Health Policy

A global public health convention for the 21st century

Johnathan H Duff, Anicca Liu, Jorge Saavedra, Jacob N Batycki, Kendra Morancy, Barbara Stocking, Lawrence O Gostin, Sandro Galea,
Stefano Bertozzi, Jose M Zuniga, Carmencita Alberto-Banatin, Akua Sena Dansua, Carlos del Rio, Maksut Kulzhanov, Kelley Lee, Gisela Scaglia,
Cyrus Shahpar, Andrew J Ullmann, Steven J Hoffman, Michael Weinstein, José Szapocznik

As shown by COVID-19, infectious diseases with a pandemic potential present a grave threat to health and wellbeing. Lancet Public Health 2021;
Although the International Health Regulations provide a framework of binding legal obligations for pandemic 6: e428–33

prevention, preparedness, and response, many countries do not comply with these regulations. There is a need for a Published Online
May 5, 2021
renewed framework for global collective action that ensures conformity with international regulations and promotes
[Link]
effective prevention and response to pandemic infectious diseases. This Health Policy identifies the necessary S2468-2667(21)00070-0
characteristics for a new global public health security convention designed to optimise prevention, preparedness, and This online publication has
response to pandemic infectious diseases. We propose ten recommendations to strengthen global public health been corrected. The corrected
governance and promote compliance with global health security regulations. Recommendations for a new global version first appeared at
[Link]/public-health
public health security convention include greater authority for a global governing body, an improved ability to respond
on March 30, 2022
to pandemics, an objective evaluation system for national core public health capacities, more effective enforcement
See Comment pages e355
mechanisms, independent and sustainable funding, representativeness, and investment from multiple sectors, and e357
among others. The next steps to achieve these recommendations include assembling an invested alliance, specifying Department of Public Health
the operational structures of a global public health security system, and overcoming barriers such as insufficient Sciences, Miller School of
political will, scarcity of resources, and individual national interests. Medicine (J H Duff PhD,
A Liu MPH, J N Batycki MPH,
Prof J Szapocznik PhD), AHF
Introduction The absence of explicit WHO authority to meaningfully Global Public Health Institute
Pandemics, which by definition span international monitor and enforce the IHR results in a world that is (J Saavedra MD), University of
borders, present a threat to the health and wellbeing of inadequately prepared to strategically manage infectious Miami, Miami, FL, USA;
societies. The COVID-19 pandemic has made collective disease outbreaks at global, national, or subnational levels. Political Sciences and
International Relations, Florida
action to achieve optimal prevention, preparedness, and The global health governance system might be more aptly International University,
response to these events a global imperative. described as a group of “transnational and national actors Miami, FL, USA (K Morancy MA);
The International Health Regulations (IHR)1 constitute pursuing their own interests”17 than a coordinated network Murray Edwards College,
University of Cambridge,
an international legal framework designed “to prevent, of collaborating stakeholders working to achieve pan­
Cambridge, UK (B Stocking MA);
protect against, control and provide a public health demic prevention and control. Rather than delegate some Georgetown University Law
response to the international spread of disease”.1 The IHR responsibility for decision making to a global body, most Center, Washington, DC, USA
set out the minimum core capacities that States Parties countries cooperate when their leadership chooses to, (Prof L O Gostin JD); School of
Public Health, Boston
must implement at the local, regional, and national levels such as when collaborating is in an individual country’s
University, Boston, MA, USA
to detect morbidity and mortality, report essential infor­ national interests.18–22 (Prof S Galea MD); Berkeley
mation, and respond effectively to contain health security The COVID-19 pandemic has highlighted these School of Public Health,
threats.2 These regulations are legally binding on all inadequacies in ways that signal an urgent need for University of California,
Berkeley, CA, USA
196 signatory States Parties.3–5 Oversight for the IHR is reform. In January, 2021, the Director-General of WHO,
(Prof S Bertozzi MD); Instituto
assigned to WHO—the primary global body for public Tedros Adhanom Ghebreyesus, noted that the pandemic Nacional de Salud Publica,
health-related activities.6 Responsibility for maintaining has shown that the current tools of pandemic prevention Cuernavaca, Mexico
these core capacities lies with individual states, with WHO and response are insufficient.23 He introduced the idea of (Prof S Bertozzi); International
Association of Providers of
providing technical assistance.7 a new convention, stating “I think a treaty is the best thing
AIDS Care, Washington, DC,
Despite clear legal obligations outlined in the IHR, that we can do that can bring the political commitment of USA (J M Zuniga PhD);
most States Parties do not comply with all requirements.8 member states”.24 This call to action is not new. Multiple Manila, Philippines
Although countries might not adhere to the IHR for voices in the global public health community have pre­ (C Alberto-Banatin MD);
Accra, Ghana (A S Dansua MA);
various reasons, a primary barrier to global achievement viously called for a more robust strategy for IHR adherence School of Medicine, Emory
of IHR goals lies in its unenforceability.7,9 Despite all and enforcement.2 University, Atlanta, GA, USA
WHO member states being legally obliged to follow the Health is a human right, and the foundation of effective (Prof C del Rio MD); Department
IHR unless they opt out of the agreement, there is no global public health security relies on shared responsibility. of Population Health and
Social Sciences, Kazakhstan
penalty for non-compliance.10–12 The IHR do not provide Given the clear and present danger posed by COVID-19 School of Public Health,
WHO with adequate power to impose sanctions, inter­ and future pandemic diseases, there is a need for the Almaty, Kazakhstan
vene, or hold States Parties accountable for breaches or international community to establish a more effective (Prof M Kulzhanov PhD); Faculty
non-compliance, meaning that WHO does not pos­ system to ensure observance of international pandemic of Health Sciences, Simon
Fraser University, Burnaby, BC,
sess the necessary authority to effectively execute this regulations such as the IHR.25,26 Global infectious disease Canada (Prof K Lee PhD); House
agreement. Moreover, under the IHR, WHO does not prevention, preparedness, and response efforts require of Representatives, Buenos
have sufficient resources, political self-determination, or coordination by an international organisation (or multiple Aires, Argentina (G Scaglia BA);
capacity to prevent nations from disregarding its technical bodies) in collaboration with national and subnational Vital Strategies, Resolve to
Save Lives Initiative, New York,
guidance.13–16 organisations.

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NY, USA (C Shahpar MD); The inexistence of an adequate system to ensure Expertise
University Hospital of coordination, collaboration, and compliance with inter­ In a global public health system, one body should exist as
Würzburg, Würzburg, Germany
(Prof A J Ullmann MD);
national public health security agreements (such as the the singular authoritative source for information, data,
Bundestag, Berlin, Germany IHR bolsters) the need to create a new convention and technical assistance. This agency should possess
(Prof A J Ullmann); Global that addresses these shortcomings. This Health Policy appropriate technical expertise and must be able to com­
Strategy Lab, York University, presents the necessary characteristics for a functional municate a clear and compelling message to the world.
Toronto, ON, Canada
(Prof S J Hoffman PhD); AIDS
global convention that can assure an effective pandemic An effective global public health security system
Healthcare Foundation, infectious disease prevention, preparedness, and res­ponse requires a singular body with technical expertise in pan­
Los Angeles, CA, USA system. The process used to identify these characteristics demic prevention, preparedness, response, and recovery.
(J Saavedra, M Weinstein BA) is presented in the appendix. We propose ten recom­ This agency should represent the authoritative source for
Correspondence to: mendations to improve the current system of global information, expertise, and technical pro­ ficiency. The
Dr Johnathan H Duff,
Department of Public Health
public health security. agency should be the single authoritative guide in case of
Sciences, Miller School of emerging and re-emerging infectious disease outbreaks—
Medicine, University of Miami, Improving the current system of global public the role that WHO is currently authorised to serve.
Miami 33136, FL, USA health security This central body should also be empowered to create
[Link]@[Link]
Authority and communicate the standards for the world with­
See Online for appendix
The governance structure for a global public health out undue political interference. The communication
system should grant necessary authority to one or must be compelling, evidence-based, authoritative, con­
more agencies, such as WHO, to coordinate pandemic sistent, and include clear expectations for countries
prevention, preparedness, and response globally, regarding public health security policies, benchmarks,
including across regions, countries, and subnational and activities.
jurisdictions. This authority could include an agreed-
on power to lead countries and other relevant agents to Evaluation
act and collaborate. The capacity of objectively evaluating countries on their
An effective global health convention requires a global progress in achieving requirements and of providing
vision and should provide an agency (or agencies) the or coordinating remediation for identified deficiencies
necessary authority to monitor, share data, and coordinate should be built into a governing framework for a global
activities across countries. This agreement should provide public health system.
a specified agency (or agencies) with the capacity to The global public health security convention and its
coordinate the collection and distribution of resources and executing body (or bodies) should provide specified
information globally. Such a convention should, when agents the authority to do objective, external evaluations
necessary (eg, during a pandemic) supersede other of countries on their compliance, and to help to remediate
authorities and bypass existing regulatory structures, any deficiencies in meeting international standards. An
includ­ing national jurisdictional authorities. An effective effective framework must emphasise external monitoring
convention requires countries to share some degree of of each country’s progress in meeting some public health
authority so that the governing agency can effectively requirements. This process should not rely extensively on
coordinate activities whenever and wherever they are countries’ self-evaluation (such as how the Joint External
needed. Such an agreement must also emphasise preven­ Evaluation system operates currently). Additionally, to
tion, including the primary prevention of infectious ensure transparency and promote compliance, the
disease outbreaks, which can involve broadening the external evaluations should be made publicly available.
existing global health security purview. The prerogative of a governance framework should
include the authority not only to evaluate but also to
Responsiveness require remediation, and the capability to assist countries
The global public health system (and its governing agency in achieving compliance. Although evaluation could be
or agencies) should possess the capability to flexibly and used to incentivise countries to participate, it might be
rapidly respond to, instil protections for, formulate most effective when framed as a tool to guide and support
interventions against, and mobilise and deploy resources countries toward desired outcomes rather than as a
for, a range of possible public health security threats and mechanism for punitive measures.
scenarios such as infectious disease outbreaks and
pandemics. Enforcement
A challenging but essential task for a governing agency Reform must equip a governing body (or bodies) with
is to possess the flexibility to prevent, prepare for, appropriate enforcement mechanisms, which can include
and respond to various scenarios in a timely manner at substantial incentives for countries to cooperate, sanctions
various jurisdictional levels. This flexibility includes the for non-compliance, or both.
capacity to meet the diverse needs of countries at any An effective global public health security convention
given stage of an infectious disease outbreak or requires a governing body (or bodies) to enforce the
pandemic. framework. Currently, a legally binding agreement such

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as the IHR has no power because it does not have adequate necessary autonomy to decide and act in the best interest
enforcement mechanisms, rendering compliance with of global public health rather than favour its principal
the IHR voluntary. contributing members. The nature of an international
Enforcement mechanisms can include incentives for representative body might be inherently political, but a
participation, penalties for non-compliance, or both. greater degree of immunity from undue political influence
Benefits for countries could include tangible resources, will promote more independent decision making.
such as financial aid or technical assistance in establishing
core capacities for pandemic prevention and preparedness, Financing
support with pandemic responses, access to data and An effective global public health security framework
information, recommendations and guidance, or other requires a sustainable financing system that protects the
services provided by a governing body. These benefits are governing body (or bodies) from political influence,
designed to promote compliance and can differ depending possible retribution, or the threat of inconsistent funding.
on the country. The incentives must be robust enough to Historically, global public health efforts have been
be effective. inadequately funded. The main organisations promoting
Penalties for non-complying countries could include pandemic prevention, preparedness, and response efforts
public reprimands, economic sanctions, or denial of do not possess sufficient resources to maintain necessary
benefits, such as those related to travel, trade, and core public health capacities.27 Adequate funding is
tourism. Moreover, public disclosures of compliance necessary for effective public health security. Additionally,
might act either as an incentive or penalty. Incentives for a lead global health agency to capably coordinate
and sanctions are a challenging balance. Incentives are pandemic prevention, preparedness, and response efforts,
more desirable than sanctions, but compliance might it must have sovereign control of its financial resources,
not be adequately achieved without some type of penalty. requiring a sustainable financing system and, probably,
Additionally, enforcement mechanisms must be adapted an independent monetary fund dedicated solely to global
to each country’s specific and unique circumstances, public health security. Sustainable financing means
especially regarding the diversity in access to resources perennial investments in all stages of infectious disease
and varying abilities to mobilise those resources. containment—especially prevention-related activities,
before outbreaks occur. Annual funding should be dedi­
Autonomy cated not only to building core capacities but also to
The governing body (or bodies) should be autonomous, contingencies for possible emergencies in the future,
having freedom of self-governance and decision making much as how insurance systems function.
processes resistant to undue political pressures. There are many ways to achieve sustainable and
The convention’s governing body (or bodies) should independent financing. For instance, funds could
possess independent decision making powers and be be contributed primarily (or exclusively) by member
insulated from undue political interference. The body states—the countries that will benefit from the governing
should have the ability to make decisions in the best body’s efforts in health security. Countries could still
interest of global health, rather than in the interests of provide some voluntary funding, whereas a certain
individual stakeholders. Autonomy prevents undue amount of contribution could be compulsory (or both, as
political pressures from interfering with effective execu­ WHO’s funding currently works). Compulsory contribu­
tion of the health convention, but does not mean the tions might provide members with a sense of being
governing body operates in a vacuum; interdependence partici­pants rather than donors. Another option might
with other agents is necessary to effectively execute a involve a tax on global private industry or international
global public health convention. Autonomy simply allows trade, such as a financial transactions tax, to provide
for independent, evidence-based decision making, free greater sustainability, legitimacy, and autonomy. Alter­
from conflicts of interest or from the pressure of the natively, philanthropic foundations, the private sector, or
individual agendas of participating entities. countries themselves could provide a permanent endow­
Currently, WHO serves as a membership organisation ment, allowing for greater autonomy and immunity from
at the behest of the World Health Assembly and its individual member states’ political influence.
member states, especially those providing substantial
financial contributions. The current financing system Representation
predominantly consists of voluntary financial contribu­ A governance structure for a global security system must
tions from select member states, making WHO parti­ be representative of all countries and other relevant non-
cularly vulnerable to political influence and inhibiting state stakeholders. The governing framework must
WHO’s ability to communicate honestly and command possess a high degree of transparency and accountability.
transparency from its member states. These limitations The governing structure must be adequately repre­
render WHO an advisory body, rather than an executive sentative of all countries. It should also include other
agency that is empowered to act and generate change. The relevant stakeholders from civil society, the public health
world’s leading public health agency must possess the sector, the private sector, and academia, among others.

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Representation creates greater legitimacy for a govern­ efforts; agree to comply with a global convention; fulfil
ing system and promotes receptivity from constituent their individual responsibilities to the global contract
countries. Representation can be reached in multiple ways. among nations; collaborate with other parties; and cede
Collective governance by nearly 200 member states might some degree of authority to a global governing body, thus
be unwieldy, so the governing body need not include all permitting that body to effectively coordinate and intervene
member countries at all times. For example, governance to prevent, prepare, and respond to infectious disease
could be achieved through regional or rotating repre­ outbreaks and pandemics.
sentative members. For a global public health security Relevant stakeholders in a global public health security
system to succeed, current global economic powers, such convention (especially individual countries) must assume
as the USA and China, should be involved. some responsibilities for the system to work effectively.
Whatever the structure, the governance system for a All stakeholders must accept the serious threats that
global public health convention must be transparent and pandemic infectious diseases pose to public health,
accountable across every level of decision making and economic security, and global cohesion. Acknowledging
action, including, but not limited to, open data sharing the severity of infectious disease outbreaks and the
thorough independent evaluations of countries’ levels of interconnectedness of countries and commiting to act is
preparedness, in statements about countries’ assessed essential. Countries must, to some extent, acknowledge
levels of compliance, and in accurately reporting infectious the collective action necessary for pandemic prevention,
disease monitoring and outcomes. even for diseases that they do not yet recognise as a threat.
Countries must also agree to comply with international
Multisectorality agreements, cooperate with other parties, and transfer
A formal pandemic prevention, preparedness, and some degree of authority to a global governing body.
response system (including governing bodies) must Sharing sovereignty over some regulatory and enforce­
involve multiple sectors at all levels of governance and ment processes and accepting inter­ventions necessary to
action. In addition to national governments, participating worldwide public health is essential to provide the desig­
agents can include the private sector, local governments, nated governing body with the capability to coordinate
and civil society. pandemic prevention, preparedness, and response efforts.
Sectors beyond public health should participate in the Furthermore, countries should be prepared for (and, in
global public health security system at all levels. The public some cases, comply with) penalties imposed by such a
health sector alone is not enough to effectively prepare the governing body. Sharing sovereignty should be seen as
world for a pandemic, nor does it typically have enough contributing to a collective effort through a coordinating
influence within countries to gather adequate national organisation than as ceding authority.
support. Many sectors face the consequences of pandemic Finally, individual countries must show national
infectious diseases, and these groups should participate in commitments to attaining and maintaining core public
prevention, preparedness, and response efforts. Public health security capacities. Showing this commitment
health activities must be reflected in the core functions of toward preparing for and responding to infectious
an entire national government, not solely the agencies disease outbreaks can include a range of tangible actions,
responsible for health. including enacting legislation, allocating resources,
In addition to national governments, participating stake­ training personnel, and employing preparedness and
holders must include the private sector, philanthropic response strategies. National laws must institutionalise
organisations, global non-governmental organisations, public health security practices to make them sustainable.
local governments, academia, communities, or non-
govern­mental organisations operating on the field level. Discussion
Relevant parties on the national, provincial, and local levels These recom­ men­dations for a global public health
must also be encouraged to participate in these activities. A security convention include principles of best practices,
challenge for a global public health security system involves suggestions for improvements to the current system,
engaging both the national governments respon­sible for and goals for a global agreement. In some aspects, they
determining participation in international agreements and affirm current practices such as advocating for a single
the local public health sectors typically responsible for authoritative source for information (as WHO serves
prevention, preparedness, and response-related activities. currently), with suggestions for associated improvements.
In other instances, they advise pragmatic changes or
Commitment present novel approaches or components to the existing
For a global health security convention to be effective, system, such as a more sustainable and politically
all relevant parties participating in the system must independent financing system. The aim of this Health
understand the threat posed by pandemic infectious Policy was not to identify the specific components of
diseases; accept the gravity of this threat; acknow­ledge their a global public health security system, nor the actions
own responsibility in contributing to effective prevention, needed to achieve the proposed qualities of such a system.
preparedness, and response; show a commitment to these Rather, these recommendations represent the essential

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qualities needed to build a more robust global system are also threats to global cooperation. Engaging the
to increase the global ability to prevent, prepare, and major global powers might also prove challenging.
respond effectively to infectious disease outbreaks,
emergencies of international concern, and pandemics. Conclusion
The specific mechanics of a global public health security The COVID-19 pandemic clearly exposed how the existing
system should be determined collaboratively by a larger global health infrastructure failed the world when it was
representative group of key agents and stakeholders. needed most, with devastating human and economic
Implementing many of these recommendations might consequences. However, with crisis comes opportunity.
involve reforming WHO to empower it with specified The lessons learned from the COVID-19 pandemic
capacities, or require other (new or existing) agencies to response efforts present a unique chance to reevaluate,
carry out some or all of these duties. The focus of these refocus, and revise the current global public health
recommendations is on the authority and duties them­ security system. Identifying the target principles of a
selves, not on determining whether WHO would be the convention is only the first step. Ensuing steps must
appropriate governing agency to execute them. An establish the specific policy systems and operational
important first step in actualising these recom­mendations structures needed to actualise these principles. Subse­
involves assembling an invested alliance. Stakeholders quent actions must then determine the mechanisms to
working towards improving the global public health effect these changes, and then work to implement them.
security system must clearly communicate the benefits of The pandemic has captured the world’s attention and
an effective public health framework to garner support. awakened political leaders to the threat of pandemic
The absence of political will presents a substantial barrier infectious disease. The current crisis could spark
to global investment in health. Creative messaging about transformation in the way the world manages health
the consequences of inaction and the cost savings provided security prevention, preparedness, and response efforts.
by effective global public health security is necessary to Contributors
reach these goals. In particular, a refocused global health JHD, JSz, JSa, AL, KM, and JNB (operational team) did the qualitative study
security movement should engage powerful political and that is the basis for these recommendations and were responsible for
concept and writing. JHD, AL, KM, and JNB led the collection and
financial entities, known champions of global health, and organisation of experts’ input for the recommendations. All other coauthors
other prominent voices of influence including religious provided input on the recommendations through interviews with the
and local leaders, celebrities, and the media. operational team and a group roundtable discussion. The operational team
Constructing a better global public health security prepared the current manuscript for publication. All authors reviewed the
manuscript and provided feedback and edits. All authors approved the final
framework does not require duplicating efforts that have manuscript and the decision to submit for publication.
already been made. Reform can build on the IHR and on
Declaration of interests
existing multilateral systems that reflect some of the MW and JSa are full-time employees of the AIDS Healthcare
principles highlighted in the proposed recommendations. Foundation. JSz was awarded a grant by the AIDS Healthcare
Although the limits of the IHR have been examined at Foundation to complete this study. JSz has received renumeration for
length elsewhere,2,12,28–33 the merits of this governance consulting services with Sandzo Pharmaceuticals. JZ has received grants
from AbbVie, AIDS Healthcare Foundation, Gilead Sciences, Janssen
instrument are well established. The IHR provides a Therapeutics, and Merck & Co. All other authors declare no competing
foundation with important attributes of an effective global interests.
health system, including public health capacity building, Acknowledgments
evaluation, and cooperation. A global public health conven­ The AIDS Healthcare Foundation provided financial support for this
tion should include robust compliance mechanisms, project. We thank Daniel Bausch, Julio Frenk, Laurie Garrett,
Ashish K Jha, Ricardo Baptista-Leite, Barry N Pakes, Esther M Passaris,
improved global public health security regulations, and the
Carl Reddy, Jaime Sepulveda, Donna E Shalala, and
authority, autonomy, and resources to implement them. Kirit Premjibhai Solanki for their input into the recommendations.
This process of reforming the existing agreements to
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