CIVICUS discusses the Pandemic Agreement with Jaume Vidal, Senior Policy Advisor at Health Action International, an international civil society organisation based in Amsterdam, the Netherlands, that works to realise the human right to health, with a special emphasis on access to health technologies.

On 20 May, the World Health Assembly adopted a resolution on the agreed text so far of the Pandemic Agreement. Now the global health community faces the task of realising the agreement. Born from the failures exposed by COVID-19, the treaty process secured agreement from 124 states despite deep global divisions and US withdrawal. Yet what was adopted represents the minimum of what’s needed, with the most contentious issues – pathogen access and benefit sharing – deferred for future negotiations. With the treaty needing 60 ratifications to enter into force and the absence of the USA casting doubt over its effectiveness, the agreement embodies both the promise and limitations of multilateral cooperation.

What’s your assessment of the Pandemic Agreement?

The Pandemic Agreement was designed to address access to pandemic response tools such as personal protective equipment, therapeutics and vaccines, as well as shortcomings in manufacturing and trade. These were issues that predated COVID-19 but became very apparent during the pandemic.

To be clear, the full Pandemic Agreement has not yet been adopted. What we have is an agreed text endorsed by a majority of states at the World Health Assembly. But key sections of the agreement – on pathogen access and benefit-sharing – are still to be negotiated by a dedicated working group. Once this is resolved, we will have the full Pandemic Agreement open to signatures.

Even if it is incomplete and took longer than expected, this was big win for the World Health Organization (WHO), its Director-General Tedros Adhanom Ghebreyesus and multilateralism more broadly. Governments successfully negotiated a text at a time of deep divisions, and despite the US leaving the WHO and the conflicts in the Middle East and Ukraine that threatened to derail the project.

Nevertheless, what has been approved is a basic text, the bare minimum required for a Pandemic Agreement. This bare minimum didn’t exist before, so it’s a step forward – but only a small one.

It should also be noted that there is a legally binding agreement, the International Health Regulations, that were amended as recently as last year. These regulations are currently far more effective than the Pandemic Agreement because they’re already in force, with 196 states already committed to them. The Pandemic Agreement is a work in an advanced state of progress, and we are close to the finish line but we are not there yet.

What are the key remaining obstacles?

Pathogen access and benefit sharing issues are the most difficult topics because they reflect a global south versus global north divide. The healthcare industry needs pathogen access to develop vaccines. These pathogens mostly exist in global south countries, which expect compensation for sharing samples, including priority access to vaccines developed from the pathogens they’ve shared.

Consider what happened during COVID-19 when South Africa shared the Omicron sample, or with H1N1 influenza when Indonesia shared samples: they faced significant delays in accessing the resulting vaccines. There’s a clear pattern here.

From a public health perspective, we support easy access to pathogens since we need them to develop responses for everyone. However, it’s reasonable for global south states to expect something in return. But they’ve already been forced to compromise at every turn, particularly on intellectual property and technology transfer. Pathogen sharing is the last red line they claim they won’t cross, which explains the deadlock.

This has been the pattern for two years: global north states blame global south states for the failure to reach an agreement, when in fact it is the European Union (EU) and previously the USA that have perpetuated the deadlock with their hard negotiating approaches. An agreement will eventually be reached, but there are still 300 days until the next World Health Assembly and the agreement will likely emerge on midnight of day 299 because that’s how international negotiations seem to work these days.

How has civil society engaged in the negotiations?

Health Action International has ‘official relations’ status with the WHO, which enables participation in governing bodies and engagement with member states. We’ve supported a Pandemic Agreement provided it was enforceable on critical areas such as intellectual property and technology transfer. Unfortunately, this hasn’t happened because throughout the process we were told to ask for what was politically feasible. Like global south countries, we compromised on various issues, such as disabilities provisions and truly enforceable transparency for licensing agreements.

However, civil society has made valuable contributions, particularly on technology transfer, where there’s now a clear commitment to making it operational, which was lacking before. There’s also progress on making access to health technologies a priority, even though stronger language was possible.

The WHO and member states struggled with civil society participation. Negotiations occurred behind closed doors, with civil society receiving second-hand information from friendly governments. Our public contributions had no effective connection to actual treaty negotiations: we’d read statements in half-empty rooms before states started negotiating or after they’d finished.

The WHO doesn’t really know how to truly engage with civil society or determine what weight to give civil society input. While it’s hard to see direct impact, however, civil society helped frame discussions through social media and media statements and advocating and lobbying with delegations.

Civil society sometimes swings between opposite positions, from principled and maximalist, opposing everything, to overly constructive, making only very small contributions. The key may be to have different civil society approaches working together, which is why broad civil society coalitions encompassing various types of organisations are particularly effective.

How might the absence of the USA affect the treaty’s effectiveness?

The situation is challenging. Look at the League of Nations, the United Nations’ predecessor: it didn’t work because major powers weren’t involved. When we celebrate that multilateralism is still alive, we may be fooling ourselves. We’ve suddenly discovered global health’s heavy dependence on US funding through USAID and contributions to the WHO.

The agreement needs 60 ratifications to enter into force. Politically, it will be difficult to achieve the ratifications needed. This goes beyond US withdrawal: Hungary, Italy, the Netherlands and Slovakia abstained on the resolution containing the agreed Pandemic Agreement text. This is concerning, particularly since the EU was the driving force behind the treaty, which was proposed by the EU Council.

Additionally, the problem with US withdrawal isn’t just money, but the cessation of all collaboration. The USA not ratifying the treaty was to be expected, because the USA has not ratified an international treaty for the past 20 years. But it’s one thing to not ratify a treaty, and a very different thing to sabotage it by refusing to share information with the WHO.

We want to believe the USA will behave responsibly, but we need to wait and see. If the USA remains non-engaged, the international community might still be able to pull this off. But if it actively campaigns against the treaty, it likely won’t survive because the USA has the means to turn many states against it.

What are the next steps?

The next steps are foreseeable. Within 300 days the intergovernmental working group on pathogen access and benefit sharing will produce an additional protocol to the Pandemic Agreement. There’s a huge incentive for states to agree since much of the agreement text is already settled. Global south states have leverage, having shown they can stall the process. I’m optimistic the agreement will open for ratification following the next World Health Assembly.

Ratification will be challenging. The agreement needs to be first signed by states, then ratified through their respective national legislative processes. The process normally requires state champions, but the Pandemic Agreement doesn’t currently have one. In the polarised times we’re living in, it’s really difficult to champion a text that is a compromise.

Reactions against the agreement have been nasty. While political opposition is understandable, the kind of backlash it’s getting is mostly in bad faith, particularly from people opposed to vaccines and lockdown mandates. Read any tweet by Director-General Tedros: the responses are crazy. This explains partly the seemingly odd positions from countries like Costa Rica and the Netherlands, traditional global health proponents now going through animated domestic debates about the topic, with the pandemic treaty being a particularly delicate issue.