The World Health Organization, established in 1948 as a specialised agency of the United Nations, is currently the global body in charge of governing the risk of and response to pandemics. It does this mainly through a governance mechanism called the International Health Regulations (IHR), the goal of which is to stop public health events that have the potential to spread internationally, with minimal interference to travel and trade. The IHR first came into force in 1969, with an initial focus on four infectious diseases – Cholera, Plague, Yellow Fever and Smallpox.
Revised in 2005, the IHR now acknowledges that many more diseases than the four originally covered may spread internationally, and that many cannot be stopped at international borders, as was demonstrated by the spread of HIV in the 1980s, SARS in 2003 and COVID-19 in the 2020s. Therefore, emphasis is now placed on the requirement that countries rapidly detect and respond to outbreaks and other public health events with the potential to spread internationally. The revised version of the IHR also includes a global safety mechanism that calls for collaborative action should a public health event be assessed as at risk of spreading internationally.
The governance of pandemics typically involves collaboration between the WHO, ministries of health and public health institutions. Some nations have established national public health institutes the role of which is to monitor public health events.
Some of those, including the US CDC, Sante Publique France, and the Nigeria CDC are among the 110 members of the International Association of National Public Health Institutes (IANPHI). IANPHI works to provide mutual support to strengthen capacity to better detect and respond to public health events. When an outbreak occurs, other national institutions, primary health care facilities and hospitals in particular, also play a major role in early detection and containment.
"The governance of pandemics typically involves collaboration between the WHO, ministries of health and public health institutions."
The IHR are a binding agreement under international law, and as such provide a framework for national legislation and responsible national and international action. But like all international law and treaties, there is no enforcement mechanism. Under the IHR, countries are required to strengthen the core capacities in public health that are deemed necessary for rapid detection of and response to a disease outbreak. Each year countries are required to do a selfassessment of their core public health capacity, and to report the outcome of their assessment to the WHO.
However, there is no sanction for non-reporting, and many countries do not report. As part of the IHR (2005) Monitoring and Evaluation Framework, the Joint External Evaluation (JEE) was developed as a mechanism where a country’s core capacity in public health is assessed by a group of international experts. All countries may request such an evaluation through the WHO on a voluntary basis. The tool was made available in 2016 and to date, over 79 countries have done so.
The revised IHR provides a decision tree which can be used by countries to determine whether a public health event in their country has the potential for international spread, and should therefore be reported as a potential public health emergency of international importance (PHEIC). The WHO Director General then conducts a risk assessment.
For this, the Director General can ask for a recommendation from an emergency committee set up under the auspices of the IHR, and/or from other experts from around the world. If the Director General decides that the event is a PHEIC, the WHO must provide emergency recommendations aimed at curbing international spread, and review those recommendations every three months until the PHEIC has been declared over.
After the Ebola outbreak in West Africa, an external review of the revised IHR was conducted, and a second review was conducted during the COVID-19 pandemic. Recommendations from that review are now being considered by the World Health Assembly of the WHO.
There are two main improvements needed for the IHR: a stronger enforcement mechanism that utilizes a combination of self-review, peer review and external review; and country capacity-building for low- and middle-income countries. At the same time the WHO is beginning discussions on the possibility of an international treaty to complement the IHR as a result of new understanding gained from the COVID-19 pandemic. These efforts are welcome, especially as COVID-19 will not be the last pandemic that humanity faces.