Strengthening global health Equity: The imperative of the WHO pandemic agreement

The formal adoption of the WHO Pandemic Agreement at the 78th World Health Assembly marks a pivotal step in global health governance, especially in light of the deep inequities revealed by the COVID-19 pandemic. At its foundation, the agreement aims to guide future pandemic responses with the principles of solidarity, fairness, and shared responsibility. Its key provisions include timely data sharing, equitable access to medical countermeasures, sustainable financing for preparedness in low-resource settings, and a strong emphasis on the One Health approach. For these objectives to be fully realized, equity must not be an afterthought—it must be the guiding principle that informs every element of the agreement.

Among its commitments, the treaty affirms the importance of equitable vaccine distribution and affordable access to pandemic-related health tools. However, one major issue remains unresolved: Pathogen Access and Benefit Sharing (PABS). A robust PABS system would oblige countries to share genetic sequence data of emerging pathogens while ensuring that the benefits arising from such data—like vaccines, diagnostics, and treatments—are distributed fairly and in a timely manner. The principle is straightforward: sharing must be reciprocal and just.

Given that microbial threats recognize no borders, fostering international cooperation in research, open access to pathogen data, and equitable benefit-sharing is essential. In this endeavor, scientific journals and the global research community have a critical role to play—championing transparency, enabling collaboration, and ensuring the swift dissemination of vital information during public health emergencies.

Another area of concern is the agreement's treatment of financing. While it emphasizes the need to boost domestic investment and attract additional financial support, it stops short of outlining concrete strategies to achieve these goals. The language remains vague, offering little in terms of actionable guidance or enforceable obligations. Equally troubling is the absence of a strong accountability framework. Although the agreement mentions monitoring implementation, it fails to establish an independent compliance mechanism—a feature commonly found in other international treaties to ensure countries uphold their commitments. Without such oversight, the risk of uneven or insufficient implementation remains high.

1. Vaccine distribution imbalances: a catalyst for structural reform

The COVID-19 pandemic revealed profound inequities in vaccine distribution, with high-income countries (HICs) securing early access to doses while low- and middle-income countries (LMICs) faced protracted delays. By March 2021, HICs had partially vaccinated 57 % of their populations, compared to just 3.26 % in low-income countries (LICs) [1,2]. This disparity persisted despite COVAX's efforts, which ultimately delivered 74 % of all vaccines to LICs but achieved only 57 % two-dose coverage in lower-income economies—10 percentage points below the global average [1].

The concentration of vaccine procurement power in wealthy nations was quantified by a 2024 analysis showing that GDP per capita, political stability, and health system strength accounted for significant inequalities in distribution [3]. Countries with higher World Power Index scores secured 9.17 % partial vaccination rates in LMICs compared to 3.26 % in LICs [3], while vaccine hoarding by HICs left 56 countries unable to meet the WHO's initial 10 % vaccination target [4]. Modeling suggests that equitable dose distribution could have averted 54–94 % of COVID-19 deaths in LMICs [5], underscoring the human cost of these imbalances.

2. Diagnostic disparities: the hidden dimension of pandemic inequality

Testing capacity disparities further exacerbated inequities, with GDP per capita strongly correlating (ρ = 0.775) with COVID-19 tests per million people [6]. Wealthier nations conducted up to 5121 tests per 100,000 population, while LMICs faced critical shortages of essential diagnostics—only 26 % of primary care facilities in low-resource settings had access to basic laboratory services [7]. This diagnostic gap created surveillance blind spots, with undetected transmission in LMICs estimated to have increased variant emergence risks by 38 % [8].

The consequences of these disparities were measurable: countries with lower testing rates underreported cases by factors of 3–5 while experiencing mortality rates 31 % higher per capita than HICs [9]. In the United States alone, counties with median household incomes below $40,000 had COVID-19 mortality rates 22 % higher than affluent areas [6,10], a pattern replicated across 86 % of studies analyzing socioeconomic mortality gradients [9].

3. Mortality syndemics: where equity meets epidemiology

The interaction between preexisting health inequalities and pandemic policy failures created syndemic mortality patterns. While HICs reported 72 deaths per 100,000 population, LICs experienced rates of 113 per 100,000—a disparity amplified by gaps in healthcare access [10]. In Mexico, districts with high income inequality saw mortality rates 2.3 × higher than equitable regions [9], while in England's most deprived areas, COVID-19 mortality exceeded affluent regions by 28 % [9].

Universal Health Coverage (UHC) emerged as a critical determinant, with LMICs achieving UHC scores above 70 % experiencing 40 % lower mortality rates than counterparts below this threshold [3]. Yet only 12 % of LICs had robust UHC frameworks pre-pandemic [7], leaving 1.7 billion people without access to essential health services during the crisis [2].

4. The path forward: from data to diplomacy

These empirical realities validate the Pandemic Agreement's focus on structural reforms. The PABS system directly addresses vaccine inequities by mandating that 20 % of pandemic-related products be allocated to LMICs during emergencies [7], while the Global Supply Chain and Logistics Network aims to reduce diagnostic disparities through regional manufacturing hubs.

However, success requires addressing root causes: countries with UHC coverage below 50 % had 3.2 × higher mortality rates during COVID-19³, emphasizing the need for the Agreement's health system strengthening provisions. Similarly, the 0.89 Gini coefficient correlation between vaccine access and economic power [3] justifies the Financial Coordination Mechanism's focus on redistributive funding.

The agreement's ratification threshold—60 member states—must be met with accountability measures ensuring compliance. As the data show, equitable access is not merely ethical but an epidemiological necessity: every 10 % increase in LMIC vaccination rates reduced global variant emergence risk by 17 % [5]. In our interconnected world, solidarity is the ultimate pandemic preparedness strategy. The global health community—governments, scientists, funders, and civil society—must unite to ensure that this agreement delivers on its promise. Equity must be the guiding principle—not just in rhetoric, but in action.

While the approved pandemic agreement may fall short of some initial expectations in terms of ambition, it nonetheless marks a significant step forward. It obliges nations to bolster their health systems—with particular emphasis on primary healthcare—safeguard the well-being of health workers and enhance access to research and development that is publicly funded. Furthermore, it aims to support the fair and efficient production and distribution of health products during pandemics, encourage the sharing of technologies, streamline international supply chains and logistics, and reinforce regulatory frameworks. Notably, it also represents the first binding international accord that explicitly commits to addressing disease outbreaks at their origin by integrating human, animal, and environmental health—a cornerstone of the One Health approach.

CRediT authorship contribution statement

Esam Ibraheem Azhar: Conceptualization, Writing – original draft. Sherif A. El-Kafrawy: Conceptualization, Writing – original draft. Ziad A. Memish: Writing – review & editing.

Funding

None declared.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Handling Editor:Patricia Schlagenhauf