The international spread of disease is a global threat. It has serious consequences for public health, for human lives and livelihoods. It ravages economies and disrupts societal activities. Throughout the Covid-19 pandemic many witnessed the gravity of health threats and observed how vulnerable and fragile our world is. 

The inequities and inequalities have also exposed how those who are marginalised and disadvantaged were worst affected by the pandemic. 

What the world has gone through is an unparalleled health and socioeconomic crisis of epic proportions. A truthful outlook of a fractured and fragile world, the insufficiency and ineffectiveness of the measures that were introduced clearly call for a reset. A global reset to bring us back on track but also to halt the current pandemic and prevent any recurrence of such disasters in future. Covid-19 and its ripples must never be repeated. In our lifetime we must prevent this from ever happening again. It is not the first global health threat. It is also not the first crisis.  

Other outbreaks, such as severe acute respiratory syndrome (SARS) and the Zika virus disease, have been reported but they were not as devastating. With SARS the world dodged a bullet. Ebola virus disease had devastating effects in West Africa. 

While most countries are still tackling the Covid-19 pandemic, others like Uganda are also battling Ebola while trying to end Covid-19. In addition, they must still find an appropriate vaccine. Uganda is not the only country; many countries had to deal with an upsurge of cholera amid the shortage of a cholera vaccine supply which must be rationed. 

Precious Matsoso (Photo: Thulani Mbele / Sowetan / timeslive.co.za / Wikipedia)

Cholera is making an unwelcome return, as the World Health Organization (WHO) recently warned, fuelled by conflict, floods, drought and natural disasters on different continents . Since the start of the monkeypox outbreak cases have been reported from 29 EU/EEA countries, and from three Western Balkan countries as well as Turkey. South Africa has had its share of outbreaks prior to Covid-19, including meningitis and listeriosis in the recent past, with listeriosis considered the largest outbreak globally. Furthermore, the country battled animal disease outbreaks, namely foot and mouth disease, and the most recent being a highly pathogenic bird flu. 

In human health, countless millions who are affected are not just a statistic, they are a family member, a friend, a co-worker, a leader and a community member that will result in a permanent loss, leaving a void not to be filled again. They are also from sectors of society that are vulnerable.

Covid-19 has added to the frailties and fragilities of these groups and has compromised access to services and treatments, particularly for the elderly, children, women, people with disabilities, migrants and displaced peoples.

With the envisaged changes globally, the goal is to prevent these health threats from happening again at such catastrophic proportions and fix the current inadequacies of preparedness and response. Health emergencies are disruptive. They compromise other services and undermine access especially if preparedness plans are absent.  

Evidently the assessment of countries, including South Africa, before the pandemic was noteworthy. The shortcomings identified were associated with limited investments in preparedness and response. Using various evaluation tools to help countries assess themselves, it was revealed that only two-thirds of WHO member countries reported having full enabling legislation and financing to support emergency prevention, detection and response. The Global Health Security Index revealed that 155 out of 195 countries had not allocated national funds over a three-year period to address epidemic threats. Those countries that scored high in these assessments through Joint External Evaluations, were not necessarily the best performers. South Africa identified gaps. For instance the interoperable, interconnected, electronic real-time reporting systems were found to be inadequate, as well as healthcare associated infection (HCAI) prevention and control programmes. 

These could be addressed in a short, medium, and long term. There were strengths associated with preparedness and response structures and networks. There were weaknesses with subnational level linkages in some of the countries. This was exposed during the Covid-19 response as the speed at which the coronavirus moved was fast. The surveillance and alert systems could not keep up and reaction was slow. This was the case for South Africa and for many other countries, as revealed during assessments and evaluations commissioned by the WHO.

Various panels and expert bodies were convened, including the Independent Panel for Pandemic Preparedness and Response, to seek evidence-based solutions on how to tackle the Covid-19 pandemic and successfully prevent and effectively manage future health threats. The primary objective of most of these global efforts was to achieve a more secure, much safer and fairer world. Coupled with these global efforts were determined national-level attempts and health systems support to respond to the pandemic and many other threats.

Sectoral interdependence  

No single government could resolve the pandemic crisis by itself without the involvement of other sectors, stakeholders, and communities. The interdependence of all sectors of society was a key component to the pandemic response. The various global health events have also exposed why this interdependence is important and why potential gaps in the national and international system’s pandemic preparedness and response are an important matter requiring attention. It is also trust and accountability that were considered important elements on how countries fared during the worst of all the crises.

The leadership and various governance arrangements, as shown locally and globally, have been assessed and have been considered to be crucial. Health threats that governments confront today transcend national borders. They are part of a complex web of geopolitical constellations and multilateral engagements. 

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In an endeavour to address the global health threats, the World Health Assembly created the Intergovernmental Negotiating Body (INB) to draft and negotiate a legally binding instrument in the form of a treaty or convention or accord. In addition, there were gaps identified in relation to the International Health Regulations. This recently established INB identified four thematic areas: a) Equity, b) Governance and Leadership, c) Systems and Technical tools and d) Financing. These were shaped by myriad recommendations and consolidation of ideas that evolved from various expert roundtables and panel reports to review the Covid-19 response. 

Equity

As we transition out of Covid-19, the true test of the strategies to recovery will be how well equity is addressed and how far will countries commit in ensuring equitable access to medical countermeasures and how these commitments will be met. There were problems of inequitable access to medical countermeasures that were identified which reflected broader unresolved access challenges. Barriers to access medicines are not new, and persist despite norms and standards that have been punted over the years. 

For example, health inequities have increased within and between countries; this is one of many areas that require regulatory measures and obligations that countries should commit to. The legal instruments that are currently under negotiation should be resolute actions that will facilitate equitable access to medical products that are needed for pandemic prevention, preparedness and response. 

Governance and Leadership

Countries and state parties must recognise that they have a duty to protect their citizens. They must assume responsibility for people within their jurisdiction, and promote and protect their health through legislative and other means. They must have safeguards and measures in place, as well as coherent and synergistic policies. The governance arrangements at country level should not be relegated to administrative structures without due regard for the whole-of-society approaches. 

This narrow approach has not been shown to work. The ultimate responsibility of the government to transform the way the country prepares and responds to pandemics must be through marshalling various sectors and formations. The government cannot do it alone. At national level it must be recognised that subnational-level and community-driven responses have been proven to be the best responses by far.

As countries sort out their national preparedness and response strategies, they must be cognisant of their obligations enshrined in global legal instruments. Taking responsibility for their populace should not be at the expense and risk of others, whether through failure to report, hoarding supplies as recently observed by unprecedented hoarding by well-resourced countries, or subjecting others to harm. This has had the dire consequence of inequitable supply and distribution. Clearly, synergistic global responses among large-scale challenges such as pandemics, call for a collective response and partnerships. 

All countries must acknowledge that they have a duty to their citizens by having effective national capacities for prevention, preparedness, and response. They also have a responsibility to comply with international obligations. Cooperating sufficiently locally and globally with other actors is a necessity. 

In addition, the best effective governance arrangements must incorporate accountability mechanisms. Accountability must be the first consideration grounded in equity and human rights. Our interdependence calls for solidarity. At national level there will be complexities cut across horizontally and vertically and these may even be multilayered. For South Africa this will require a shift in gear in the way the government operates. A move from an exclusive governmental-focused approach to an inclusive approach of plurality of non-governmental organisations (NGOs), community-based organisations, development partners, various formations and groups, bi- and multilateral organisations, public-private partnerships (PPPs), sector entities, creating a network of “hyper-collective action”. 

At global level, the issues may be exacerbated by multiple actors. In the absence of defined mechanisms for how they interact with each other, a much more coherent architecture may be a consideration. Global health governance should foster international collaboration with the aim of building a safe and healthy world. Better coordination within normative frameworks and multisectoral approaches is needed to tackle animal and human health, including antimicrobial resistance (AMR). One Health approaches need better articulation at the country level to address threats to environmental, human and animal health. What has been significant is convergence in thinking, particularly regarding how the threats to human, animal and environmental health are inextricably linked and why there is a need for a One Health approach. 

At a global level the quadripartite interagency and multisectoral collaboration need to be an integral part of pandemic preparedness planning. At a national and regional level, multisectoral approaches and whole-of-society approaches must be the way to go. South Africa, through its established governance arrangements, has the building blocks to start working from.

Systems and technical tools

The health systems must be strengthened to quickly respond, and mobilise and allocate a trained and capacitated health workforce. They must be provided with the tools of the trade. Expand capacities for R&D to address potential pandemics and build on existing expertise and technological platforms. The legal, regulatory environments must be enabling and responsive. Increased concerns about security of supply of needed medical interventions and measures for preparedness, resilience and response in many countries led to the realisation that more obligatory measures may be needed to get the firm commitment of state parties. 

Technology transfer and knowledge sharing should be promoted and enhanced in an environment that is enabling and conducive. Within the multilateral system it must be in collaboration with other UN bodies and at national level it must percolate through various sectors and within the legal and regulatory frameworks.

The ACT Accelerator was launched by the WHO with various partners as a global collaborative effort to develop tools such as diagnostic tests, treatments and vaccines to diseases. It may have had its shortcomings but has played a significant role and should now be transformed into a permanent platform that can advance equitable and effective access to vaccines, diagnostics, therapeutics and other supplies. The next phase of ACT-A will be crucial, especially its vaccine arm, the Covid-19 Vaccines Global Access Facility (COVAX Facility). It was established mainly to ensure global, equitable access, but its work was impeded by insufficient funding. It must be reconfigured to achieve sustained access for all countries to Covid-19 vaccines, tests and treatments.

Financing

Sustainable and predictable financing arrangements must be addressed.  The risks of redirecting funding from other programmes may reverse gains made on HIV/TB/malaria. Redirecting these resources to fill Covid-19 gaps or other pandemics or disasters may not be desirable. Closing the preparedness gap does not entail needlessly cutting resources in a self-destructive way from other priority programmes. It requires sustained investment in a comprehensive manner. 

The creation of a Pandemic Fund is notable and is a good start. However, further details of its modus operandi must still be worked out. This facility should have a broad mandate to be available not only for direct pandemic responses, but also for the containment of smaller outbreaks and for governments to address the recovery of the health system to make it more resilient.

Outbreaks start and end in communities. Our successes in containment and mitigation will depend on how we build trust, people’s trust, and confidence in health authorities. Engagement of local communities to promote pandemic literacy and understand health communications and working directly with marginalised populations on risk communication policies is a good start. In addition, health promotion and education can be incorporated to have an integrated approach. South Africa can learn from the experience of countries that dealt with epidemics and performed well but may not have been noticed, as reflected by Resolve to Save Lives. 

A realistic view is needed on what different actors can and will do both domestically and internationally. This means supporting institutions, and providing incentives and convincing those with power to act upon the key thematic areas by making wise investments. 

The objective realities we confront are the geopolitics and polarisation that are undermining global collaborative efforts and national mechanisms to coordinate in a sustainable manner. Addressing these may not be easy or straightforward. Far more balanced and principled approaches may be needed if we are to succeed. 

The best possible options to achieve the goal of preventing future pandemics should be considered without compromising the basic principles of solidarity, inclusiveness and accountability. The complexity of these problems calls for systems approaches and networked responses at all levels, nationally, regionally, and globally. Unless there is recognition of these approaches the policymakers will have to move out of their policy silos to a much better integrated and inclusive approach that is built on trust. DM

Precious Matsoso is chairperson of the World Health Organization’s (WHO) Independent Oversight and Advisory Committee and former director-general of the Department of Health. Matsoso was a participant on a panel at Daily Maverick’s The Gathering and this essay is an extension of comments made then