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

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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. Public Funding Should Prioritise Public Benefit: Enforceable measures should ensure equitable distribution of health products developed with public funding.16 Public funding for diagnostics, therapeutics, vaccines, and associated infrastructure should include conditions ensuring public interest, particularly emergency use.17, 18 Member States should have provisions that enable them to mandate the sharing of discoveries,19, 20 including march-in rights if agreements with companies cannot be reached regarding licencing or other measures necessary to protect public health. Equity and Solidarity Should Underpin Arrangements and Financing of Pathogen Access and Benefit-Sharing (PABS): PABS should be underpinned by professional collaboration and oversight, building on existing voluntary efforts by providing long-term funding.21, 22 Full access cannot be decoupled from a pandemic agreement that is supported by shared funding, ensuring delivery across countries at times of need. This shared financing is essential to guarantee access and should include resources for stronger capacity building. This approach aims to reduce the vulnerability of Low and Middle-Income Countries (LMICs) to pandemics, serious outbreaks, and natural disaster

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