Time for reform: local and global health governance
Shortcomings in political and societal resilience have been laid bare by the Covid-19 pandemic, but by taking a systematic and fair approach to pandemic prevention, preparedness and response – and with the right investments – the world is capable of finding effective solutions
The Covid-19 pandemic plunged the world into a formidable global health crisis in 2020. It has claimed millions of lives and affected more than 200 countries. As of 15 August 2022, there were 587 million confirmed cases of Covid-19 and 6.4 million reported deaths, excluding deaths from the disruption of services, especially for life-threatening non–Covid-19 conditions. While there has been slow progress in ending the pandemic due to limited access to Covid-19 vaccines in Africa and the continued emergence of variants, the large human monkeypox outbreak has had no clear link to endemic countries. Of the 44,503 cases reported, 99% have been reported from locations that have not historically reported monkeypox. Despite low mortality, this has raised serious concerns about a possible change in transmission that could pose a greater global threat.
The negative impacts of Covid-19 have been felt across sectors and at all levels. Inequities and inequalities have been laid bare and continue within and among countries. Covid-19 has further exposed the vulnerability of individuals and communities, the interplay with other infectious and non-communicable diseases, and the disproportionate effect on ethnic groups, the poor and informal sectors in countries of all incomes. The threats to human, animal and environmental health are inextricably linked, and have consequences on economic activity and disruptions. Economic recovery is inequitable: the gross domestic product per capita of developed countries is forecast to recover fully by 2023, but remains elusive elsewhere. Developing countries in Africa foresee a gap of 5.5 percentage points of GDP per capita compared to pre-pandemic projections.
More crucially, systems caved due to fragility and associated threats. In the health sector, the health crisis revealed poor surveillance and weakened health systems, scrambles for supplies and lack of access to medical countermeasures. In the environmental sector, planetary emergencies are increasing with intensified droughts, floods, extreme temperatures and wildfires. More broadly, shortcomings in political and societal resilience across the globe have been exposed. At the United Nations Glasgow climate conference in 2021, global efforts to hold countries accountable for reducing greenhouse gas emissions and promoting adaptation were inadequate, with more challenges than solutions being reported.
A legally binding instrument
There have been calls to improve local and global health governance for a globally coordinated response to a future pandemic or public health emergency. However, the debates have no traction. The pandemic has fast-tracked decisions for bold moves by World Health Organization members to adopt an international instrument or agreement through inclusive engagement by countries and other relevant stakeholders.
The recent discussions in the intergovernmental negotiating process were preceded by a systematic approach that entailed developing a digital platform to identify substantive elements to include in a WHO convention, agreement or international instrument (CAII) on pandemic prevention, preparedness and response. Extensive deliberations and written submissions created a basis for global governance mechanisms and collaboration for a collective response to pandemics. The proposed technical solutions will likely be negotiated through global health diplomacy, although the imbalance of negotiating power between North and South has shifted through coalitions among the Global South.
Ultimately, the CAII must be an efficient global and national governance mechanism that aims to end the current crisis and prevent similar crises from happening again. This requires joint action of the health and non-health sectors, public and private health sectors, communities, and civil society at the country level through the whole of society, to engage many different stakeholders and all of government to facilitate cross-sector problem-solving. Strengthening the global health architecture requires synergies in efficient global health governance through the WHO, United Nations agencies and bilateral organisations; in effective global governance for health through the World Health Assembly, UN General Assembly, World Trade Organization, Human Rights Council and other global health initiatives; and in governance, which refers to the institutions and mechanisms established at national and regional levels to contribute to global health governance and governance for global health.
Substantive elements
The technical contents of the CAII have been proposed on preparedness, prevention and response capacity, health systems resilience, the vital role of primary health care and universal health coverage. There has also been a focus on strengthening surveillance, including on potential zoonoses in wildlife and domesticated animals, as well as on genome sequencing and sharing real-time data for global risk assessment and timely responses to prevent small-scale outbreaks from spreading into an epidemic or pandemic. Strengthening public health laboratory and health workforce capacities – the backbone of preparedness, prevention and responses – requires maintainable and adequate funding, from sustainable domestic sources. Nonetheless 28 low-income countries require significant funding support from development partners.
One highly contentious issue is addressing the global inequities in access to pandemic response products, including vaccines, therapeutics and diagnostics. The WTO’s decision on intellectual property rights in June 2022 focused on Covid-19 vaccines, rather than all pandemic response products. The CAII must synchronise with the WTO to address this inequitable access to pandemic response products.
Indeed, equitable access can be resolved by increasing manufacturing capacities to match the demand of a global population of 8 billion in pandemic situations, through transferring technology and know-how from high- to low- and middle-income countries. The availability of products in the market requires efficient application of novel WHO and national regulatory pathways and emergency-use procedures. In addition, ensuring synergies and alignment with other international legal regimes and the International Health Regulations, including gender equity and human rights, should be the primary principles of the CAII.
Recognising the WHO as a primary actor during a pandemic, the CAII should reside in an institution with a strong track record, and a competent authority with good governance arrangement. It should be subject to periodic review of its relevance and effectiveness.
The substantive elements of the new CAII should be informed by scientific evidence on what works and what does not. They should fill the gaps and address the failures of the current pandemic responses, especially the stark inequity across countries. Of course, these scientific technical solutions will be shaped through global health diplomacy in negotiation, reconciliation and consensus building.
