Global Health Governance: What Each Position Is Protecting

When COVID-19 was declared a Public Health Emergency of International Concern on January 30, 2020, the WHO had been aware of an unusual pneumonia cluster in Wuhan for several weeks. The declaration followed days of internal deliberation — deliberation constrained by the fact that the WHO's authority to investigate, name, or coordinate a response to an outbreak inside a member state depends entirely on that member state's consent to cooperate. The International Health Regulations, the international treaty that governs how states report and respond to disease outbreaks, require member states to notify the WHO of events that may constitute a public health emergency. They do not require states to grant WHO investigators access to affected areas. They do not authorize the WHO to independently verify outbreak reports. They do not give the WHO any enforcement mechanism against states that underreport, misreport, or delay. The system is, by design, dependent on state voluntary compliance — and states have consistent economic and political incentives to comply late or partially.

What followed over the next several years — the global pandemic, the inequitable distribution of vaccines, and the eventual adoption of a Pandemic Agreement whose key PABS annex was still unfinished in spring 2026 — was not primarily a scientific failure or even a logistical one. It was a governance failure, rooted in the same structural tensions that define every debate about who governs the global commons. The WHO exists to coordinate global health security. But it can only operate at the pleasure of its member states, whose domestic economic and political interests diverge from — and sometimes directly conflict with — the requirements of effective pandemic response. The negotiations toward a Pandemic Accord (formally, the WHO Pandemic Agreement, sometimes called the CA+) that began in 2021 culminated in the Agreement's adoption on May 20, 2025, then shifted into a second-stage fight over the Pathogen Access and Benefit Sharing (PABS) annex that WHO member states were still negotiating in March 2026. The whole process has been contested at every point — not because negotiators disagree about whether pandemics are dangerous, but because the institutional design choices required to prevent the next one require giving up something each position in this debate is protecting.

The WHO is 80 percent funded through voluntary, earmarked contributions — meaning that the majority of its budget is controlled by donors who specify what the funds can be used for. The United States and the Bill & Melinda Gates Foundation are among the largest contributors. This funding structure shapes what the WHO can research, what it prioritizes, and what it says publicly about controversies involving powerful member states. The International Health Regulations were substantially revised in 2005 after the SARS outbreak demonstrated that the existing framework was inadequate. They were amended again, after extended negotiation, in June 2024. Neither revision granted the WHO meaningful independent investigative authority. Whether the adopted Pandemic Agreement and its still-unfinished PABS annex will change this depends on what the negotiating parties are willing to give up — which is another way of asking what they are most trying to protect.

What global health security and pandemic preparedness advocates are protecting

The window of time between the emergence of a novel pathogen and the moment it becomes uncontainable — and the recognition that closing that window requires surveillance infrastructure, mandatory reporting obligations, and international coordination that no single state can provide for itself. The global health security case for a strengthened WHO begins with the epidemiology of emergence: the majority of pandemic-potential pathogens originate at the interface of human and animal populations in low- and middle-income countries with limited public health infrastructure. The H5N1 influenza viruses, the Ebola outbreaks, COVID-19 itself — all emerged in environments where local health systems lacked the laboratory capacity to identify novel pathogens quickly, the epidemiological workforce to characterize them accurately, or the political incentives to report them promptly. The Global Preparedness Monitoring Board, established jointly by the WHO and World Bank in 2018, documented the consistent underfunding of pandemic preparedness infrastructure — not because governments considered it unimportant, but because preparedness investments are politically invisible until they're needed, by which point the window has closed. Global health security advocates are protecting the recognition that pandemic preparedness is a global public good with the defining features of all global public goods: the benefits of investment are diffuse, the costs are concentrated, and no individual actor has sufficient incentive to provide it at the level the world needs.

The WHO's capacity to exercise something approaching the authority its founding constitution describes — including the ability to send investigators to outbreak sites without waiting for host-state permission, and to publicly name a potential emergency before political pressure forces a diplomatic delay. The 2009 H1N1 pandemic, the 2013–2016 West Africa Ebola outbreak, and COVID-19 all involved documented delays in WHO emergency declarations — delays that allowed transmission to establish globally before coordinated response was possible. The Independent Panel for Pandemic Preparedness and Response, convened by the WHO in 2021 and co-chaired by former New Zealand Prime Minister Helen Clark and former Liberian President Ellen Johnson Sirleaf, concluded that the COVID-19 outbreak could have been contained if WHO had issued its PHEIC declaration in early January rather than late January 2020, and if governments had acted on it immediately. The delay reflected not a failure of scientific judgment but of institutional authority: WHO Director-General Tedros Adhanom Ghebreyesus was navigating member-state political pressure — including from China, whose cooperation the WHO requires to function in its largest country — at precisely the moment when decisive naming was essential. Global health security advocates are protecting the principle that a pandemic response institution that cannot act before outbreak politics become favorable is not a pandemic response institution.

The One Health framework — and the argument that preventing the next pandemic requires governing the animal-human-environment interface where most dangerous pathogens originate, not merely responding after human transmission is established. The One Health approach, which connects human health governance with animal health and environmental health governance, represents the furthest-upstream version of the global health security case. Its advocates, including the Lancet One Health Commission and the tripartite alliance of WHO, FAO, and WOAH (the World Organisation for Animal Health), argue that the governance gap at the human-animal interface — where industrial livestock production, deforestation, and wildlife trade concentrate the conditions for spillover — is the most important preventable driver of pandemic risk. Industrial animal agriculture, concentrated in a handful of countries that exercise significant influence over food safety and agricultural governance negotiations, is among the most consequential but politically difficult targets for One Health governance. The Pandemic Agreement text and the follow-on annex negotiations have addressed One Health largely in aspirational language; the binding provisions remain focused on the human health governance track.

What national sovereignty and WHO-skeptical advocates are protecting

The authority of democratic governments to make public health decisions for their own populations — and the skepticism that binding international obligations, negotiated among delegations insulated from domestic accountability, will produce policies that reflect the preferences of the people most affected by them. Sovereignty-first critics of strengthened WHO authority make an argument that should be distinguished from the American right-wing version that circulated as viral misinformation — the claim that the Pandemic Accord would grant the WHO power to override national lockdowns, mandate vaccines, or deploy international health police. No version of the Pandemic Accord under negotiation contains those provisions; the claim was factually wrong. But the underlying concern — that international governance frameworks negotiated by technical and diplomatic elites constrain democratic policy-making without democratic authorization — is a real tension in international law, and not only in health. The IHR's restrictions on trade and travel measures following a PHEIC declaration (designed to prevent states from imposing economically damaging restrictions that slow outbreak reporting) are a genuine constraint on state behavior. Sovereignty advocates are protecting the principle that the consent of the governed applies to international obligations as much as to domestic ones — that there is a democratic accountability deficit in governance frameworks whose binding elements are set by UN negotiating processes that bear no direct relationship to what any population voted for.

The specific concern about WHO institutional capture — and the structural conflict of interest created when an institution dependent on earmarked donations from powerful states and private foundations is asked to adjudicate emergencies that those donors have interests in. The WHO's funding structure is an acknowledged governance problem. The US is its largest single member-state contributor; the Bill & Melinda Gates Foundation is its second-largest donor overall, contributing more than most member states. Both have specific programmatic interests — the Gates Foundation in polio eradication, immunization programs, and primary health care delivery models that reflect particular technological and institutional preferences. The earmarked structure means that WHO staff work in programs that donors have defined, which may or may not align with the organization's official priorities or with the needs of member states that contribute little. Critics across the political spectrum — from global south advocates who argue that the WHO overweights the preferences of wealthy donors to conservative skeptics who argue that the WHO deferred to China on COVID-19 reporting to avoid jeopardizing contributions — have identified this structure as a fundamental governance problem. The Pandemic Accord's financing provisions, which would significantly increase the WHO's assessed (non-earmarked) funding, represent a partial response to this structural critique; sovereignty advocates who support the goal of a more independent WHO while resisting expanded mandatory authority are protecting the recognition that these two goals may require different solutions.

What health equity and global south advocates are protecting

The recognition that the current global health architecture concentrates both resources and governance authority in wealthy nations — and that a "reformed" pandemic architecture that preserves those concentrations while adding new reporting obligations on low-income countries is not reform but an extension of an extractive relationship. The COVID-19 vaccine distribution illustrated the structural position of low-income countries in the global health system with unusual clarity. High-income nations, which represent 16 percent of the global population, had secured orders for 60 percent of initial vaccine doses by late 2020. COVAX — the WHO-led vaccine sharing mechanism that promised to provide low-income countries with doses covering 20 percent of their populations — delivered 4 percent by the end of 2021. Wealthy nations that had secured excess doses did not release them to COVAX during the period when they would have had the most impact; instead, they administered third and fourth booster doses while health workers in sub-Saharan Africa and Southeast Asia remained unvaccinated. The public health consequences were documented in real time: the Alpha, Delta, and Omicron variants emerged in populations with low vaccine coverage, circulated globally, and drove waves that imposed costs on the wealthy nations whose vaccine hoarding had allowed them to emerge. Health equity advocates are protecting the recognition that vaccine nationalism is not only unjust — it is, on its own terms, epidemiologically self-defeating.

The TRIPS waiver — and the argument that intellectual property protections on pandemic vaccines and therapeutics constitute a governance choice to prioritize pharmaceutical revenue over human life, and that technology transfer provisions in the Pandemic Accord must be binding, not aspirational. In October 2020, India and South Africa submitted a proposal to the WTO to temporarily waive intellectual property protections on COVID-19 vaccines, treatments, and diagnostics. The proposal was supported by over 100 low- and middle-income countries and blocked for over a year by the United States, European Union, Switzerland, and United Kingdom under pharmaceutical industry pressure. A substantially watered-down version was eventually adopted in June 2022. Médecins Sans Frontières (MSF), which has campaigned on access to medicines for decades, described the outcome as "a bad deal" that did little to enable generic vaccine manufacturing in low-income countries. Achal Prabhala and colleagues at AccessIBSA have argued that the real barrier to generic vaccine production was not the IP waiver text but the absence of genuine technology transfer — the actual know-how, materials, and regulatory support that manufacturers need to produce complex biologics. The Pandemic Accord's PABS (Pathogen Access and Benefit Sharing) mechanism attempts to link pathogen sharing to equitable access to resulting vaccines — echoing the viral sovereignty logic articulated by Indonesian Health Minister Siti Fadilah Supari in 2006, when Indonesia withheld H5N1 samples from the WHO-coordinated network, arguing it was unjust for Indonesia to provide the raw material for vaccines it would not be able to afford. Health equity advocates are protecting the principle that the pathogen samples produced in poor countries and the vaccines manufactured from them in rich countries constitute a single value chain whose benefits cannot justly be distributed entirely to one end.

The argument that pandemic preparedness in low-income countries requires sustained investment in health system capacity — not just emergency response infrastructure — and that surveillance obligations imposed on resource-constrained health systems without accompanying resources represent an unfunded mandate with a troubling power dynamic. The revised International Health Regulations include strengthened reporting obligations that require member states to develop core capacities for detecting and notifying potential emergencies. As of the last systematic assessment before COVID-19, fewer than one-third of WHO member states had met those IHR core capacity requirements. The gap is not primarily a matter of will: it reflects the chronic underinvestment in primary health care infrastructure in low- and middle-income countries that has defined international health financing since structural adjustment programs dismantled health systems in the 1980s and 1990s. Lawrence Gostin of Georgetown Global Health Law has argued that IHR obligations imposed without corresponding resources function as a form of governance that benefits wealthy nations — who receive early warning of outbreaks originating elsewhere — while imposing costs on poor ones who are expected to build surveillance infrastructure they cannot afford. The Pandemic Accord's provisions on capacity-building and technology transfer are intended to address this asymmetry; whether they do so through binding commitments or aspirational language is among the most contested elements of the ongoing negotiations.

What WHO structural reformers are protecting

A WHO capable of exercising independent scientific and public health judgment — free from the structural conflicts of interest created by earmarked donor financing, member-state political pressure, and the institutional incentives that lead international bureaucracies to protect their relationships with powerful members at the expense of their stated mandates. Devi Sridhar, the University of Edinburgh global health scholar whose analysis of COVID-19 governance has been among the most precise, argues in Preventable (2022) that the WHO's central problem is not that it lacks authority on paper — the WHO Constitution gives it broad investigative and norm-setting powers — but that it has been systematically de-resourced and politically constrained such that those powers are largely notional. The organization that could send investigators to Wuhan in December 2019 without waiting for Chinese consent is not the organization that exists. The organization that could issue binding recommendations to member states about border measures, personal protective equipment stockpiling, and health system capacity is not the organization that exists. What exists is an organization that can coordinate, advise, and convene — but that must do so through the consent of the member states it is meant to hold accountable. Structural reformers are protecting the recognition that the distance between the WHO's constitutional authority and its operational authority is not an accident or an oversight; it is the product of decades of member-state decisions to fund the WHO selectively, staff it politically, and deny it the enforcement mechanisms that would make it genuinely independent.

The independence of scientific communication — and the critique that the WHO's capacity to issue clear public health guidance was compromised, during COVID-19, by political pressures from large member states whose cooperation was institutionally essential. The WHO's initial recommendations against mask use in community settings, its delays in acknowledging airborne transmission, and its handling of early investigations into the origins of COVID-19 have been extensively analyzed and criticized. Some of this criticism conflates scientific uncertainty (on masking and aerosol transmission, early evidence genuinely was limited) with institutional failure (on origins investigation, the political constraints were more clearly operative). Jeremy Farrar, who served as Director of the Wellcome Trust during the pandemic and then became WHO Chief Scientist, has written that the pandemic exposed a "catastrophic failure of political leadership" — not only at national levels but in the capacity of international institutions to provide authoritative guidance that political leaders could not easily dismiss. Structural reformers are protecting the function of independent scientific authority in a governance system: not infallible scientific judgment, but institutional capacity to represent scientific consensus without filtering it through political calculation about member-state relationships.

What the argument is actually about

The pandemic governance debate is, at its foundation, a debate about the conditions under which sovereignty can be pooled — and whether the institutions that would need to hold pooled authority can be structured to exercise it equitably rather than as an extension of existing power asymmetries. The global health security argument requires, at minimum, that states report outbreaks quickly and accurately, share pathogen samples with international surveillance networks, and allow WHO investigators access to affected areas. None of these requirements is compatible with full state sovereignty over the terms and timing of disclosure. China's management of information in the early weeks of COVID-19 was a sovereignty exercise — as was the United States' bilateral vaccine-purchasing strategy during the vaccine-scarcity period of 2021. Both imposed costs on the global system. The question the Pandemic Accord is attempting to answer is whether sovereign states can be induced to make different choices by institutional design — by altering the incentive structure through financing, benefit-sharing, and reciprocal obligations. The answer depends on whether the institutional design is trusted by states that have been on the receiving end of global health governance when it did not protect them.

The PABS mechanism — and the structural paradox at the heart of pathogen surveillance: the countries most likely to host emerging pandemic threats are the least well-positioned to benefit from the vaccines and therapeutics their pathogens enable. The Pandemic Influenza Preparedness (PIP) Framework, adopted by the WHO in 2011 after Indonesia's H5N1 sample-sharing dispute, was the first attempt to link pathogen sharing to benefit access. It established a partnership contribution system under which manufacturers using the WHO's influenza surveillance network would provide doses, financing, or technology transfer. The PABS mechanism in the Pandemic Accord extends this logic beyond influenza to all pandemic-potential pathogens. Its core logic is simple: the genetic information in pathogen samples is the raw material for vaccines and diagnostics; states that provide that information are contributing to a value chain; they should receive equitable access to the value produced. The mechanism's complexity — and the difficulty of negotiating it — arises from the same productive ambiguity that undermines commons governance in other domains: does "equitable access" mean affordable prices, technology transfer, reserved production capacity, or something that cannot be specified in advance of the specific emergency?

The WHO funding structure as governance architecture — and the recognition that an institution that cannot act without the consent of the states it regulates, and cannot exist without the donations of the donors whose interests it must not antagonize, has been designed, whether deliberately or incrementally, to fail in precisely the moments when its success matters most. The most important structural reform in the Pandemic Accord negotiations is the proposed shift toward significantly higher assessed contributions — core funding that the WHO can allocate without donor specification. This reform would reduce the structural dependence that shapes WHO institutional behavior. It requires wealthy member states to pay more and to relinquish the influence that earmarked funding provides. The resistance to this reform reflects something important: the current funding structure, which critics frame as a governance failure, simultaneously functions as a governance mechanism — one that gives the states and foundations with the most resources the most influence over what the WHO does. Reforming it redistributes institutional power, which is why it is contested. The global health governance debate is not, at bottom, about pandemics. It is about whether the international institutions that govern global commons can be redesigned to serve the people who need them most, or whether their design will continue to reflect the interests of the people who fund them.

The next pandemic will begin where the last one began: in a place with limited diagnostic infrastructure, constrained public health capacity, and a government that has learned, from watching how the world responded to the last outbreak in its region, that early reporting carries economic and political costs that international solidarity will not adequately compensate. The Pandemic Accord is an attempt to change that calculation — to make early reporting, pathogen sharing, and rapid response cooperation rational choices for the states that most need to make them. Whether it succeeds depends on whether the governance architecture it creates is trusted by those states — not because it is fair by abstract measures, but because it is fair by the experience of states that have been in the position of having something the world needs and watching that something be taken, processed, and sold back at prices they could not pay.