Rising UN Engagement in Global Health Governance

Public health has become increasingly salient in international affairs, with the UN elevating underlying determinants of health as a political priority while bringing together state and non-state actors to advance global health goals. Operationalized through the UN General Assembly, such UN political statements on global health have achieved many of the goals of formal norm-setting without requiring the adoption of a treaty or the establishment of new institutions.Reference Kickbusch and Buss¹ The General Assembly’s diplomatic focus on health inequities has brought increasing political attention to global health governance while bringing together other critical sectors such as education, social protection, and human rights.Reference Burci and Kümmel²

To provide high-level political support for specific health issues, the UN has convened a series of HLMs to advance global health. Leading up to this year, the UN has convened four HLMs on HIV/AIDS (2006, 2011, 2016, and 2021), three on non-communicable diseases (NCDs) (2011, 2014, and 2018), and one on antimicrobial resistance (AMR) (2016), tuberculosis (TB) (2018), and universal health coverage (UHC) (2019).Reference Buse, Mialon and Jones³ These HLMs have looked to adopt “political declarations” that, while non-binding soft law, have carried significance in international affairs — representing the highest level of commitment of UN Member States, facilitating accountability through international mechanisms, catalyzing civil society action, and building consensus on commitments that can be “hardened” over time through international law.Reference Sekalala and Masud⁴

Heralding this UN attention to global health, the September 2000 Millennium Declaration,⁵ followed by eight Millennium Development Goals (MDGs) to be met by 2015, invoked widespread political concern for health in the UN General Assembly, focusing global policy on the vicious cycle linking poverty and health.Reference Freedman⁶ Created as a normative framework for a global campaign to advance human development, four of the eight MDGs set health-related targets—including the reduction of maternal and infant mortality, the prevention of HIV and malaria infection, and the eradication of extreme poverty and hunger—with the MDGs seeking to address these health conditions through specific indicators to structure national health policy and monitor public health outcomes.Reference Ruggie⁷

Policymakers met the following year in a June 2001 UN General Assembly Special Session (UNGASS) on HIV/AIDS—the first such meeting devoted to a specific health threat—dealing belatedly with an issue then of primary concern to the world’s most impoverished regions.⁸ With HIV/AIDS framed initially by the UN Security Council as a “threat to international peace and security,”⁹ this security framing yielded in the General Assembly to a focus on public health, human rights, and international development.Reference Rushton¹⁰ Building from the HIV-related MDGs, the UNGASS on HIV/AIDS brought together state representatives, international organizations, and nongovernmental organizations to reinforce HIV/AIDS as a political priority in international affairs and call for the formal creation of a global fund.Reference Parker¹¹ Through the Declaration of Commitment on HIV/AIDS, the UNGASS asserted UN leadership in the HIV/AIDS pandemic response, elevating political attention and financial commitments that would alter global governance over HIV/AIDS and would be followed by four subsequent HLMs and Political Declarations to address the rising pandemic.

Global health has since become increasingly prevalent in the political statements of the UN General Assembly.Reference Rodi, Obermeyer, Pablos-Mendez, Gori and Raviglione¹² Convening an HLM on the underlying determinants of NCDs in 2011, the UN General Assembly sought to promote greater action against the most prominent NCDs (specifically diabetes, cancer, cardiovascular disease, and chronic respiratory disease) and their commercial determinants (tobacco, alcohol, poor diet, and inadequate physical activity).Reference Morrison¹³ The HLM raised political recognition of NCDs, rallying advocates against the injustices driven by transnational corporations and trade regimes and proposing solutions to advance global health governance.Reference Sridhar, Morrison and Piot¹⁴ While lacking concrete obligations, advocates drew from this HLM to reframe the discourse on chronic diseases, shifting from “blaming individuals” for poor health behaviors to focusing on the underlying social and environmental determinants of NCDs, with the UN and WHO developing follow-up commitments to track national progress.Reference Alleyne, Stuckler and Alwan¹⁵

As the MDGs concluded in 2015, the UN General Assembly came together again to develop a new, broader global development agenda, the 2030 Agenda for Sustainable Development. Under the 2030 Agenda, the UN General Assembly set 17 SDGs, including a specific goal on health and encompassing a wide range of other health-related goals.¹⁶ The SDGs were framed as intersectional, addressing interconnections across determinants of health, and within these goals are discrete targets aimed at addressing specific health indicators, including maternal mortality rates, essential health services, and vaccine coverage.Reference Dagron and Rowe¹⁷ While progress has fallen far short in meeting several targets, the SDGs have provided a basis for building partnerships for intersectoral development initiatives to support health and wellbeing across institutions of global governance.¹⁸ Drawing from the SDGs, continuing HLMs offered additional opportunities to focus on specific agenda items, with the UN General Assembly developing subsequent HLMs on AMR, TB, and UHC — to “fast-track” multisectoral and multistakeholder engagement and recommend specific health actions by 2030.

As the failure to prevent the COVID-19 pandemic became clear, the UN system moved to recognize the staggering humanitarian upheaval, economic instability, and health insecurity presented by this new coronavirus — leading to a 2020 UN General Assembly Special Session on the pandemic response.Reference Guterres¹⁹ Yet early global health diplomacy in the pandemic response centered on Geneva, with the World Health Assembly developing key resolutions to facilitate global solidarity and, where challenges arose, committing WHO Member States to amend the IHR and develop a Pandemic Accord. While early UN General Assembly resolutions would look to WHO leadership as the world faced a new health threat, the General Assembly subsequently adopted resolutions and held high-level events recognizing that pandemic PPPR required more than just the health sector — positioning the UN General Assembly to drive multisectoral cooperation to mount a global response to control and contain pandemic threats.²⁰

Developing a UN HLM on Pandemic Prevention, Preparedness, and Response

Through the September 2023 HLM on PPPR, the UN General Assembly would seek to redress the catastrophic failures of the international community to prepare for and respond equitably to the COVID-19 pandemic. The timing of this HLM in New York was pivotal, as negotiations were already underway in Geneva to substantially amend the IHR and negotiate a new Pandemic Accord.Reference Meier, Habibi and Gostin²¹ Advocates hoped that UN engagement would be transformational for PPPR. They looked to the leaders gathered in New York for the highest-level political support for global health law reforms, underscored by strong new commitments in a first-ever Political Declaration to address PPPR.Reference Gostin, Wetter, Finch and Halabi²²

In September 2022, the UN General Assembly adopted the first resolution, tabled by South Africa, which led a group of 12 countries to muster support for an HLM on PPPR. The resolution noted the failures of the COVID-19 response, described it as “one of the greatest global challenges in the history of the United Nations,”²³ and recognized the need for coordinated, multilateral, multisectoral, whole-of-government, and whole-of-society approaches. With the adoption of this resolution, cosponsored by a total of 129 states, countries signed on to mobilize political will at the international, global, regional, and national levels to prevent, prepare for, and coordinate future responses to pandemic threats.²⁴ Reflecting the need for high-level political support, the resolution was seen as an opportunity to provide momentum to the Pandemic Accord negotiations in the World Health Assembly while elevating PPPR beyond health governance, including through the creation of a High-level Health Threats Council under the UN.²⁵

The President of the UN General Assembly appointed Morocco and Israel as co-facilitators to lead the process of coordinating the HLM and negotiating the Political Declaration. This choice came as a surprise to advocates, which expected to see South Africa in this role, given the leadership of the South African ambassador in marshaling the resolution to hold the HLM. In February 2023, the co-facilitators adopted a “modalities resolution” to specify the details of the meeting, which would include an opening segment, a plenary segment for general discussion, two multistakeholder panels, and a brief closing segment. It clarified that the goal of the September 2023 meeting was to “mobilize political momentum, including through the integration of a multisectoral approach to pandemic prevention, preparedness, and response, given the multifaceted consequences of pandemics.”²⁶ Seeking to have the President of the General Assembly convene this HLM in collaboration with WHO, it concluded that delegates in New York would approve a “concise and action-oriented political declaration” that was to be informed by and aligned with the two ongoing negotiations in Geneva — the amendments to the IHR and the negotiation of a Pandemic Accord.

Although the original resolution designated WHO to co-convene this HLM, this caused some tension from the start. First, the HLM for many aimed to elevate pandemics beyond the remit of the health sector. However, the PPPR, TB, and UHC meetings were grouped in people’s minds and practice as “the three health meetings” at the UN General Assembly. Secondly, for TB and UHC, multistakeholder partnerships were explicitly named in the modalities resolution — to support the respective facilitators in engaging nongovernmental actors, including civil society and the private sector. In contrast, no such role in the PPPR HLM was designated for civil society. Finally, WHO was perceived as having a vested interest in keeping the focus of negotiations in Geneva, thus lacking a genuine commitment to see a meaningful or strong outcome from the New York process.

Following two UN co-facilitator trips to Geneva to coordinate with WHO, its Member States, and relevant intergovernmental organizations such as the WTO—complemented by a multistakeholder interactive meeting with Member States, civil society, and other groups on May 8—the Declaration’s first draft (so-called “zero draft”) was distributed in June 2023. The zero draft was fourteen pages in length and covered wide-ranging issues, outlined in 29 preambular and 46 operative paragraphs; however, the substantive obligations largely focused on health concerns, despite the widely documented social and economic disruptions caused by COVID-19 and the UN’s stated objective to address the multisectoral aspects of pandemic threats.

The negotiating process moving forward was scheduled to include three separate “readings” at the UN before the document would be placed under the so-called “silence procedure” for adoption. (Under a silence procedure, a draft resolution is circulated in advance, giving states a deadline to respond: if there is no response, or the “silence is not broken,” it is assumed that all states support the resolution. This procedure, adopted when states could not meet during the COVID-19 emergency, was intended as temporary to minimize the need for in-person gatherings.²⁷) The zero draft was first discussed by states in a closed meeting on 7 June, following which the co-facilitators created a “compilation text,” including comments from all states, which was discussed on 26-27 June. Following that subsequent meeting, the co-facilitators revised the document for discussion on 5-6 July and then revised it again. Rather than hold a third and final reading at the end of July as originally planned,²⁸ the final draft was produced following bilateral consultations on 23-25 August between the co-facilitators and Member State representatives. On 28 August, the text was placed under the silence procedure.

While the HLM ultimately adopted the Political Declaration, several state and non-state actors expressed reservations with the manner of diplomatic negotiations and the content of the Political Declaration. Non-governmental advocates consistently expressed concerns that the process did not sufficiently address the multisectoral dimensions of PPPR, nor had it engaged meaningfully with civil society and other non-state actors.Reference Gostin, Wetter, Halabi and Finch²⁹ These advocates highlighted that co-facilitators had repeatedly rejected opportunities for civil society engagement, including during the May 2023 World Health Assembly in Geneva, where consultations focused almost exclusively on WHO Member States. Unlike other HLMs, the PPPR HLM and Political Declaration had no formal mechanisms for civil society engagement, severely limiting participation in the process. Throughout June, July, and August, civil society expressed concerns that the Political Declaration texts, in each iteration, would not lead to the transformational changes recommended for the international system — as the language was too health-focused, had few measurable commitments, and established weak accountability mechanisms.³⁰ Four days prior to the HLM, eleven states, including Russia, Belarus, North Korea, and others who opposed the use of sanctions (“unilateral coercive measures”), issued a letter of concern detailing that developing countries had not been sufficiently included in negotiations for the SDG Summit political declaration or any of the declarations relating to TB, UHC, and PPPR.Reference Cullinan³¹

While the HLM accepted the final PPPR text unanimously and with no formal debate on 20 September 2023, concerns were subsequently raised during the formal adoption of the Political Declaration on 5 October. With over two hours of interventions, individuals and groupings of Member States raised concerns and reservations over both the HLM negotiating process and Political Declaration content. The “G-77 and China” argued that the Declaration presented a “take-it-or-leave-it” approach, that Global South proposals were ignored, and that developing countries were pressured to comply with the text. High-income countries noted separate reservations, including watered-down language on human rights, vulnerable groups, and gender. The “Friends of the Charter” group, supported by countries including South Africa, repeated concerns about universal coercive measures and their effect on access to medical countermeasures during a pandemic. Even as WHO and some Member States raised concerns that the HLM could interfere with the negotiations underway in Geneva,Reference Fogarty³² this “Geneva vs. New York” tension remained pervasive in the HLM and its resulting Political Declaration.

Advancing Global Health Law Under UN Governance?

Evidenced by the process and outcome, UN Member States missed an opportunity to strengthen PPPR governance, finance, and equity with concrete multisectoral actions, targets, and accountability mechanisms. The Political Declaration includes almost no measurable commitments except to hold another HLM in September 2026, well after negotiators in Geneva are scheduled to have concluded their work to develop IHR amendments and a new Pandemic Accord — and much of the political momentum that drove UN leaders to meet will have been lost. The HLM set out to scale up efforts to strengthen PPPR, yet the Declaration falls short in the following core domains:

Sustained political leadership and multisectoral action. COVID-19 demonstrated that pandemics can be world-altering events that touch every government sector and every aspect of society, but the Political Declaration fails to commit to high-level leadership necessary for sustained, whole-of-government action. The HLM and the Declaration were opportunities to elevate multisectoral action on pandemics to the highest political levels, enhancing the UN General Assembly’s role in overseeing PPPR, including by endorsing a High-Level Global Health Threats Council, but only 13 heads of state participated in the HLM.Reference Bristol³³ Despite the imperative for multisectoral advancements, states largely used the HLM to congratulate themselves on actions and investments already underway,³⁴ while leaving all responsibility for reforms to WHO and the Geneva processes.

Equity. Global health leaders have long called for strong norms and commitments to operationalize equity; however, the Political Declaration deploys weak language, with commitments that merely “urge” equitable and timely access to countermeasures and call for states to “promote” technology transfer and the supply and distribution of affordable medicines.³⁵ Although the Declaration reaffirms the right of states to use flexibilities in the TRIPS Agreement to overcome intellectual property obstacles to essential medicines, it fails to address the barriers to exercising these flexibilities and thus merely reinforces the status quo. The Declaration could have generated high-level political support for new mechanisms to ensure the equitable end-to-end development and deployment of medical countermeasures, but its use of soft language has led advocates to view the Declaration as only “paying lip service” to equity.³⁶

Accountability and compliance. The Political Declaration neglects to structure robust accountability and compliance mechanisms for PPPR commitments, instead acknowledging “the need for Governments, at all levels, to strengthen … multisectoral monitoring and accountability, as appropriate.” Without clear independent accountability and compliance mechanisms, state commitments will prove meaningless.Reference Hanbali, Hannon, Lehtimaki, McNab and Schwalbe³⁷ Yet despite this imperative for accountability, the Declaration supported neither the establishment of peer review mechanisms under consideration in Geneva nor an independent mechanism for monitoring state implementation. Such accountability mechanisms — with a formal role for civil society — remain necessary to identify compliance gaps and link unmet obligations with financial and technical assistance.Reference Kavanagh, Wenham, Da Fonseca, Helfer, Nyukuri, Maleche, Halabi, Radhakrishnan and Waris³⁸

Financing. Where the Political Declaration could have committed States to long-term preparedness and emergency financing targets, it instead resolves to “recognize that health financing requires global solidarity” and “leverage existing financial tools … to mobilize … timely, reliable, flexible, equitable, predictable and sustainable funding, … as well as funding for rapid surge financing.” This aspirational language is insufficient to close critical resource gaps. Although both the Global Preparedness Monitoring Board and the Independent Panel for Pandemic Preparedness and Response had recommended that the Declaration commit States to fully finance national preparedness plans and support international financing needs,³⁹ recognizing that wealthier nations have an obligation to provide greater support, the Declaration did not establish any differentiated financing commitments.⁴⁰