Treaty considerations

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