Equity with Accountability in Pandemic Preparedness

Before asking how power in global health should be rebalanced, reformers must confront a prior question: have existing policies and practices created a growing dependency on donor countries and international organisations? In many low-resourced countries, earmarked finance, externally selected priorities, imported program designs, a growing non-state and donor-dependent workforce, and donor reporting requirements have weakened the link between national choices and national accountability. 

If that dependency has hollowed out or undermined sovereign responsibility, the answer cannot be another layer of international coordination. The architecture must instead return responsibility for health outcomes to those directly invested in population health, particularly national governments. The World Health Organization’s (WHO’s) mandates, functions, resources, and authority should progressively contract where functions can be performed effectively closer to affected populations, as countries recover the capacity and express accountability to make their own choices (IHRP, 2026a, 2026b).

The Right to Health Sovereignty Policy Report International Health Reform Project · Brownstone Institute Buy on Amazon

Sovereignty here does not mean isolation; it means that international cooperation should support governments that remain politically and financially accountable for decisions made in their name.

Recent proposals for reforming pandemic governance begin from a familiar diagnosis. The global health system is fragmented, public trust has deteriorated, poorer countries exercise too little influence, and inequality magnifies the damage caused by outbreaks (Lal et al., 2026; Cullinan, 2026). Much of this is true. Yet the remedies advanced in a new Nature Health commentary and in the draft United Nations Political Declaration on Pandemic Prevention, Preparedness and Response (PPPR) do not follow from that diagnosis. They largely reaffirm the institutions, financing models, and biomedical priorities that drove the loss of trust in the first place (Brown, Bate, and Bell, 2026).

The contradiction is stark. Global health leaders condemn inequality while supporting a preparedness architecture that can transfer scarce public resources from low- and middle-income countries towards international organisations, development-finance intermediaries, consultants, surveillance contractors, universities, and pharmaceutical manufacturers concentrated in wealthier states. 

They call for power to be ‘rebalanced,’ but offer few realistic and enforceable means by which powerful institutions would surrender authority rather than serve their own interests (Lal et al., 2026). They conflate access to centrally selected commodities with health equity—the equivalent opportunity to live a healthy and fulfilling life (Brown, Bate, and Bell, 2026). Above all, they avoid the transparency regarding evidence and error that restoring trust requires. Trust was lost for a reason. Repeating the policies underlying that loss will not restore it.

The WHO does not ordinarily possess formal power to order national lockdowns, vaccination mandates, or other domestic measures. Its practical influence is nonetheless considerable. Emergency declarations, technical standards, model laws, procurement arrangements, donor conditions, and reputational pressure can narrow the choices available to governments, particularly those dependent on external finance and expertise. The relevant sovereignty question is therefore not whether the WHO can legally command a state, but whether the surrounding institutional system makes departure from its preferred policies politically or financially bearable.

A Diagnosis without an Institutional Test

Lal and colleagues’ Nature Health commentary, ‘Reforming global health for an age of mistrust, fragmentation and overlapping crises,’ identifies three desired transformations: rebalancing power, reinforcing systems, and restoring trust. It recognises that the Lusaka Agenda, Accra Reset, regional proposals, scholarship, and UN reports remain poorly coordinated, and it warns that institutional solutions cannot resolve what are fundamentally political problems (Lal et al., 2026).

This is a useful starting point. The principal writer of Kofi Annan’s 2002 report on internal UN reforms for his second term concluded that hidden behind the details of reform proposals is the larger question of whether the UN should be ‘the forum of choice or last resort for collective-action solutions to global problems’ (Thakur, 2017, p. 355). The struggle to reform the organisation, including specialised agencies such as the WHO, is therefore not simply a management upgrade or process improvement, but a contest over the distribution of policy authority between different levels of governance.

Accordingly, WHO reform must encompass power structures, incentives, and accountability, not merely technical coordination. Legitimacy comes from reflecting the will of populations, not corralling them to comply with an increasingly detached global health industry.

But the Nature paper never subjects its own preferred institutions to a demanding institutional test. Who specifically must cede power, to whom, through what legal or financial mechanism, and with what sanction for failure? Who determines when a global priority should override a national one? Who decides whether another dollar spent on genomic surveillance delivers more health than a dollar spent on tuberculosis control, maternal care, nutrition, sanitation, or reliable primary care? ‘Rebalancing,’ ‘reinforcing,’ and ‘restoring’ are appealing verbs, but without answers to these questions they describe aspirations rather than reforms.

The proposed route—complementary reform tracks led by states, operationalised through the World Health Assembly, and extended through the UN General Assembly—also risks reproducing the fragmentation the authors criticise (Lal et al., 2026). More tracks, forums, reporting requirements, and coordinating processes can generate work for the global health system without transferring meaningful authority to countries or communities. Institutional proliferation is not necessarily pluralism. It may instead add layers through which money and decisions pass before reaching frontline services.

The paper also treats mistrust too much as a governance condition to be managed and too little as a rational response to institutional behaviour. Trust cannot be restored by declaring inclusiveness, improving messaging, or convening more inclusive forums. It must be earned through transparency, admission of error, correction, and limits on authority.

Yet Lal et al. offer no serious Covid-19 autopsy. They do not distinguish between harm caused by the virus and harm caused by policy responses, including school closures, restrictions on movement and work, interruption of routine health services, and the imposition of broadly uniform policies on populations with radically different age structures and disease burdens. A reform agenda that cannot examine the last emergency is poorly placed to govern the next one.

Neither Lal and colleagues nor the proposed UN declaration acknowledges the broader political backlash against globalism. That backlash draws strength from resistance to the expanding administrative state and from the fear that consequential decisions are being transferred from elected governments to national and international technocrats who are difficult to remove and rarely bear the costs of error. Health is not exempt from this conflict. Indeed, pandemic policy intensified it because restrictions reached deeply into schooling, work, travel, worship, family life, and ordinary medical care.

Some claims made against the WHO are exaggerated, but that does not invalidate the underlying concern about authority becoming increasingly remote from democratic correction. Treating this resistance as a communications problem, misinformation, or insufficient solidarity avoids the central question of democratic control.

The same avoidance appears in the mismatch between empirical evidence and recommended policy. Paul, Brown, Bell, and colleagues found that many Covid-19 strategies were poorly effective, inefficient, and inequitable. They argued for context-specific responses grounded in the full range of health needs rather than a single health-security objective (Paul et al., 2024). Their analysis challenges the presumption that a standardised package of interventions can be recommended across populations with radically different risks, institutions, and competing health priorities.

The financial evidence is no stronger. Brown, von Agris, Tacheva, and Bell examined the WHO–World Bank case for US$31.1 billion in annual preparedness spending. They found that its claimed return depends on crude baselines and assumptions—not observed outcomes—including 100 percent mitigation of pandemic economic damage, rapid vaccine development that completely blocks transmission, failure to separate direct disease costs from indirect and policy-induced costs, and substantial undervaluation of comparator diseases (Brown et al., 2026). A governance architecture built on such models should not be expanded until its central claims survive independent testing against historical and epidemiological data.

The Nature paper and UN declaration also avoid the unresolved origins of Covid-19. The WHO’s scientific advisory group reported in 2025 that both zoonotic spillover and a laboratory-related incident remained on the table because essential information had not been provided (WHO, 2025). This matters for institutional design. An agenda built mainly around natural emergence, One Health, and broad wildlife and pathogen surveillance is not a substitute for laboratory biosafety and biosecurity, disclosure and oversight of high-risk research, grant and subaward transparency, occupational monitoring, incident reporting, and independent laboratory audit. Despite some overlap, the approaches are fundamentally different. Building the former while declining to examine the latter risks heavy investment with little likely benefit.

The UN Declaration: Agreement by Accumulation

The draft UN Political Declaration is weaker still. It identifies nearly every fashionable concern associated with pandemics—inequality, gender, climate, One Health, financing, surveillance, resilient systems, research, manufacturing, misinformation, and access to medical countermeasures—but attaches few measurable responses, credible deadlines, or mechanisms of accountability to them. Health Policy Watch, despite being broadly sympathetic to the preparedness agenda, acknowledges that the text’s principal weakness is its failure to set out concrete steps (Cullinan, 2026).

This is multilateral agreement by accumulation. Every constituency receives language; almost none receives a test of delivery. The declaration calls for financing but does not establish a transparent method for calculating need, tracking what is genuinely additional, identifying what existing spending has merely been relabelled, or showing which programs are displaced (Cullinan, 2026).

It promotes geographically diversified manufacturing without specifying how facilities will remain viable between emergencies, who will own technology and know-how, or how subsidies will improve health more than alternative investments. It invokes monitoring and accountability while allowing almost five years before the Secretary-General reports on implementation (Cullinan, 2026).

The most conspicuous operational date is the call for universal access to sexual and reproductive health services by 2030 (Cullinan, 2026). Whatever the merits of that objective, it does little to clarify how countries should prevent or manage a pandemic. It is also likely to become the focus of US opposition and objections from some African and other Islamic states, distracting attention from unresolved questions that actually determine whether the pandemic system will work. A declaration so expansive that it becomes a vehicle for unrelated ideological disputes may be politically busy while remaining operationally empty.

The procedure compounds the weakness. Under the silence procedure, governments must actively object or the text is treated as agreed (Cullinan, 2026). Some states may understandably reserve their limited political capital for the Pathogen Access and Benefit-Sharing negotiations in Geneva rather than contest a largely nonbinding declaration in New York. Their silence should not be mistaken for substantive assent to the Pandemic Agreement, the 2024 International Health Regulations amendments, or an unfinished PABS system. The declaration nevertheless ‘welcomes’ and reinforces those processes, smoothing over real disputes concerning sovereignty, reciprocity, costs, intellectual property, and access (Brown, Bate, and Bell, 2026).

The calendar makes this pretence of resolution especially difficult to defend. The seventh Intergovernmental Working Group meeting ran from 6–17 July 2026 and ended without agreement on the PABS annex. WHO then scheduled an eighth meeting for 14–18 September (WHO, 2026), immediately before the UN High-Level Meeting on 25 September. The planning schedule circulated to participants also set aside 2–13 November for a ninth negotiating block and 30 November–4 December for further intersessional work.

In other words, the process is being carried forward until December at least, while the possible formal consideration of the annex has already slipped to the Eightieth World Health Assembly in May 2027 unless a special session is convened earlier (WHO, 2026). This is more than delay. It risks becoming a strategy of kicking the can from one session to the next: each extension preserves the appearance of momentum, postpones the political decision, and keeps countries and institutions invested in a process whose central bargain remains of highly questionable worth.

Equity Is Not the Delivery of the Same Commodity

Both the Nature paper and UN declaration use the language of equity without defining what an equitable outcome would be. Their dominant model equates equity with access to vaccines, diagnostics, therapeutics, and other countermeasures. Access matters, particularly during scarcity. But commodity equity is not health equity (Brown, Bate, and Bell, 2026). An elderly European gains little from access to antimalarial treatment, just as a young African resident at low risk from Covid-19 may gain less from another vaccine dose than from reliable malaria prevention or primary care.

Populations differ in age, prior immunity, nutrition, endemic disease burden, health-system capacity, and exposure to economic disruption. During Covid-19, an additional vaccine dose did not have the same expected value for a young person in sub-Saharan Africa as for an elderly person in Europe (Brown, Bate, and Bell, 2026). Nor did a uniform restriction impose the same cost on a salaried remote worker as on a day labourer in the informal economy. An equitable system must allow countries to compare the marginal health benefit of a pandemic intervention with benefits forgone elsewhere and to choose the greatest benefit for their own populations. Equal shares of a globally selected product do not constitute equal benefit—or, necessarily, any overall benefit at all.

The largest sustained improvements in population health have depended on ordinary foundations: nutrition, sanitation, living conditions, maternal care and childcare, vaccination against established diseases, tuberculosis and malaria control, and accessible primary care. A reform program that redirects staff and resources from these priorities towards permanent emergency systems may interrupt the very progress it claims to protect (IHRP, 2026a, 2026b).

This distinction exposes a deeper contradiction. The system is described as a remedy for inequality even as it asks poorer countries to finance surveillance, sequencing, regulatory alignment, emergency planning, stockpiles, and manufacturing readiness. The obligations—sharing pathogens and data, building systems, reporting, and spending—are relatively visible and monitorable. The promised benefits—timely access, affordable prices, meaningful technology transfer, and emergency support—depend on manufacturing concentration, intellectual-property control, export policy, contracts, and political decisions in producer countries (Brown, Bate, and Bell, 2026). The transfer upward is predictable; the reciprocal benefit is contingent.

Preparedness Has Beneficiaries Even When No Pandemic Occurs

The draft declaration calls for sustainable financing for preparedness without confronting the apparent inequity regarding its recipients. The WHO, the World Bank, the G20, and related agencies have promoted annual pandemic prevention, preparedness, and response expenditure of US$31.1 billion, including US$10.5 billion in new international financing and excluding further One Health and manufacturing costs. Brown and colleagues show that the return-on-investment case supporting this request is under-evidenced and unreliable (Brown et al., 2026). The Pandemic Agreement itself is not a US$31.1 billion fund, but it strengthens the policy framework through which long-term expenditure can be justified, coordinated, and normalised.

The recurring beneficiaries are identifiable: the WHO and other international bodies gain mandates and staff; the World Bank and development banks administer finance; consulting firms design and evaluate programs; universities receive research grants; laboratory and technology companies sell sequencers, reagents, cloud storage, and surveillance systems; and pharmaceutical firms receive support for platforms, trials, production capacity, and advance procurement. These activities may sometimes be valuable. The problem is not that anyone is paid. It is that the institutions defining preparedness needs often overlap with those administering funds, implementing programs, supplying products, and judging success.

Consider a donor-financed sequencing laboratory established as a preparedness asset. The initial equipment may be supplied externally, while reagents, software licenses, maintenance, specialist training, and reporting remain dependent on foreign vendors or grants. Skilled staff may be drawn away from routine diagnostics that address the country’s daily disease burden. The laboratory is then counted as new national capacity even though its continuing operation—and the priorities it serves—remain externally determined. This is capacity on a balance sheet but dependency in practice.

Meanwhile, opportunity costs remain largely invisible. A sequencing machine has an invoice; antenatal visits never made do not. A simulation exercise has a participant list; tuberculosis cases arising from diverted staff do not appear in preparedness accounts. A stockpile can be counted; unfunded nutrition services cannot. Calls for more preparedness finance therefore require a burden of proof, not merely a financing target.

A More Credible Declaration

A serious political declaration would be shorter and more demanding. It would require an independent Covid-19 policy review that separates pathogen harm from intervention harm and examines differential effects by age, income, and country. It would make new preparedness spending conditional on transparent cost-benefit and opportunity-cost analyses and publication of the full financial chain from donor to final contractor. It would distinguish core capacities useful for everyday health from expensive systems maintained mainly for speculative threats.

It would also define reciprocity before demanding compliance: no pathogen- or data-sharing obligation without enforceable terms governing access, pricing, intellectual property, liability, and technology transfer. It would preserve national discretion to allocate resources according to local disease burdens and demographic conditions. And it would require regular, independent evaluation against health outcomes—not the number of plans written, laboratories opened, exercises conducted, or funds ‘mobilised.’

Covid-19 vaccine development showed that governments can mobilise enormous resources, run development stages in parallel, finance at-risk manufacturing, and deliver products rapidly when they see compelling reasons to do so. The later failures of allocation, transparency, and proportionality also show that speed is not the same as sound public health. The lesson is to maintain a modest foundation of genuinely useful capacity, coupled with preauthorised surge mechanisms and strong safeguards—not to fund every component of a permanent emergency architecture at maximum readiness. The transferable principles are temporary appropriations, advance contracts, parallel development, and automatic termination or review when the emergency ends.

These principles offer the basis for a different distribution of responsibility, resources, authority, and accountability. Local and national governments should own routine health capacity, set priorities according to disease burden, and answer politically for outcomes. Regional bodies can pool functions that genuinely benefit from proximity and shared infrastructure, including reference laboratories, procurement, training, and cross-border coordination.

The global level should be narrower: rapid verification and communication of cross-border threats, technically sound voluntary standards, transparent comparative data, and temporary surge coordination when national and regional capacity is exceeded. A function should remain international only when its benefits are substantially cross-border and it cannot be supplied adequately at national or regional level. International assistance should build replaceable national capability rather than permanent dependence.

The financing model should reflect the same hierarchy. Countries should fund ordinary capacity through normal budgets; regional pools should support shared functions; and global emergency resources should be released only after defined triggers, with time-limited mandates, published contracts, independent evaluation, and automatic sunset clauses. Functions should migrate downward when capacity exists, while programs that cannot demonstrate additional health value should close. Under this model the WHO would retain a small set of genuinely international functions, but its expanding operational, financing, and norm-setting ambitions would contract as sovereign responsibility recovered.

Health resilience is built from the ground up, not from the top down.

The Nature paper is right that global health reform is a contest over power. The UN declaration illustrates why that insight matters. Without explicit limits, independent evaluation, and national authority to reject low-value obligations, ‘reform’ can become a means of consolidating the same system under new language. The result is a familiar global health bargain: poorer countries contribute data, compliance, resources, and legitimacy; institutions and firms in wealthier countries receive more predictable financing and authority; equity becomes a catchphrase legitimising the system; and international organisations strengthen the positions of those already presiding over expanding budgets, authority, and size.

That will not restore trust. It will give the people who preside over the system more work while asking those who already distrust it to assent—sometimes merely by remaining silent. The unresolved origin of Covid-19 illustrates the deeper failure: institutions are designing the next surveillance architecture before honestly testing whether it addresses the pathway that produced the last pandemic. It is time for a more honest and transparent discussion—not silence.

References

1. Brown, G. W., Bate, R., and Bell, D. (2026). The Pandemic Agreement at an Impasse: Proportionality, Political Incentives, and the Future of Global Health Governance. International Health Reform Panel, 25 June 2026. https://internationalhealthreformpanel.org/reports/the-pandemic-agreement-at-an-impasse
2. Brown, G. W., von Agris, J., Tacheva, B., and Bell, D. (2026). ‘An investment too good to be true? Reassessing the World Health Organization and World Bank return-on-investment estimates for pandemic preparedness.’ Health Economics, Policy and Law, 1–10. https://doi.org/10.1017/S174413312610067X
3. Cullinan, K. (2026). ‘Exclusive: Here is the ‘Final Text’ of UN Political Declaration on Pandemics—Although Its Adoption Is Far From Guaranteed.’ Health Policy Watch, 6 August 2026. https://healthpolicy-watch.news/exclusive-here-is-the-final-draft-of-un-political-declaration-on-pandemics/
4. International Health Reform Panel (IHRP) (2026a). The Right to Health Sovereignty: Policy Report. https://internationalhealthreformpanel.org/reports/the-right-to-health-sovereignty-policy-report-april-2026
5. International Health Reform Panel (IHRP) (2026b). The Right to Health Sovereignty: Technical Report. https://internationalhealthreformpanel.org/reports/the-right-to-health-sovereignty-technical-report-april-2026
6. Lal, A. et al. (2026). ‘Reforming global health for an age of mistrust, fragmentation and overlapping crises.’ Nature Health, published 4 August 2026. https://doi.org/10.1038/s44360-026-00179-x
7. Paul, E., Brown, G. W., Bell, D., Ridde, V., and Sturmberg, J. (2024). ‘Preparing for pandemics needs a dose of public health and a booster of ‘complex thought’ (Errare humanum est, perseverare diabolicum).’ Global Policy, 15(5), 969–978. https://doi.org/10.1111/1758-5899.13449
8. Thakur, R. (2017). The United Nations, Peace and Security: From Collective Security to the Responsibility to Protect, 2nd edn. Cambridge: Cambridge University Press.
9. World Health Organization (WHO) (2025). ‘WHO Scientific Advisory Group issues report on origins of COVID-19,’ 27 June 2025. https://www.who.int/news/item/27-06-2025-who-scientific-advisory-group-issues-report-on-origins-of-covid-19
10. World Health Organization (WHO) (2026). ‘WHO Member States continue negotiations on the Pathogen Access and Benefit Sharing Annex,’ 20 July 2026; and ‘Seventh meeting of the Intergovernmental Working Group on the WHO Pandemic Agreement,’ 6–17 July 2026. https://www.who.int/news/item/20-07-2026-who-member-states-continue-negotiations-on-the-pathogen-access-and-benefit-sharing-annex