Reform or Revolution in Global Health?

By Precious Matsoso, Paulo Buss & Leigh Kamore Haynes

CAPE TOWN/RIO DE JANEIRO/BRUSSELS – The World Health Organization’s governing body of health ministers has responded to a call from dozens of world leaders for a new international treaty for pandemic preparedness and response, and will hold a special session in November devoted to such a treaty. It is a positive step. But the global response to COVID-19, and adequate preparation for future pandemics, requires much more.

As the COVID-19 crisis has shown, the current global health infrastructure is simply not up to the task of managing – let alone preventing – a pandemic. But the pandemic has also shown that we must not focus only on infectious-disease outbreaks. We must also respond to the pandemic of inequity that the crisis has highlighted.

Every year, more than 16 million people in low- and middle-income countries die from preventable causes. The vast majority are relatively poor, have limited access to education, are marginalized, or live in low-income countries. In other words, as the WHO’s Commission on Social Determinants of Health pointed out more than a dozen years ago, “Social injustice is killing people on a grand scale.”

The only vaccine against this pandemic is a global health infrastructure built on principles of equality and human rights. Beyond dramatically reducing preventable deaths, such an approach would vitally complement the proposed treaty to strengthen global pandemic preparedness and response. That is why we advocate for the Framework Convention on Global Health (FCGH), another proposed treaty, one based on the right to health.

The right to health goes beyond responding to emergencies like the coronavirus outbreak to encompass a responsibility for ensuring universal access to the underlying determinants of health, such as nutritious food and preventive care. As long as these factors are ignored, poor and marginalized populations will continue to suffer disproportionately from diseases like diabetes and hypertension, which increase the risk of complications and death from other illnesses, like COVID-19.

The right to health also demands accountability, including independent monitoring, redress for violations, and policy solutions to prevent their recurrence. This would reduce corruption and lead to stronger health systems that protect health workers and the public, use funding efficiently, and allocate services and resources equitably.

The latter point is crucial. Marginalized populations, such as migrants, are likely to rely on public health-care systems. Yet the health facilities that are accessible to these communities are often unaccountable or under-resourced. In a system based on the right to health, resources would be allocated according to need, rather than wealth or connections, leading to more equitable health outcomes.

Equity and accountability are essential to public trust, which in turn is vital to reduce vaccine hesitancy and ensure broad compliance with public-health measures, such as mask-wearing and social distancing, during outbreaks. Participatory decision-making and a sense of public ownership over health systems would also foster trust.

The FCGH would support the creation of such health systems by establishing clear and meaningful standards, such as for the full inclusion of marginalized populations. It would also provide countries with useful tools and guidance, including comprehensive roadmaps, national programs of action, and impact assessments. And it would include concrete commitments for countries to make progress in building health systems based on the right to health.

Those commitments would also account for private-sector engagement. For example, the FCGH could oblige governments to include provisions in contracts with private entities that ensure universal access to the medical technologies (such as vaccines) they develop. This can be achieved through affordable pricing, sharing of technology and know-how, data openness, and licensing. A framework for national and international funding, adapted to national contexts through participatory processes, would help ensure sufficient resources.

Such a treaty would be fortified by a comprehensive accountability regime, including independent monitoring and reporting, strategies to overcome implementation shortcomings, and creative incentives, such as favoring high-performing countries’ nationals for global health leadership positions. Realistic sanctions – including diversion of international health assistance from governments to NGOs responding to areas of noncompliance – would also be needed.

A treaty focused specifically on pandemic preparedness and response certainly could improve global health security and even equity in, say, vaccine access. So, it is good news that the international community is moving in this direction.

But the COVID-19 crisis exposed more than just our lack of pandemic preparedness; it also exposed the extent of systemic health inequities and how those inequities can exacerbate a public-health crisis, putting everyone at risk. By bolstering cooperation, accountability, and equity, the FCGH would improve global health security, not least by helping to prevent new public-health threats from gaining traction. That is why world leaders must urgently launch a process to establish the FCGH.

As Tedros Adhanom Ghebreyesus stressed in March, a pandemic treaty would strengthen international health infrastructure. But the FCGH would transform it.

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Precious Matsoso, former director-general of South Africa’s Department of Health and former chair of the World Health Organization’s Executive Board, is a member of the recently concluded Independent Panel on Pandemic Preparedness and Response. Paulo Buss, Director of the Center for Global Health at Fundação Oswaldo Cruz (Fiocruz), is President of the Alianza Latinoamericana de Salud Global (the Latin American Alliance for Global Health). Leigh Kamore Haynes, a professor at Simmons University, is Chair of the Framework Convention on Global Health Alliance.