No time to lose: Pandemic agreement—Urgency over complacency; unity over fragmentation

The 77th World Health Assembly (WHA) concluded in June 2024, and global leaders have shared their reflections, drawing lessons from COVID-19 that highlight common shortcomings. These include deficiencies in research and development, technology transfer, access and benefit-sharing, supply chain logistics, regulatory enhancements, and international coordination and communication.¹ Ironically, these very issues have stalled progress on the pandemic agreement. What lies ahead? Will delays in preparation prove costly?

While not meeting treaty or convention status, the Pandemic Agreement is evolving into a comprehensive global framework for pandemic prevention, preparedness, and response. From a global public health and security perspective, expanding beyond superficial statements of readiness is necessary. Critical aspects must accelerate. We consider five key challenges below:

Global pandemic preparedness demands greater urgency and unity, to ensure an early Pandemic Agreement that allows strong measurable progress. The former co-chairs of the Independent Panel for Pandemic Preparedness and Response (IPPR) urged leaders to unite,² act promptly during the interpandemic period, and there is ‘no time to gamble’.³ The Association of Schools of Public Health in the European Region (ASPHER), with the Global Network for Academic Public Health (GNAPH), advocates for strengthening national and global health systems to enhance preparedness, response, and resilience against future pandemics. This involves substantial investment in healthcare infrastructure, workforce training, public health surveillance systems and research, development and improvements in practice.⁴

Timely implementation of multiple preparedness measures is crucial to prevent and mitigate the impacts of future pandemics. Building and maintaining public trust through transparent communication and community engagement is fundamental. ASPHER underscores the role of public health institutions in fostering trust and confidence in pandemic-related health measures. Modern public health countermeasures and health technologies helped mitigate losses during COVID-19 compared to historic plagues, but preparedness and response could have been much better.

The proposed Pandemic Agreement needs concrete action and should complement International Health Regulations, and other WHO and UN treaties, aiming for a cohesive approach to global health emergencies and wider disasters, as outlined in the Sendai Framework for Disaster Risk Reduction (DRR).⁵ The Global Assessment Report 2023 on DRR ⁶ highlights how conflicts and humanitarian disasters are reversing global development, indicating the need to link pandemic preparedness to wider threats where possible.

Countries need to prioritise pandemic responses based on their populations' needs. While WHO provides support, it does not override national laws and respects their sovereignty. Member states must each ensure their country's legislation supports pandemic efforts, enhances equity, and balances human rights in their response measures. The Pandemic Agreement could facilitate collaborative efforts during future global health crises by setting minimum standards to address lessons from COVID-19 and other outbreaks.

ASPHER continues to review the pandemic ‘lessons learnt’ from European countries.⁷ Country-level inquiries into pandemic preparedness deficiencies continue to provide valuable insights. The Spanish evaluation emphasised the need to clarify the balance between national and provincial powers, underlining the importance of a clear and sufficient legal framework to ensure legal certainty for decision-makers.⁸ The recent UK Inquiry into preparedness highlights the need to be better prepared for more than influenza viruses, comprehensive exercising and testing of systems, flexibility of response and recognising existing inequalities.⁹ ASPHER will continue collaborating with partners to improve future pandemic preparedness, building community trust and transparency to counteract misconceptions and misinformation. In reviewing the pandemic response worldwide, a systemic and structural pattern of erosion of Public Health (PH) expertise and services emerged.¹⁰ ASPHER advocates for a well-staffed public health workforce focused on equity and the precautionary principle. ASPHER is expecting to collaborate with international partners to ensure the Pandemic Agreement fully incorporates these essential elements and embraces competency frameworks, such as applied infectious disease epidemiology.¹¹

The COVID-19 pandemic highlighted the need to embed the One Health approach in our institutions as a policy cornerstone to help prevent future pandemics. ASPHER recognises that most other novel human infectious diseases in the past 2 decades have been of zoonotic origin, such as SARS-CoV-1, swine flu, MERS, COVID-19, Mpox, Ebola, Zika virus, and recently H5N1. Experts continue to identify potential candidates for the next pandemic, advocating for a flexible and resilient approach to unknown pathogens.

ASPHER advocates for a One Health approach, highlighting the interconnectedness of human, animal, and environmental health, as a critical foundation for the Pandemic Agreement. Holistic perspectives are crucial for effective prevention and response strategies, addressing a variety of health determinants, from ensuring food safety and security, to sustainable food production and reducing inequities. Public health measures underscore the importance of conserving natural resources and improving health. One Health approaches also seek to address threats posed by climate-driven disasters and rapidly spreading transboundary diseases.

ASPHER promotes One Health perspectives emphasising the importance of inter- and multi-sectoral understanding of vulnerabilities and fostering information exchange among One Health partners. This collaborative and multidisciplinary strategy is essential for strategic coordination, research, capacity building, stakeholder engagement, and applied joint interagency activities.¹² It also supports high level of health protection in all policies and enhances Health in All Policies (HiAP).¹³ Additionally, it broadens the concept to Health For All Policies, ¹⁴ using updated tools for integrated Health Impact Assessment, identifying co-benefits, and ensuring that health remains a priority across various sectors, creating a win-win situation. However, to achieve this, we must recognise inequalities, vulnerabilities and complexity, such as syndemic phenomena, and we must ‘move beyond our silos’¹⁵ to focus on promoting an integrated well-being-based economy, addressing social, environmental, and commercial determinants of health and health equity.

Negotiations on public health and health policy priorities in the agreement should include ratified common principles, formulating legal obligations, and publicising the necessity of effective mechanisms to deliver PABS. These negotiations should be supported by arrangements ensuring long-term collaboration, shared financing, and measurement of the extent to which mutual obligations are being met. Additionally, these negotiations would identify and address any unforeseen loopholes in the agreement that could lead to the exploitation of LMIC by global corporations or acquisitive behaviour by member states.

The International Health Regulations 2005 (IHR) provide a comprehensive revised legal framework for countries to define their rights and obligations in managing public health events and emergencies, including cross-border collaboration. IHR determines if an international health threat event qualifies as a Public Health Emergency of International Concern (PHEIC). The seven PHEICS since 2005, Influenza A H1NI, Polio, Ebola (twice), Zika, COVID-19 and Mpox showed the major benefits of IHR for global cooperation in urgent responses, while highlighting aspects for updating their rapid and complex decision-making processes, such as clarity on when the panel of international experts have split opinions or where the judgement of WHO leaders diverges from the panels' assessments.¹⁵

The COVID-19 pandemic clarified that IHR need updating to strengthen global preparedness and response to public health emergencies. Consequently, amendments from the Member State-led Working Group were adopted at the 77th WHA.²⁷

This revised IHR process aligns with strengthening global health in the pandemic agreement and will introduce essential safeguards to protect travellers' rights and personal data, ensuring standards of confidentiality and data protection conform with best practices. They also require prior informed consent and a non-discriminatory approach to applying health measures such as medical examinations and vaccinations.

The updated IHR ³⁶ will allow the WHO to improve early warning systems and issue public health alerts for events that may constitute a PHEIC. These modernised regulations reflect current realities and aim to improve global health security. However, to reduce hesitation in declaring a PHEIC, it is recommended to replace the current binary mechanism with a tiered, or traffic light system, that would allow a public health event to progress through increasing levels of global alert, signalling a developing outbreak that does not yet constitute a PHEIC.³⁷

ASPHER supports the fundamental surveillance functions of alerting, preventing, detecting, assessing, and notifying the WHO within 24 h after a similarly rapid, accurate assessment of public health emergencies, in accordance with IHR-2005.

The Intergovernmental Negotiating Body (INB) is actively working on the proposals, and governmental commitments must not fade away. Immediate and decisive action is required to finalise and implement the pandemic agreement, ensuring we are better prepared for such inevitable health emergencies. The ASPHER Public Health Emergency Taskforce will continue to review progress, highlight developments, alert on evolving health threats, and remain actively engaged in informing core competency and curricular developments to build a robust health workforce.

Ariane Bauernfeind led the writing of this manuscript. All authors contributed to the original draft preparation: i. Global Pandemic Preparedness is achievable: led by John Reid and John Middleton. ii. One Health Approach as a Foundation: led by Nadav Davidovitch, Mohamud Sheek-Hussein and Henrique Lopes. iii. Equitable Access to Pandemic-Related Health Products: led by AMC, Meri Koivusalo and Amitabha Sarkar. iv. Global Public Health Surveillance: Timely Data Sharing Across Boundaries: led by Alison Mccallum, Manfred S. Green and Colette Cunningham. v. Linking to the International Health Regulations: Strengthening Global Health Security: led by Colette Cunningham and Mohamud Sheek-Hussein. Review & Editing: Ariane Bauernfeind and John Reid. Critical revision: John Reid.

The authors declare no conflicts of interest.