COVID-19 revealed the limitations of the International Health Regulations

When the WHO declared SARS-CoV-2, the virus which caused COVID-19 disease a Public Health Emergency of International Concern (PHEIC), the WHO’s highest alarm in response to an infectious disease outbreak, ‘none of us will be safe until everyone is safe’ was the mantra for rallying global solidarity. The rapid spread of the virus beyond the walls of China signified an imminent danger and the cosmopolitan norms embedded in WHO’s IHR was seen as central to international cooperation among states. The IHR which was last revised in 2005 under article 21 of WHO’s constitution and entered into force in 2007 has been a key mechanism for global health emergency governance. Among other functions, the IHR empowers the WHO Director General to declare a PHEIC and make temporary recommendations in a way that minimises interference to international travels and trade.

Yet, for COVID-19, despite WHO’s plea for collective action, state-centred, nationalistic responses prevailed.3 11 Many countries deviated from WHO’s recommendations, abandoned platitudes of solidarity and pursued isolationist policies. We saw near total shutdown of borders, bans on export of medical supplies and the rise of ‘vaccine nationalism’. Even though such policies proved to be ineffective, they conflict with science and produce grossly inequitable outcomes.13 14

COVID-19 further exploited the geopolitical cracks between the major powers, centred on the origin of the virus and demonstrated the limitations of multilateral institutions in coordinating nation-states.15 16 These challenges impeded WHO’s efforts to mount an effective global response and prevented poorer countries with low economic and political bargaining power in accessing essential medical supplies. As Fidler argues, COVID-19 shredded ‘the perennial claim that a harmony of interests exists between low-income and high-income countries on health security’.17

The African experience and response to inequities in the global emergency preparedness system

Africa’s response to COVID-19 exceeded the expectations of many in the global community. African countries, led by the Africa Centres for Disease Control and Prevention (Africa CDC) and through the African Union (AU), rapidly embraced a joint strategy in addressing some of the gaps in their response capacity. In the wake of the pandemic, we saw strong collaboration between the public-health community, political decision-makers and regional development banks in Africa. Days after the first case of COVID-19 was reported in Africa, African Union (AU) Health Ministers agreed to a Joint Continental Strategy for COVID-19, committing to cooperate in response to the pandemic.18 This contrasts with some of the initial challenges faced by other regional bodies, such as the EU, in coordinating vaccine purchase and delivery when vaccines became available.19 20 This synergy across Africa however, led by the Africa CDC, led to innovations/initiatives such as the Partnership to Accelerate COVID-19 testing, the African Vaccine Acquisition Task Force and the Africa Medical Supply Platform that increased testing capacities and enabled pool procurement of essential medical supplies at a fair and fixed price.21

These measures helped in mitigating viral spread. However, much of the continent still faced significant challenges in access to COVID-19 vaccines against the backdrop of vaccine hoarding by wealthier countries,14 export restrictions22 and an intellectual property rights regime which monopolises scientific knowledge for health innovations.

The absence of a dispersed manufacturing system for vaccines meant African countries had to rely on COVAX, which had promised to secure timely access to vaccines for all countries regardless of their income level. However, the COVAX facility was pushed down the queue of buyers by richer countries who stockpiled doses that were in excess of their population need.23 In instances where vaccines eventually arrived in Africa, supplies were often too little, too late or near to if not expired.24 The unpredictability of supplies was a challenge for long-term planning by countries. Although supply chain bottleneck has since improved, the erosion of multilateralism and the subjugation of the health of poorer countries to the security needs of richer countries was predictably inequitable.

The challenges of a pandemic treaty in an unequal world

Proponents of the treaty believe that it will ‘foster an all-of-government and all-of-society approach, strengthening national, regional and global capacities and resilience to future pandemics’.25 While this is a worthy objective and such regulations for international health could strengthen global health security, including trade, transportation and the environment,26 and could increase access to medicines—especially for developing countries during emergencies—in practice, where the will of states reigns supreme in the international system, it may not guarantee a unified or equitable response in the event of another outbreak.27

COVID-19 has shown us some of the challenges intergovernmental organisations faced in ensuring nation states comply with international rules during public health emergencies. Africa’s dependence on other countries, especially for essential diagnostics and vaccines, rendered the continent vulnerable. Moreover, some of the major stakeholders who championed the treaty talks are the same high-income-countries who imposed undue travel restrictions, hoarded vaccines and have spent 2 years resisting the IP Waiver proposed by India and South Africa in 2020.28 Without caution, the preponderance of major stakeholders from developed nations in the treaty’s development may lead to a top-down treaty approach.29

Claims that States’ non-compliance with the IHR or their failure to abide by equitable vaccine-sharing mechanisms such as COVAX requires a treaty, need to consider why such a new instrument would generate the political commitments that these existing tools could not. What incentives would a treaty offer that could make political leaders behave differently during another outbreak, and choose not to hoard vaccines and instead prioritise populations who are at risk thousands of miles away? Particularly as many governments are driven by appeasing their electorate, who will hold them accountable if they fail to deliver quickly enough.

Faviero and colleagues have suggested embedding an independent oversight mechanism in the treaty that could hold states accountable.30 For instance, linking countries’ compliance with preparedness and response as a criterion for IMF periodic evaluation of their economic indices. Similarly, Hannon et al have called for the elevation of pandemic governance to the level of the United Nation (UN) General Assembly.31 While it seems principled in theory, however, such an approach risks undermining one of the aims of the treaty—to strengthen the powers of WHO. Yet, these suggestions barely address mainstream considerations on equity for developing countries.

As Moon and Kickbusch argue, the challenges of ensuring that states comply with international rules highlights ‘an enduring feature of the global system: the self-interested behaviour of sovereign states especially, when their perceived interests lie elsewhere’.32 From COVID-19 to Mpox outbreak, there is little about these events that have reflected a change in the prioritisation of the security needs of powerful state actors even as treaty negotiations are ongoing.33 Rather, these tragedies ‘teaches age-old lessons about the collateral damage caused by great power machinations, the hypocrisy of high-income countries on equity, and the never-ending neglect of the health problems that low-income nations disproportionately experience’.34

So, irrespective of the treaty aspirations or subsequent outcomes, global health security as Rushton asserts, ‘has always been (and will continue) to be defined through practice’ and such practices as multiple PHEIC has shown us ‘is inevitably fundamentally affected by the distribution of power in the international system’.35

What this implies is that Africa must more consistently and effectively assume responsibility for its own health security through a coordinated and integrated approach as demonstrated in the wake of the COVID-19 pandemic

Changing the status quo—A New Public Health Order in Africa

At the sidelines of the United Nations General Assembly in September 2022 in New York, African leaders made a call for a New Public Health Order.36 As opposed to colonial models of development, the New Public Health Order represents a roadmap for sustainable health outcomes and health security in Africa that is defined by five pillars. These include: strong African Public Health Institutions; Investment in Public Health Workforce and Leadership Programs; Increased Domestic Investment in Health; Respectful, Action-Oriented Partnership and Expanded Manufacturing of Vaccines and Diagnostics.

This move by African leaders further reiterates the earlier push by the Africa CDC for an increase in country leadership and ownership, and regional solutions in addressing health security and inequities in the aftermath of the West Africa Ebola Outbreak.37 The same push was also evident in the wake of COVID-19 pandemic and has become even more crucial given the gross inequities in access to diagnostics, therapeutics and vaccines that plagued the continent for COVID-19.21

Thus, a key focus of the new public health order is the expansion of manufacturing of medical products (vaccines, therapeutics and diagnostics). An example of this is the Africa CDC–AU-led Partnership for Africa Vaccine Manufacturing which aims to scale the number of vaccines manufactured in Africa from 1% in 2020 to 60% by 2040.38 Several continental initiatives to support this vision are also gaining momentum such as the recently ratified Africa Medicines Agency—a specialised institution of the AU focused on harmonising regulatory functions among states’ parties and African regional economic communities.39 In addition, the Africa Development Bank (AfDB) has established a foundation—the Africa Pharmaceutical Technology Foundation—to finance and facilitate access to technologies.40 The WHO has also established a hub for mRNA vaccines in South Africa with links to other countries in Africa, to further ensure technology transfer and specialised training for local manufacturers.

While these efforts are promising, they are not without their challenges. The ultimate viability of local manufacturing in Africa speaks to a broader set of considerations that needs to be addressed. These include incentives that would derisk investment and guarantee predictability in demands. Although, there are continental efforts to harmonise markets in Africa to facilitate economies of scale such as the implementation of a common regulatory framework, a platform for pool procurement and the Africa Free Trade Area Agreement.41 Additionally, there is a rising debt burden amidst newer loans and austerity measures instituted by international financial institutions, which has led to a reversal in social sector spending, including those on health commodities in many low-income and middle-income countries according to a report by Oxfam.42 43 This debt burden has been further aggravated by the pandemic, rising interest rates and war and instability in some parts of Europe.44

While development loans may have spillover effects on population health, the ensuing debt servicing requirements may have detrimental effect on health through constraining fiscal space for government health expenditures.45 As such, countries' high ratio of debt servicing to health expenditure in Africa could potentially hinder domestic health emergency preparedness reforms, such as efforts to strengthen regional supply chains and access to medicines during emergencies. The temporary halt of COVID-19 vaccine production at Aspen in South Africa due to insufficient domestic demand, for example, highlights this dilemma.46 The unpredictability of demands could be a major setback for the AU–Africa CDC plan to scale local vaccine manufacturing capacity from 1% to 60% by 2040.

While COVID-19 has shown that going forward, there is a need for greater self-reliance. However, there is still a need for Africa to be embedded within the multilateral pandemic preparedness mechanisms while ensuring that its voice and needs are included in pandemic preparedness funding mechanisms such as the Pandemic Fund.

The Pandemic Fund—towards equitable financing for pandemics?

The new Financial Intermediary Fund for pandemic preparedness that was proposed by the Group of Twenty (G20), now housed at the World Bank aims to ‘support the development, procurement and deployment of countermeasures and essential medical supplies’.47 However, there are concerns that the fund may replicate the top-down pattern of global governance that privileges high-income-countries48 as demonstrated during COVID-19. For example, low-income countries were only allowed a seat on the Pandemic Fund board after strong global criticism.49

In addition, there are also concerns that such a fund could also reaffirm the current price monopolies in the pharmaceutical sector without substantial considerations to developing countries’ capacities.24 Relying solely on the Pandemic Fund top-down mechanism to strengthen pharmaceutical capacity in Africa is, therefore, may not result in equitable financing for pandemic preparedness for African countries. As such, there is a need to ensure representation of African countries in the decision-making mechanisms of the Pandemic Fund.

The limitations of top-down pattern of solidarity in global health expose a system in dire need of reform even before the current pandemic.50 51 As a result, other pandemic financing mechanisms will also need to consider questions of equity. For instance, the white paper recently released by GAVI, which is a major supplier of childhood vaccines in Africa, outlined the organisation’s plans to diversify its supply procurement, with a focus on investing in African manufacturers.52 While the timeline for such transition is still unclear, these changes in GAVI’s business model are a potential step in the right direction towards equity—but will need to ensure that the needs and capacity of African countries are considered.

To ensure equitable pandemic financing, the Pandemic Fund will need to include a holistic, bottom-up approach in its design and implementation, which takes into account country needs, and includes representation of African countries and regional actors. One way to do this is to centre a regional organisation such as Africa CDC in its governance and operations—such as the inclusion of Africa CDC as an implementing partner of the Pandemic Fund.

Hence, in addition to designing the World Bank Pandemic Fund in a sustainable way that takes into consideration local realities, institutions such as the G20 could also provide an arrangement that would give countries more budget flexibility to meet their pandemic preparedness and response plans.53 African countries should be able to leverage development finance, capital markets and debt restructuring among other tools needed to create the fiscal space for health investment in line with national and regional priorities of building a new public health order in Africa.

However, the ultimate guarantor of Africa’s health security lies in increased domestic investment. Many countries in Africa still lack basic health infrastructure required to combat endemic diseases let alone respond to public health emergencies. Without adequate domestic investment in efficient primary healthcare services, delivery and social protection schemes and surveillance and laboratory capacities and workforce, disease outbreaks will continue to exacerbate existing inequalities.54 55