandemic preparedness and response under the IHR (2005) contain few mechanisms for coordination across legal regimes (which extend beyond public health and trade to include investment, civil aviation, human rights, and peace and security); instead, states are left to “accommodate their competing international obligations.”163 A coordinator position, however, is not likely to be sufficient or appropriate to address these issues. Moreover, given the current political deadlock that plagues the Security Council, as well as concerns about unduly “securitizing” public health, elevation to this intergovernmental forum is a risky strategy for achieving effective collection action on pandemic preparedness and response.

The proposal for a Global Health Threats Council provides a different model for elevating the level at which states deliberate on global health security. As conceived by the WHA’s independent panel, a new head-of-state-led council would help to address weaknesses in leadership at the global level and generate positive impacts from cooperation that would also be felt at the national level.164 While some might argue that a better approach is to convene, when needed, heads of state under the auspices of the WHO, effective pandemic preparedness and response is about more than health policy alone. A new head-of-state council would have broader scope than could be provided by any construct flowing from the WHO’s constitution.

Establishing such a council nevertheless faces two challenges: the first is to maintain a separate body of pandemic governance at the head-of-state level that remains actively engaged outside the context of an emergency; the second is to avoid replicating the competitive dynamics that exist among great powers in the Security Council. The first problem could be addressed, in part, by ensuring that a Global Health Threats Council would have the backing and authority of the UN General Assembly and by creating “routine” links with key policy-makers in pandemic preparedness and response at the national level. The second challenge could be reduced if such a council stays clear of battles over foundational norms or principles and instead remains focused on the practical tasks of coordinating the actions of different actors and ensuring sufficient financing for their efforts. Nevertheless, even if a new body might avoid falling into some of the well-established patterns of rivalry and deadlock that affect the UN Security Council, diplomats would not be able to sidestep the painstaking work of finding areas of common ground between key states such as the United States and China.
 

6.3.3 A Permanent Platform for Equitable Access to Diagnostics, Treatments, and Vaccines
 

A third set of reform proposals that should be actively pursued relate to the creation of a reliable and geographically diverse supply of medical countermeasures and tools to address pandemics. A stand-by production capacity for both finished products and inputs into the supply chain would shorten the response time to an unfolding crisis. But it could also help to ensure more equitable access to diagnostics, treatments, and vaccines by reducing the short-term trade-offs for countries seeking to meet both domestic and global needs.165 The proposals for such a platform include innovative ideas on how to incentivize the private sector through a combination of “push” factors (such as cofunding of research and development and supply capacity) and “pull” factors (such as assured procurements).166 These reform ideas also try to address some of the weaknesses in COVAX as a mechanism for ensuring global access to vaccines.

COVAX was forged in a nonideal context wherein advanced countries already had advanced purchase commitments. Furthermore, because COVAX was promising to provide enough vaccines to cover 20 percent of countries’ populations (later expanded to 30 percent), high-income states were always going to have to negotiate their own contracts to cover the rest of their citizens. Once they began doing so, the impetus to negotiate for 100 percent coverage soon took hold. The system therefore included an in-built incentive to defect from the arrangement and over-order vaccines. That impetus was driven, in large part, by the acute performance legitimacy concerns of today’s advanced democracies. But those same concerns had the effect of transforming COVAX into a form of multilateral aid: the scheme provided pool procurement primarily for low- and middle-income countries and handled negotiations around vaccine reliability, indemnification, and regulatory concerns.

Theories of democratic accountability and certain influential strands of political theory167 argue that governments can justifiably prioritize the health and well-being of their own citizens. Such a position would be ethically defensible, however, only if it did not entail excess purchases of vaccine doses and was balanced by high-income countries taking other proactive steps to expand vaccine access and manufacturing—steps that leading democracies have either avoided or been very slow to take. But even if such steps were taken, democratic accountability pressures are such that many high-income countries do not perceive the sharing of doses, before a vaccine is fully available to their own citizens, to be politically feasible on the sort of timescale that global health advocates believe to be most effective or just.

In the case of COVID-19, however, the even bigger challenge confronting the goal of vaccine equity has been vaccine scarcity. This issue has three main sources. First, a supply chain problem was “baked into” the COVAX mechanism through its specific targets. The initial vaccination target of 20 percent, which at the outset appeared ambitious because it would ensure that those individuals most at risk would be protected, subsequently proved insufficient in light of the toll of the pandemic and the longer-term goal of providing enough coverage to reach herd immunity.168 Insufficient early financing of COVAX made supply shortages all but inevitable, and these shortages, in turn, led low-income countries to use grants and loans from the World Bank—designed for administering vaccines—to finance doses.169 The second constraint on vaccine supply stemmed from the limited amount of global manufacturing capacity. Not only COVAX but all countries around the world relied on a small set of vaccine producers. Third, despite mechanisms to address patent-related intellectual property issues, including schemes for compulsory licensing and “open source” manufacturing,170 many countries still lack the technical know-how needed to take patent licenses forward and thus contribute to expanding global production.

The design of any permanent, negotiated platform to supply critical diagnostics, treatments, and vaccines should therefore begin with the recognition that the ACT Accelerator program suffered from various forms of inequity: large donor countries were seen to have outsize influence over the scheme, and access to testing capacity, supplies, treatments, and vaccines was ultimately dependent on the good will of donors—leaving much of the world’s population with restricted and delayed access. The proposals of the WHA’s independent panel, which envisage “end-to-end” planning for research and development, technology transfer, clinical trials, and manufacturing processes, are designed to transform pandemic preparedness and response from a charity model to a shared-fate model, in which more societies participate in the production and distribution of the requirements for meeting potential pandemic challenges.171

Even if such a platform is not agreed upon by all states, it could form the basis of a concerted effort on the part of a grouping of advanced liberal democratic states (whether through the G7, the G20, or the EU). This is one area of cooperation that does not require universal membership and could benefit from early catalytic leadership by a set of countries whose reputations were severely damaged by their early performance during the pandemic and their continued failure to address vaccine access.
 

Endnotes

• 151Brown and Held, “Health,” 168.
• 152Alvarez, “The WHO in the Age of the Coronavirus,” 580.
• 153IPPPR, COVID-19, 54.
• 154G20 High Level Independent Panel, A Global Deal for Our Pandemic Age, 12–13.
• 155Ibid., 32–34.
• 156WHO, “WHO, Germany Open Hub for Pandemic and Epidemic Intelligence in Berlin,” press release, September 1, 2021.
• 157G20 High Level Independent Panel, A Global Deal for Our Pandemic Age, 33.
• 158As defined by the Centers for Disease Control and Prevention, One Health is “a collaborative, multisectoral, and transdisciplinary approach” to achieving optimal health outcomes, “working at the local, regional, national, and global levels” and “recognizing the interconnection between people, animals, plants, and their shared environment.” See Centers for Disease Control and Prevention.
• 159This conclusion features in the reports of the Council on Foreign Relations, the independent panel appointed by the WHA, and the G20 High Level Independent Panel.
• 160Council on Foreign Relations, Improving Pandemic Preparedness, 77.
• 161Ibid., 78.
• 162IPPPR, COVID-19, 47.
• 163Alvarez, “The WHO in the Age of the Coronavirus,” 584.
• 164IPPPR, COVID-19, 47. For the proposed terms of reference for the Council, see ibid., 71–74.
• 165G20 High Level Independent Panel, A Global Deal for Our Pandemic Age, 23.
• 166See ibid., 36–39; and IPPPR, COVID-19, 54–55.
• 167See, for example, David Miller, National Responsibility and Global Justice(Oxford: Oxford University Press, 2007); and Allen Buchanan, Justice, Legitimacy and Self-Determination(Oxford: Oxford University Press, 2003).
• 168COVAX’s initial supply problems were magnified by one final challenge: though the first vaccines to conclude trials were mRNA vaccines, these were not the vaccines COVAX had invested in.
• 169With the restructuring of COVAX in June 2021, vaccine doses will now be sent to low-income countries, thereby freeing up money to help these states manage logistical challenges and avoid wastage.
• 170Countries are already able to issue compulsory licenses under the Trade-Related Aspects of Intellectual Property framework of the WTO. However, the process is slow and marked by legal obstacles and pressures from pharmaceutical companies that make it difficult to act quickly during public health emergencies. Moreover, the framework is limited to patents only and thus does not address other intellectual property restrictions, such as trade secrets. The Biden administration, building on an earlier proposal from South Africa and India, has therefore called for the negotiation of a temporary waiver of intellectual property rights protections for technologies that are needed to prevent, contain, or treat COVID-19, including vaccines and vaccine-related technologies. This proposal seeks to extend such a waiver beyond patents.
• 171IPPPR, COVID-19, 54–55.

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 and the need for consensus decision-making, they are likely to make only modest progress;172 and that without movement on underlying incentives or specific efforts to manage the spillover effects of geopolitical competition on global health, investment in cooperative arrangements and institutions such as the WHO is unlikely to accelerate.

This is why efforts to improve pandemic preparedness and response should rely not on one solution or negotiating process but should instead embrace a range of strategies that assemble a “patchwork”173 of interlinked rules, processes, and organizations to fulfill the critical functions of pandemic governance. Instead of being focused solely on states or on a single institution (like the WHO), such efforts—to return to the concept used at the start of this paper—would be “polycentric.” The resulting patchwork for pandemic preparedness and response could be a combination of club-based commitments among a smaller set of states to launch new initiatives (such as a permanent COVAX); stronger peer review of national policies to uncover particular deficiencies in national preparedness; specific financing facilities to support and incentivize states to improve their infrastructure for addressing public health emergencies; new provisions in economic institutions that link resources to progress on pandemic preparedness; enhanced support for nongovernmental monitoring and reporting on levels of preparedness for pandemics; and a stronger global surveillance network.

The academic research on international cooperation indicates that, to succeed, those advocating for and designing such arrangements must squarely confront the distribution problems that have undermined cooperative efforts on pandemic preparedness and response and therefore create venues and mechanisms to foster political dialogue—both among today’s rival powers and between low- and high-income countries. They must also battle against the increasing desire on the part of political leaders and publics to “return to normal”. Above all, they must work to ensure that the opportunity presented by the crisis of COVID-19 will be translated into concrete achievements on global cooperation.

Endnotes

• 172This has been the lesson of the UN Framework Convention on Climate Change.
• 173Keohane and Victor, “Cooperation and Discord and Global Climate Policy.”