A reinvigorated multilateralism in health: lessons and innovations from the COVID-19 pandemic

The COVID-19 pandemic has brought into sharp focus the shared frailty of societies in the face of common threats. If the world is to respond successfully to future pandemics and other emerging challenges, it will be essential to develop new public health instruments and a framework that redefines the rules of global governance. In many ways, a quantum lift in global health is needed similar to that achieved at the turn of the 21st century. That was a time when new multilateral initiatives with innovative governance and financial arrangements were established (eg, Gavi, the Vaccine Alliance in 2000, The Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002, and adoption of the WHO Framework Convention on Tobacco Control in 2003), and development assistance for health expanded at an unprecedented rate.¹ However, the circumstances in 2022 are different and therefore call for original solutions. We outline the lessons that must be learned and the innovations that must be adopted to realise that purpose.

Global health faces a sovereignty paradox.² We live in a world of sovereign nation states where health is mostly a national responsibility. However, the determinants of health and the means to fulfil that responsibility are increasingly global.³ No single country can control on its own the health risks associated with globalisation or generate by itself an effective response to most global challenges. The way to solve this paradox is not for nation states to sacrifice but rather to share their sovereignty by mobilising global collective action through vigorous multilateral institutions.

Unfortunately, the global alarm systems did not perform as expected during the COVID-19 pandemic, and there is consensus about the main sources of this failure. The early and consistent calls to strengthen the surveillance and response system designed to confront global threats were ignored.⁴ It is a sad irony that a miniscule proportion of the costs to the global economy of COVID-19 could have financed a robust global alarm and response system.⁵

This failure cannot happen again. All countries should introduce structural adjustments in the global health system to protect everyone in an increasingly interdependent world. Such improvements should be agreed on while the COVID-19 pandemic continues and not later when attention will wane. The global health community owes it to the millions of people who have lost their lives and their livelihoods in this pandemic to apply the lessons we have learned at huge cost. The recommendations from the Independent Panel for Pandemic Preparedness and Response in 2021⁶ and the 2022 report of the Lancet Commission on lessons for the future from the COVID-19 pandemic⁷ offer thorough analyses in this respect. Here we focus on six key lessons from the COVID-19 pandemic (panel ). Several innovations have been proposed to put these lessons into practice. We highlight three innovations that together could make the world safer and better prepared for the next pandemic.

Panel. Six lessons from the COVID-19 pandemic.

Pandemics are becoming more common as a result of unsustainable practices, so all countries should strengthen their commitment to sustainable development

Increased frequency of pandemics is as anthropogenic as climate change.⁸ The way humans abuse the planet (eg, the destruction of habitats, unsanitary and inhumane mass production of poultry and livestock, and the sale of live wild animals in so-called wet markets) allows pathogens to cross the species barrier. COVID-19 should be a wake-up call about the need to protect our planet.

When dealing with a pandemic, it is necessary to supersede the false dilemma between public health and economic goals, both of which must be pursued in a synergistic way

There is consensus that to resume economic life after a lockdown it is necessary to have the pandemic under local control. A rushed reopening strategy can produce not only new cases and deaths, but also major economic losses.⁹ The pandemic has provided a dramatic demonstration that health is not only a consequence of but also a condition for economic growth and prosperity.

The COVID-19 pandemic has revealed and magnified social inequities, which make it necessary to build specific mitigation interventions into preparedness plans

The COVID-19 pandemic has disproportionately affected marginalised groups.10, 11 In future pandemics, programmes to deal with the structural determinants of infection rates and public policies to improve access to health care will have to be implemented. Inequities among countries must also be addressed. Because all governments are expected and required to prioritise their own people, it is crucial to develop a mechanism for distributed production of vaccines and protective equipment that will ensure equitable access to these and other life-saving resources.

National leadership is crucial in the response to a global public health threat

The huge variation in the effectiveness of national responses to the COVID-19 pandemic demonstrates that trust in rational, science-based leadership, which provides clear guidance and brings people together, is crucial for effective collective action during moments of uncertainty.¹²

Regional collaboration promotes health security

Pandemics frequently prompt governments to block the export of goods that are essential for the protection of their respective populations.¹³ This constraint is compounded by geopolitical tensions. Since very few countries are self-sufficient, regional collaboration can help overcome this constraint and strengthen health security, as exemplified by the European Union and the African Union.

No local response to a pandemic can be effective without global solutions

The brightest point of the pandemic has been the unprecedented level of international collaboration to develop the global public goods—tests, treatments, and vaccines—that are enabling the world to solve the current crisis. Global efforts, however, require more than like-minded individuals and institutions to work together. They require agile global governance supported by national governments committed to international collective action as the only means to face common threats.

The first innovation is the establishment of an international sentinel network of health-care facilities that can rapidly collect and share data about any emerging disease and thus avoid potential national cover-up of outbreaks.¹⁴ A complementary mechanism to promote epidemiological transparency consists of an insurance scheme that would protect countries from harm to their economies as a result of reporting disease outbreaks in a timely way—something that would benefit the rest of the world.

A second innovation is to harness adaptable technological platforms so that the scientific community can move swiftly in identifying the nature of new pathogens and developing the tools to combat future outbreaks of infectious diseases, including diagnostic procedures and devices, treatments, and vaccines. Such coordinated action has advanced rapidly during the COVID-19 pandemic, but with better preparedness planning further progress can be made.

A third innovation is the creation of a multinational rapid deployment force with the standing capacity to use innovative tools. This approach would control future disease outbreaks before they could spread globally—something akin to the proposal by Bill Gates to establish a GERM (Global Epidemic Response and Mobilization) team, which should be led by WHO.¹⁵

As a foundation for these innovations, all countries should immediately commit to the strengthening of their national preparedness plans under the supervision of WHO and its regional offices. These plans should meet clear goals in terms of inputs, human resources, and protocols.

To take advantage of these and other innovations, it is necessary to develop frameworks that will enable national actors and the international community to solve the sovereignty paradox. What is required is a bold meta-innovation of multilateralism that will make all other innovations possible.

There has been much discussion about the imperative of reforming the institutional architecture of global governance. To date most calls for reform have focused on the secretariats of multilateral organisations—and there are indeed huge opportunities to improve their performance. However, it is equally important to review the behaviour of member states, which often weaken multilateral institutions deliberately (eg, by resisting their coordinating authority) or passively (eg, by failing to pay assessed contributions on time).

The lessons from the COVID-19 pandemic point to the crucial need to strengthen the effective enforcement of improved International Health Regulations through incentives that promote participation and respect for rules, as well as sanctions that curtail non-compliance. A global public health convention or treaty that redefines the rules and norms of global governance for health security is needed for sovereign states to accept such enforcement authority.¹⁶ The World Health Assembly has initiated the process to develop an agreement of this type,¹⁷ which the Intergovernmental Negotiating Body considers should be legally binding.¹⁸ A new global health instrument must establish clear mechanisms to guarantee the autonomy and authority of WHO to effectively coordinate the prevention, preparedness measures, and response to pandemics and other global health challenges.

An effective global health convention also requires a solid financing system that protects its governing body from political influences and fluctuations. Global health security demands robust, sustainable, and sovereign funding. Such funding needs to mostly come from regular mandatory contributions by member states and not from voluntary, unpredictable, and earmarked donations. In a positive reversal of previous reluctance, WHO member states are planning for a substantial increase of mandatory contributions by 2030.¹⁹ Additionally, a robust financial framework would make it possible to support a sustainable prevention, preparedness, and response fund at the World Bank in close coordination with WHO (and potentially also with The Global Fund), which should operate under transparent rules allowing for an agile mobilisation of resources.²⁰

These efforts must also consider the rapidly evolving financial constraints that face national, regional, and global institutions due to the COVID-19 pandemic, the climate crises, the war in Europe, and the ensuing global economic instability, including rising energy and food prices. Since these headwinds could lead to further resource constraints for health, it is imperative that national, regional, and global investments yield the largest returns in terms of improved health outcomes.

At the same time, meta-innovation of multilateralism cannot depend solely on regional and global institutions. These efforts need to be reinforced by networks of devoted scientists and other groups. This approach is exemplified by philanthropic groups engaging in global surveillance innovations, as well as the Coalition for Epidemic Preparedness Innovation (CEPI) and some vaccine companies stimulating a distributed multilateral and speedy production of vaccines.²¹

Driven by the frailty that the COVID-19 pandemic has uncovered, the guiding force of the new global agenda should be a renewed commitment to global solidarity and sustainable development. In these perilous times, such a commitment has become vital.