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To address the lack of preparedness by countries and the world for COVID-19 and future pandemics, there is now a global push for a new health treaty on preparedness and response that would supplement and strengthen the WHO International Health Regulations.
Although the concept of a new treaty is attractive and has the potential to improve preparedness if structured effectively, focus on a treaty could do more harm than good if the treaty process delays or replaces the necessary efforts to strengthen preparedness now.
For any treaty instrument to be useful, there must be careful consideration of its structure, negotiation process, development, implementation, enforcement mechanisms, independent monitoring and governance.
Because the treaty process is inherently slow, and time is not on our side, we must consider faster processes and ensure that we build on momentum already generated toward making necessary improvements in global health preparedness and accelerate work on creative, practical solutions to strengthen and sustain core capabilities of public health systems in every country and every community of the world.
As the world continues to grapple with the COVID-19 pandemic, it is clear that countries were not as prepared as they needed to be and did not consistently respond as mandated by the international health regulations (IHR).1 2 To address these shortcomings, there is now a global push for a new health treaty on preparedness and response that would supplement and strengthen the IHR.3 4 Although this effort has the potential to improve preparedness if structured effectively, discussions must address potential pitfalls and be designed carefully to parallel rather than replace the necessary efforts to strengthen preparedness now. Otherwise, focus on a treaty could do more harm than good.
The concept of a new treaty is attractive—WHO Director-General Tedros Adhanom Ghebreyesus has called it a ‘very good idea’5—but has substantial risks. The treaty process is slow, and takes time that we simply do not have to strengthen global pandemic response capacity. The focus on developing a treaty could derail momentum for action on the ground to improve preparedness now. Wordsmithing, and interpretation of that wordsmithing, can supplant action.
One treaty model being pointed to is the framework convention on tobacco control (FCTC), the world’s first treaty on public health.6 The FCTC took 8 years to negotiate, another 3 years to ratify and many more years to agree on protocols for the different components. The FCTC’s first protocol, on illicit trade, was adopted and then entered into force 7 and 13 years after the FCTC itself came into effect.7 Additionally, the FCTC had little practical impact until it was paired with an implementation strategy—the MPOWER tobacco control technical package8—which was not developed until 3 years after the FCTC entered into force.
The FCTC along with the MPOWER technical package have been a useful combination. Since MPOWER was introduced, global adult smoking prevalence has declined nearly 15% (from 22.5% to 19.2%) and most countries have implemented at least one strong tobacco control policy.9 This was largely due to the robust evidence base and existing resources for tobacco control, which has led to slow but steady progress in reducing tobacco use worldwide.
By agreeing to spearhead a request by some member states to begin the groundwork for negotiating a binding treaty on health security, WHO will ultimately put the ball back in the court of countries, many of which did not comply with the existing IHR during the COVID-19 pandemic.
Proponents of a treaty argue that, given the magnitude, scope and scale of global disruption caused by pandemics, a strong, bold and rapidly developed instrument is now required.4 The treaty would supplement the IHR, while coordinating and regulating fields beyond health, and would serve to bring countries together and rekindle much needed global collaboration.
There is a strong possibility that many countries, including the USA, might not ratify it.10 Of particular concern is the risk that a treaty negotiation with hypothetical outcomes may detract from what can—and should—be done today.
For a treaty and treaty process to be useful, it would need to incorporate the following components:
First, any such treaty must build on and be developed in parallel with current efforts to strengthen preparedness, not replace them. We cannot afford to squander the momentum that has already been generated toward making necessary improvements in global health preparedness.
Second, there must be meaningful, effective and legally binding enforcement mechanisms. Although parts of the FCTC are legally binding, compliance by countries is still largely voluntary, and this has left billions of people still largely unprotected by effective tobacco control programmes.9 The FCTC is governed by a weak secretariat: without a strong governing structure, even a good treaty will be undermined. The IHR is also legally binding, but again there is minimal ability to force countries to meet their global health security commitments. For example, one firm requirement of the IHR is to submit an annual report on adherence and performance (the state parties annual report).11 However, the format of this report limits its utility, reports from many countries have not reflected reality on the ground and there is no verification mechanism. A WHO proposal for a universal health and preparedness review, a new peer review system for emergency preparedness and healthier populations, has the potential to be more meaningful if structured correctly and independently verified.12 Other considerations include moving the Global Preparedness Monitoring Board to report to either the UN Secretary-General or the UN Security Council, or creating a Global Health Threats Council led by heads of state.13
Third, a treaty will be of limited benefit without a technical package such as MPOWER. A set of benchmarks identified by WHO could form the framework of a technical package.14 Countries could commit to stepping up in core preparedness levels each year, supported by innovative financing arrangements including additional grant funding, debt-to-grant conversion programmes and time sliced funding contingent on progress.
Fourth, develop a target for preparedness that establishes clear metrics for progress and a pathway forward for measurement, accountability and improvement. For HIV, the ‘90–90–90’ goal established by the United Nations15—ensuring that 90% of people infected with HIV know their status, getting sustained treatment to 90% of those diagnosed and suppressing the viral load of 90% of patients on treatment—translated evidence into concrete action. We have proposed a new global target of ‘7–1–7’, whereby every country should be able to: identify any suspected outbreak within 7 days of emergence; report and begin investigation and response within 1 day; and mount an effective response—defined by objective benchmarks—within 7 days.16
Fifth, a treaty needs to be crafted so that it can open the doors for governments, including heads of state, to be actively involved in strengthening health security. Sustained political will at the highest levels of government will be necessary to galvanise action and accountability to make the substantial financial, technical and political investments needed to improve our capacity to find, stop and prevent future pandemics. Even with the FCTC and MPOWER, sustaining political will for tobacco control has been difficult and progress has been limited, particularly on financial action such as effective taxation of tobacco products.17
Sixth, do not combine a treaty negotiation with action to strengthen national and international institutions now, including reform of WHO. Although WHO is essential and remains pivotally important for a more effective global response, its role needs to be better defined and there must be stronger support from partners and development of new global capacities.18 Attempting to incorporate the treaty process into any broader reform initiative will likely frustrate both efforts.
Seventh, consider carefully which agencies should lead the treaty development process. WHO could use its constitutional powers, but may not have sufficient resources or, some argue, the mandate to host such a negotiation. Important cross-cutting areas will need to be addressed—such as finance, trade, cross-border travel, supply chain management, food security, law enforcement and national security, and the broader economic and social disruptions caused by a pandemic—that may be outside of WHO’s purview.7 Improving response to future pandemics and adopting all-of-government and all-of-society approaches to accomplish this, as suggested by treaty proponents, may need to be routed through a political framework in the wider United Nations system, possibly led by either the UN Secretary-General or the Security Council.19
Eighth, consider a framework convention approach, as was done with the FCTC, instead of a formal treaty.13 A framework would be an easier path that could leave some detail to later protocols and guidelines, but only if countries could agree on definite timelines to complete negotiations on such instruments quickly.
Strengthening global capacity to prevent, detect and respond to pandemic threats requires sustained commitment and effective governance from every country, effective use of existing and new funding and other resources, the support of strong and accountable global leadership and operational excellence with robust technical support and rigorous accountability in public health systems throughout the world.18
If approached correctly, a new preparedness treaty or other negotiated agreement among countries might help catalyse progress to improve our preparedness for future pandemics and other health emergencies. But unless we are careful about the process of development and implementation, effort on a treaty could hurt more than it helps. Whether we embrace a new international legal instrument or not, we need to work now on creative, practical solutions to strengthen and sustain core capabilities of public health systems in every country and every community of the world. We cannot allow ourselves to remain unprepared for the next, inevitable pandemic threat, and time is not on our side.
Data availability statement
All relevant data are included or referenced in the article.
The authors thank Amanda McClelland, RN, MPH for critical review of the manuscript and Drew Blakeman, MS for assistance with manuscript preparation.
Handling editor Seye Abimbola
Contributors Each of the listed authors (TRF, MB) meet the criteria for ‘Authorship’ in accordance with the ICMJE recommendations as outlined below: substantial contributions to the conception or design of the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding Resolve to Save Lives, an initiative of Vital Strategies, is funded by Bloomberg Philanthropies, the Bill & Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation. Resolve received additional funding for the COVID-19 response from the Stavros Niarchos Foundation and the Start Small Foundation.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.