From a review of the latest articles, news, reports and the agenda of the 74th World Health Assembly (WHA) on the governance and role of the World Health Organization (WHO), it suggests to consider two aspects of “legal and governance” for preparation for the next pandemic; 1) Strengthening the governance of WHO, 2) Revision of International Health Regulations (IHR, 2005).

First of all, the below information explains why the governance of WHO should be strengthened and suggests how its governance can be improved for the preparedness of next pandemic.

The novel infectious diseases have emerged as a major public health concern over the past 10 years all over the world. Since 2009, there have been 6 PHEIC (Public Health Emergency of International Concern) declarations by WHO; 2009 H1N1 pandemic, 2014 Polio, 2014 outbreak of Ebola in Western Africa, 2015-16 Zika virus epidemic, the 2018-20 Kivu Ebola epidemic, and the ongoing COVID-19 pandemic (Mullen, 2020). PHEIC is defined as “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response” (WHO(b), 2016)

On March 11th 2020, COVID-19 was declared as a “Pandemic” by WHO. Since its declaration, it revealed that there were huge gaps in capacity to respond to COVID-19 by countries, and a greater shortage of medical equipment, medical personnel, and healthcare facility for diagnosis and treatment in more vulnerable countries. However, this situation is not only confined to low and middle-income countries, but also is occurring in highly developed countries, including United States and European countries.

Therefore, the international community has reported that through the experience of COVID-19, major problems have been discovered in terms of WHO’ governance in responding to new infectious diseases; 1) managing concurrent public health emergencies, 2) interrupted programming and implementation due to COVID-19, 3) political instability (e.g., government turnover, institutional capacity, conflict, other crises, security), 4) difficulties in dialogue across government institutions beyond health (WHO(d), 2021). These major challenges have triggered to weakening the governance of WHO in response to a novel infectious disease. But at the same time, these challenges also provide opportunities for WHO to prepare for the next pandemic (WHO(d), 2021);

1) working with different stakeholders, especially the private sector, academia, civil society and communities

2) leveraging advocacy for health in national agendas given the momentum gained from WHO’s preparedness and response to the COVID-19 pandemic

3) the opportunity to strengthen resilient health systems and preparedness to advance the health-related Sustainable Development Goals

4) potential for increased financing for health

5) continuing to utilize strategic and operational mechanisms through interaction across the three levels (headquarters including Global Service Center [GSC], regional offices, and country offices [WCOs]) of the Organization to move forward with the implementation of the Thirteenth General Programme of Work, 2019–2023 (*GPW 13). For 5 years of period, GPW 13 targets the following areas; 1) One billion more people to benefit from universal health coverage, 2) One billion more people better protected from health emergencies, 3) One billion more people enjoying better health and well-being (WHO(c), 2018)

However, despite these opportunities, the continued deterioration of WHO’s governance from major challenges could lead to greater global public health risks around the world. Therefore, in order to prepare and response to the next pandemic more effectively, the governance of WHO should be strengthened through the improvement in the following areas;

• Background
  Countries with non-compliance for the existing treaty and the Regulations supported by WHO is gradually increasing. Consequently, there is a growing concern that the governance of WHO has been weakening gradually in response to a novel infectious disease through the experiences in the past 10 years. Under this critical condition, the development of a new treaty including revision of the existing Regulations are urgently needed to strengthen and restore the governance of WHO. The European Council and the president of WHO called for the development of a legally binding treaty to prepare for the next pandemic with 27 world leaders on March 27th 2021.
• Recommendation
  To develop the new treaty, it requires at least those four conditions; 1) before negotiating a new treaty, nations need to study why existing agreements are not working, 2) if a new treaty is to be administered by the WHO, nations need to have an honest conversation about whether they will give the agency more powers. 3) a treaty needs researchers and non-governmental organizations (NGOs) to be actively involved, 4) international treaties need the world to sign up (Nature 2021).

• Background
  The source of WHO’s budget is heavily relying on the World’s powerful countries such as United States, some EU countries (e.g. United Kingdom), Japan, China, and others. Through the experience of COVID-19, WHO is now in a situation where its roles and powers in the global community are much diminished when political confrontation occurs between major countries such as United States and China. Recently, due to this political confrontation, the former US President Donald Trump has called for a suspension of WHO funding.
  
  Under the WHO’s Programmed budget 2020-2021, the funding for country-level work accounted 55% of the total WHO funding. These funding were allocated for base programs (32%), emergency operations, including COVID-19 response (54%), Polio (13%), and special programs (1%). However, flexible funding for country-level work was only 10.2%, which could delay WHO’s sustainable and effective technical cooperation within the country (WHO(d), 2021).
• Recommendation
  The mobilizing resource is one of the key functions of WHO. At country level, country-offices can continuously secure mobilizing funds as grants through bilateral partners. For instance, WHO is helping countries to access and implement grants from the Global Fund such as GAVI (Vaccine Alliance). These grants appear to be gradually increasing the WHO budget.

• Background
  It is reported that less than 45% of all WHO staff members were working as professional and general staff in the 149 country offices. Of all international employees, 22% worked in country-offices, of which only about 41% were working in health emergencies, outbreak and crisis response, and polio. This was soon found to be a limitation in improving universal health coverage, encouraging a healthier population, and strengthening national health data, due to a lack of well-trained and professional staff in national-level work. (WHO(d), 2021).
• Recommendation
  WHO needs to ensure sufficient, flexible, mobile and high-performing workforce who fits for purpose. One of the WHO priorities is improving gender equality for the workforce. The number of female employees increased from 33% in 2015 to 39% in 2020, but higher gender equality is needed, especially at the professional level. It should also improve communication, resource mobilization, partnerships, and data/health information management skills among employees.

• Background
  The country offices often collaborated with the European Union, followed by bilateral agencies, and the World Bank. EU is the main collaborating partner with the regions in Africa, Americas, and the European Region. In the Eastern Mediterranean, South-East Asia, and Western Pacific regions, bilateral agencies were the main partners with country offices (WHO(d), 2021).
• Recommendation
  WHO needs to more actively engaged with various national and international partners, including governments, academia, communities and civil societies, as well as bilateral and multilateral agencies at country level. Particularly, the close collaboration between country offices and bilateral and multilateral partners can develop more partnerships at country-level work. Through more enhanced partnership can extend the range of work fields, country-level work can include disease-specific programs to health systems and policy and research work.

As previously introduced, one of the major problems of the weakening of WHO governance is that countries have significant limitations in implementing IHR to respond to new infectious diseases. The below background information is to explain the need for revision of IHR by WHO.

Over the past year, WHO released more than a hundred guidelines related to COVID-19 with the support of international experts and continuously updating data. Also, these technical guidelines are developed to help countries to prevent, diagnose, and response to COVID-19. However, some countries have difficulties in adapting these guidelines due to lack of capacity in their health system.

According to the WHO, “The International Health Regulations (2005) (IHR) provide an overarching legal framework that defines countries’ rights and obligations in handling public health events and emergencies that have the potential to cross borders.” (WHO(a), 2021) However, through the COVID-19 experience, the main reasons why the existing IHR did not function properly in response to a new infectious disease were pointed out as follows; 1) WHO lacks authority to enforce IHR and is under-resourced, 2) WHO often defers to affected member states in public health crises, 3) Most WHO member states disregarded WHO guidance on travel restrictions (CFR, 2020).

As noted above, the implementation of IHRs in countries has been limited in public health emergencies over the past decade. Therefore, in order to prepare for and respond to the next pandemic, it is necessary to amend the regulations so that the IHR can be implemented more effectively. Amendments to the following areas may be considered in the IHR. Amendments to the IHR on the following items will be formally discussed and revised through the 74th WHA (May 24th - May 31st, 2021) (WHO(e), 2021);

• Background
  During a public health emergency, legislation is used to establish specific emergency response committees, provide public health response measures (e.g. limiting and restricting activities and movement of individuals and community), protect vulnerable groups, and regulate and establish the standards for health workforce, drugs, and medical equipment.
  
  In the past 10 years, through the experiences of a novel infectious diseases such as SARS, H1N1, or MERS, Some States Parties amended their health emergency legislation and established a better legal preparedness to responds to COVID-19. However, many States Parties still have outdated public health legislations or those are not fit-for-purpose.
• Recommendation
  Legislation reform and development may take a long process. Before a public health emergency, countries need to prepare for administered, funded, and fully implemented legislation.
  
  To do so, States parties should periodically review existing legislation and ensure a legal framework for managing health risks and emergencies. It also needs to enable the establishment and designation of national NFPs, and the formation of responsible authorities for the implementation of the IHR.
  
  WHO need to provide tools and technical guidance for States Parties to implement IHR in their national legislation. Tools may include checklists, detailed process guidance, templates and model legislative text.

• Background
  The major function of the NFPs is to share public health information that needed by WHO in a timely manner. However, the structures of NFPs are different by countries and these countries have different views on the role of NFPs. Also, some States Parties do not establish NFPs formally as a national center or office.
  
  States Parties are obliged to ensure NFPs to perform their functions under the requirement in Article 4 of IHR. However, the Regulations does not specify how NFPs should be organized by States Parties.
  
  NFPs have a weak authority on decision-making process through national health authorities because they are not usually engaged directly with other agencies or sectors.
• Recommendation
  Each State Party should establish the national authority responsible for IHR implementation. Through a multisectoral and whole-of-government approach, it needs to ensure the NFPs’ functionality and deliver of other IHR obligations. The authority for NFPs should be given to participate in the national emergency planning, national health committees, or similar bodies.
  
  Also, strengthening the capacity of NFPs is required through regular training and workshops at the national and regional levels. A guidance that clearly addresses the function of NFPs need to be shared by WHO.
  
  Additional stakeholders (e.g. professional organizations and academic institutions) may support IHR implementation and monitoring in collaboration with NFPs.

• Background
  Many States Parties have reported poor preparedness and response capacity for public health emergencies. Through COVID-19 experiences, it has been shown that there are significant gaps in preparedness for a pandemic between countries, using current tools and processes. (e.g., essential public health functions such as diagnosis/testing, treatment capacity, etc.). Also, the implementation of health measures by States Parties were uneven and insufficient
• Recommendation
  Within the broader national healthcare system, WHO needs to support countries to integrate the core capacities for public health emergency preparedness, surveillance, and response. Gender-equality should also be integrated into the core capacities of IHR.
  
  WHO needs to continue to strengthen tools and processes for assessing, monitoring and reporting IHR core capacities. This may allow more accurate analysis at national and subnational levels.

• Background
  WHO’s rapid risk assessment is an internal process to analyze formal and informal information about possible spread of international infectious disease.
  
  Although WHO conducts risk assessment for COVID-19 through collecting information through the EIS (Event Information Site), DON (Domestic Outbreak News), or GOARN (Global Outbreak Alert and Response Network), some of important information covered in full risk assessment was not published publicly by WHO.
• Recommendation
  WHO needs to develop more standardized form to collect a broader information, including microbiological information (e.g., pathogen, whole genome sequence), infection epidemiology (e.g., transmission patterns, attack rate), clinical information (e.g., disease treatment modalities, immunity), disease burden (e.g., clinical features, case-fatality rate), healthcare capacity (e.g., vaccines and treatments), and public health capacity (e.g., capacities in the affected area for surveillance and appropriate public health measures).

• Background
  The first cluster of severe pneumonia cases from COVID-19 was collected through well-integrated reporting and surveillance system in China. However, in general, there is a difficulty in identifying the outbreak of zoonotic diseases in early phase.
• Recommendation
  Through the experiences of COVID-19 pandemic, an innovative technology including genomic sequencing for outbreak alert and response system is expected to be very useful for the rapid development of diagnostics, treatment, and vaccines.
  
  As a part of “One Health” approach related to zoonotic diseases, WHO should work closely with the global partners such as the FAO (Food and Agriculture Organization of the United Nations), UNEP (United Nations Environment Programme), and as well as other networks and stakeholders.
  
  The genomic surveillance combined with animal, food, and environmental sectors can increase understanding of zoonotic diseases, enabling a better preparedness and response to a novel disease.

Through the experiences of COVID-19, there is the need to reform in a various public health fields. To prepare and response more effectively for the next pandemic, WHO emphasizes not only the importance of the medical field, but also needs an analysis of various factors that directly affect public health in a wide area around the world, and the major strategies are as follows; 1) strengthening public health infrastructure, 2) priority in protecting vulnerable groups, 3) environment protection, 4) protection from climate change. Additionally, the use of spatiotemporal mechanism can analyze the transmission of a disease in time and space among population group and this technology may help to control and prevention of infectious disease more effectively and efficiently.

The international community may need to establish the following detailed strategy in public health reform (WHO(f), 2020; WHO(g), 2021);

• Increase the investment in Primary Health Care [PHC]
  The essential health services are in great needs in many parts of the world. Also, the reduction of spending on PHC decreases the performance of healthcare system and increases health risks, particularly in vulnerable groups. WHO recommends to increase additional 1% of GDP on PHC by nations, and the improvement in PHC-oriented system leads to better health outcomes constantly. By 2030, the global aims to achieve the universal health coverage (UHC), including creation of additional 10 million full-time jobs for healthcare workers and strengthening gender equality efforts. Particularly, the role of women in health and social care should be strengthened with providing equal opportunities and reducing gender pay gap.
• Accelerate equitable access to COVID-19 technologies between and within countries
  Many countries are facing with secure of safe and effective vaccines for the prevention of further infection of COVID-19, as well as medical supplies such as medical oxygen and personal protective equipment (PPE), reliable diagnostic tests, medicines, and etc. Although the ACT-Accelerator (ACT-A) aims to establish testing and treatments for COVID-19 in low- and middle-income countries, it requires additional $22.1 billion to deliver these tools. Now, the COVAX established by the WHO with global partners distributes vaccines worldwide, however, the global community needs to secure effective vaccines continuously for vulnerable groups.
• Strengthen health data through enhanced national health information system
  According to the WHO’s global assessment data, only 51% of countries included disaggregated data in their published national health report. Particularly, the data for vulnerable, poor, or discriminated groups are most likely to be missing from these national data. Therefore, it requires to improve the quality of the national health data that includes disaggregated information such as sex, wealth, education, ethnicity, race, gender and place of residence.

• Priority in health and social protection
  Due to the impact of COVID-19 in many parts of the world, it has been causing the instability of health and social protection such as job-loss, increase of poverty, education disruption, and threats to nutrition. Therefore, groups which are vulnerable to infectious diseases in a community should be in priority for health and social protection.
• Establish safe, healthy and inclusive neighborhoods
  About 80% of the world’s population who live in rural areas live in poverty and these populations lack access to basic water and sanitation services. City leaders should improve transport systems, and water and sanitation facilities for people access to healthy housing and safe neighborhoods.

• Protect and preserve the source of human health
  Human activities such as deforestation, intensive and polluting agriculture practices increase the risk of new emerging infectious diseases. More than 60% of these diseases originate from animals, livestock, mostly from wildlife. Therefore, it needs a comprehensive plan to reduce the risk of future epidemics through early detection and control of disease outbreaks, including its source.
• Improvement in water and sanitation services in occupational environment
  About one quarter of all deaths around the world are avoidable from environmental and occupational risks. In many regions, basic health services to prevent infectious diseases such as handwashing are still lacking. In order to reduce the transmission of viruses such as SARS-CoV-2, it is essential to build a safe occupational environment and healthcare facility with water and sanitation services for workers. Therefore, creation of healthier environment, establishing environmental regulations, and ensuring health systems that are resilient to climate change are critical to prevent future disease outbreaks.
• Promote healthy, sustainable food systems
  People with insufficient diet or unhealthy food, and high calorie diets are at a higher risk of infectious diseases. In particular, those with obesity and diabetes are at a greater risk and deaths from COVID-19. Clearing land for livestock accounts one-fourth of global greenhouse gas emissions which is the single largest environmental driver of new infectious diseases. The world needs a healthy diet to save millions of lives, reduce disease risks, and greater reductions in greenhouse gas emissions.

• Build healthy, liveable cities
  People who live in cities produce a great amount of greenhouse gas emissions. In high-density population, it is encouraged to take more public transport, walking, and cycling rather than using private cars. It benefits to reduce air pollution, injuries from road traffic, and prevent millions of people dying from physical inactivity.
• Ensure a quick healthy energy transition
  Currently, exposure to air pollution causes one out of eight for all deaths worldwide. Burning fossil fuels are known as the major cause of polluting air which drives the climate change, and more than 90% of people breathe these polluted air. The energy transition from fossil fuels to renewable energy can lead to cleaner environments and healthier people.

Council on Foreign Relations (CFR). Improving Pandemic Preparedness Lessons from COVID-19. Independent Task Force Report No. 78. New York, United States; 2020

Mullen, L Potter C, Gostin LO, Cicero A, & Nuzzo JB. An analysis of International Health Regulations Emergency Committees and Public Health Emergency of International Concern Designations. Review. BMJ Glob Health. 2020;5(6):e002502

Nature. Editorial: The world must learn from COVID before diving into a pandemic treaty (April 8th, 2021). Available at
https://www.nature.com/articles/d41586-021-00866-7

WHO(a). International Health Regulations. Available at
https://www.who.int/health-topics/international-health-regulations. 2021

WHO(b). International Health Regulations (2005) Third Edition. Geneva, Switzerland. 2016.

WHO(c). Thirteenth General Programme of Work 2019-2023: Promote Health Keep the World Safe Serve the Vulnerable. Available at
https://www.who.int/about/what-we-do/thirteenth-general-programme-of-work-2019---2023, 2018

WHO(d). Seventy-Fourth World Health Assembly provisional agenda item 17.3 (A74/INF.3). WHO Reform: WHO presence in countries, territories and areas: 2021 report. 26 April 2021

WHO(e). Seventy-Fourth World Health Assembly provisional agenda item 17.3 (A74/9 Add.1). WHO’s work in health emergencies: Strengthening preparedness for health emergencies: implementation of the International Health Regulations (2005). 5 May 2021

WHO(f). WHO Manifesto for a healthy recovery from COVID-19 (May 26th, 2020). Available at
https://www.who.int/news-room/feature-stories/detail/who-manifesto-for-a-healthy-recovery-from-covid-19

WHO(g). WHO urges countries to build a fairer, healthier world post-COVID-19 (April 6th, 2021). Available at
https://www.who.int/news/item/06-04-2021-who-urges-countries-to-build-a-fairer-healthier-world-post-covid-19