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Despite the reforms that had been made to improve pandemic preparedness and response in previous decades, some key deficiencies in the WHO-led regime complex for global health security remained, and these hampered the chances for a timely and effective response to COVID-19.

To begin, it was already well known that far too few countries had the “core capacities” identified under the IHR (2005) and that sufficient political and financial commitment was lacking to fully implement the IHR provisions. However, lack of compliance with the IHR’s core capacities was not necessarily the primary factor in the Wuhan disease outbreak transforming into a pandemic. What was more striking was that many of the first and most high-profile countries to be affected by COVID-19 were so-called high-capability states (including China, South Korea, Taiwan, Italy, the United Kingdom, and the United States), only some of which responded effectively in the early phases. This suggests that the metrics used to assess pandemic preparedness, as well as the existing system of national self-assessment and reporting, were presenting a distorted picture.

COVID-19 also highlighted the limits of what the WHO, created and financed by states, can do when confronted with a global pandemic. While it does have processes and procedures for information gathering, its resources and operational capacity were never designed for a comprehensive system of global surveillance that would extend to the high-income and high-capability countries that were part of the initial epicenter of the outbreak. Still—and contrary to some criticisms of the organization56—the WHO did act rapidly after it first received information (from a nongovernmental source) about the Wuhan outbreak. But rapid action in the face of an emerging pandemic is not always effective action. In the case of the WHO, its initial guidance on travel measures and masks turned out to be incorrect advice for the COVID-19 pathogen. The WHO exercised the authority it had to issue temporary recommendations but did so in ways that later required it to reverse its advice—thus damaging its credibility.

A more consequential limitation of the WHO underscored by this pandemic concerns its intergovernmental character: it is susceptible to political pressures from states that are wary of facing external scrutiny and potential stigmatization, which can in turn affect how the WHO executes its powers. Academic research on international institutions has long been preoccupied with the challenge of making such institutions accountable to the member states that create them, while simultaneously insulating them from parochial political attempts to steer or reverse their activities.57 COVID-19 demonstrated that, although the 2005 reforms to the IHR gave the director-general authority to signal that a member state was not cooperating effectively, or to declare a PHEIC over a state’s objections, the exercise of that discretionary authority ultimately depends upon the individual occupying this role.

From December 2020 to March 2021, the WHA’s independent panel identified specific aspects of the WHO’s performance that relate, in part, to these long-standing issues. Panel members criticized the WHO’s delay in convening its Emergency Committee, declaring a PHEIC, and issuing warnings about human-to-human transmission of the virus.58 The latter problem stemmed in large part from China’s delay in releasing the data it had about human-to-human transmission—which occurred in the same period that key WHO officials were publicly commending China’s efforts.59 In light of its assessment, the independent panel set out a series of recommendations designed to stabilize the organization’s funding, enhance its power and independence, and improve the quality, timing, and clarity of its technical advice. A critical part of any discussion of how to reform the WHO’s approach to pandemic preparedness and response, however, is to distinguish those weaknesses that are actually inherent to the IHR from those that stem from the particular choices of individuals or the specific reactions to political pressures.

The key changes advocated by the independent panel include a dramatic increase in member states’ assessed contributions to the WHO’s budget; a single, seven-year term for the WHO director-general (to provide a longer mandate but to avoid the political dynamics of reelection); greater professionalization of recruitment processes for senior-level WHO staff (with the aim of depoliticizing hiring); strengthened governance capacity in the WHO’s executive board, including through a Standing Committee for Emergencies; and—perhaps most controversial for member states—powers of independent investigation.60 While the report of the panel underlined the need for the WHO to remain central to global health governance as the lead coordinating organization—a conclusion echoed by the expert panel advising the G2061—it also insisted that the organization could not fulfill all of the functions needed to avert another pandemic.

The convening of the WHA in May 2021 fell short of reaching agreement on the reforms to global health security governance advocated by the panel. Most notably, it did not take steps to strengthen the WHO’s authority; instead, member states established a working group to discuss various aspects of WHO reform. The WHA also did not agree to changes in the organization’s funding base—member states approved the WHO’s budget for 2022–2023 but did not agree to increase assessed or mandatory state contributions, with all increases in the budget to be funded by voluntary contributions. Hopes that the Biden administration’s more positive engagement with the WHO would lead to meaningful institutional reforms were also dashed, as the United States (with Russia) put the brakes on European calls for the WHA to authorize immediate negotiations on a pandemic treaty. Key U.S. officials have advocated for particular amendments to the IHR that have been discussed over the years—such as a system of graded health alerts prior to the determination of a PHEIC, reforms to the composition of the WHO’s Emergency Committee to improve upon its guidance, and an IHR compliance committee or review conference to convene member states on pressing issues.62 But they have thus far refrained from publicly supporting either an enhancement of the powers of the WHO or an increase in assessed contributions.63 In addition, geopolitical rivalry overshadowed discussions in and around the WHA in May 2021, as the U.S. president tasked his intelligence community to investigate the origins of the COVID-19 virus and then asked the WHO to conduct its own “science-based” study—a request that China quickly rebuffed.
 

One area where collective action did emerge was in vaccine development, review, and distribution. Several regulatory authorities—including the European Union (EU) European Medicines Agency, the U.S. Food and Drug Administration, and Health Canada—actively collaborated by sharing data and information during their reviews of COVID-19 vaccines. This form of cooperation helped to speed up the regulatory process, including the WHO’s Emergency Use Listing, while ensuring that standards for the safety and efficacy of health products were met.

The second example of active collaboration was the launch, in April 2020, of the Access to COVID-19 Tools (ACT) Accelerator. Hosted by the WHO, this mechanism convened scientists, governments, businesses, civil society, philanthropists, and global health organizations to accelerate the development of tests, treatments, and vaccines and to ensure their equal distribution. The vaccine pillar of the ACT Accelerator, COVAX,64 was designed to function as a central procurement mechanism for all countries, wherein wealthier countries would buy into the scheme and their funding would finance COVID-19 vaccines for low-income countries. COVAX was thus intended to operationalize the idea of global solidarity by ensuring that all countries, including low- and middle-income ones, would receive a share in the vaccines that the scheme purchased. In addition, the COVAX strategy was meant to advance purchase commitments in ways that would assist pharmaceutical companies in developing and producing effective vaccines.

Despite the promise of this initiative, as of early December 2021, COVAX has distributed only 617 million doses of COVID-19 vaccines to 144 participating countries—less than half of its stated goal of 1.4 billion doses by the end of 2021.65 In addition, by the end of 2021, when 70.4 percent of residents in high-income countries and 72.5 percent of residents in upper-middle-income countries had completed the initial COVID-19 vaccination protocol, just 3.99 percent of those in low-income countries were fully vaccinated.66 Of the doses that were sent to low-income countries, there have been continued challenges in administering the available vaccines, with thousands of doses remaining undelivered and at risk of spoilage. Despite high-level gatherings of state officials—including at the Global Health Summit of the G20 and the WHA—the stubborn problem of inequitable vaccine access, which featured in earlier pandemics, remains unaddressed. Furthermore, and notwithstanding the calls to share the financial burden of fighting the pandemic, only half of the needed resources for the ACT Accelerator have been pledged.67

The prospect of a continuing shortfall prompted the G20, through its own expert panel report, to call on the world’s international financial institutions to include the financing of global public goods, such as global health security, as part of their core mandates.68 This would include an additional U.S.$15 billion per year, over the next five years, for pandemic preparedness and response, based on predetermined contributions distributed between the WHO and a new Global Health Threats Fund. The International Monetary Fund has already developed an ambitious and detailed $50 billion plan to “vaccinate the world” and accelerate economic recovery—objectives it insists go hand in hand.69 The Global COVID-19 Summit, convened by U.S. President Joe Biden in September 2021, attempted to galvanize support for these objectives by encouraging purchases or donations of additional vaccine doses (including through COVAX); committing to expedite the delivery of the two billion doses already promised; and calling for additional funding to ensure that low- and middle-income countries have the capacity to administer doses over the coming months.70

A broader phenomenon of “vaccine nationalism,” however, underlies the remaining gap between the aspirations of schemes like COVAX and what has actually been achieved. From the earliest months of the pandemic, states with the resources to produce or buy successful vaccines secured privileged access and/or manufacturing capacity.71 This included leading democracies such as the United States, United Kingdom, and EU countries, as well as countries that drew upon the doses within COVAX well before most developing countries had even begun their vaccination programs.

Finally, geopolitical competition, rather than a global public goods perspective, also continued to shape access to vaccines as the pandemic unfolded. China adroitly stepped into the global vaccine access crisis by both selling and donating vaccines in ways that advanced its foreign policy interests, with doses going primarily to states participating in its Belt and Road Initiative. But China has also taken pains to demonstrate its concern for vaccine equity, with President Xi Jinping reiterating at the latest meeting of the UN General Assembly his country’s promise to make two billion doses available globally by the end of 2021.

Notwithstanding the lingering questions about the safety and efficacy of China’s vaccine, which have limited the impact of its “vaccine diplomacy,” the perception that Beijing might be gaining a strategic advantage has motivated responses from other states with interests in the region, such as India and Russia, which have donated doses to Asian countries.72 Worries about China and Russia gaining a “first mover” advantage in assisting strategically important countries also led the United States to engage in its own form of vaccine diplomacy—through the vaccine initiative launched by the Quadrilateral Security Dialogue in March 2021 and the decisions reached on vaccine sharing at the June 2021 G7. At the COVID-19 summit he convened in the autumn of 2021, President Biden coupled his pledge for an additional 500 million Pfizer doses with the claim that the United States was now the world’s “arsenal of vaccines,” thereby invoking his country’s vocation in World War II and revealing the political motives underpinning its global health policy.

But while Washington’s narrative stresses how the United States is leading the charge to address inequities in treatments and vaccines, global health advocates maintain that the pledges of the United States and other high-income democracies remain inadequate.73 Overall, the pattern of states’ vaccine donations, which do not map onto countries with the greatest COVID-19 case burden or largest populations, suggests that geopolitical dynamics are a prime driver of continuing inequities in vaccine access.74