Pursuing Equity: An Analysis of the Africa Group’s Positions during the Negotiations of the Revised International Health Regulations and the WHO’s Pandemic AgreementAbstract
The Africa Group has emerged as a leading voice in global health governance, advocating for equity in two key pandemic instruments: the 2024 revision of the International Health Regulations (IHR) and the WHO-led Pandemic Agreement. This study provides a review of the Group’s official proposals (2022–2025) for both instruments. It questions how – and with what objectives – they were articulated and assesses the extent to which they advance equity, especially in the sharing of health products and technologies. Grounded in Critical Global Health Studies, we hypothesize that the Africa Group’s equity demands were not fully addressed in the final texts. We categorize the proposals into four priority areas and compare them to the latest drafts of these international instruments to assess incorporation. Several proposals were partially included – such as language on allocating a share of health products to developing countries and a joint financing mechanism. However, many core demands, particularly enforceable equity measures and benefit-sharing obligations, were softened, reworded, or excluded. Political flexibility by African states enabled consensus, but effective implementation hinges on future negotiations and sustained advocacy. Overall, these instruments partially respond to the Africa Group’s agenda yet fall short of transformative reform, leaving equity commitments largely non-binding.
Key words
Pandemic Agreement; International Health Regulations; African Union; World Health Organization; equity; global health governance
Resumo
O Grupo Africano emergiu como uma voz de destaque na governança global da saúde, defendendo a equidade em dois instrumentos centrais relacionados a pandemias: a revisão de 2024 do Regulamento Sanitário Internacional (RSI) e o Acordo sobre Pandemias liderado pela OMS. Este estudo apresenta uma revisão das propostas oficiais do Grupo (2022–2025) para ambos os instrumentos. Questiona-se como, e com quais objetivos, essas propostas foram articuladas, e avalia-se em que medida promovem a equidade, especialmente no compartilhamento de produtos e tecnologias em saúde. Fundamentado nos Estudos Críticos de Saúde Global, o artigo parte da hipótese de que as demandas de equidade do Grupo Africano não foram plenamente contempladas nos textos finais. As propostas são categorizadas em quatro áreas prioritárias e comparadas às versões mais recentes desses instrumentos internacionais para avaliar seu grau de incorporação. Diversas propostas foram parcialmente incluídas, como a linguagem sobre a alocação de uma parcela de produtos de saúde para países em desenvolvimento e a criação de um mecanismo conjunto de financiamento. No entanto, muitas demandas centrais, especialmente aquelas relacionadas a medidas vinculantes de equidade e obrigações de compartilhamento de benefícios, foram suavizadas, reformuladas ou excluídas. A flexibilidade política dos Estados africanos possibilitou o consenso, mas a implementação efetiva depende de negociações futuras e de uma defesa contínua. De modo geral, esses instrumentos respondem parcialmente à agenda do Grupo Africano, mas ficam aquém de uma reforma transformadora, mantendo os compromissos de equidade em grande medida não vinculantes.
Palavras-chave
Acordo sobre Pandemias; Regulamento Sanitário Internacional; União Africana; Organização Mundial da Saúde; equidade; governança global da saúde
Introduction
The African continent has often been portrayed as either a recipient of global health interventions or a hotspot for humanitarian crises and disease outbreaks. From HIV/AIDS to Ebola, Africa has carried a double burden in global health narratives: securitization and neglect (Nunes 2016). According to the Copenhagen School, securitization occurs when an issue is framed as an existential threat requiring exceptional measures (Buzan, Wæver and de Wilde 1998). Securitization has been evident during recent health emergencies in Africa, such as the 2014-2016 Ebola epidemic in West Africa, when the international response emphasized containment and surveillance over addressing the epidemics’ underlying social determinants (Ventura 2016).
These emergencies have also reflected a pattern of neglect – especially the failure to address poverty, weak health systems, and limited access to innovation. During the COVID-19 pandemic, African countries faced severe delays in accessing vaccines and treatments, despite actively contributing to global surveillance by sharing genomic data of variants like Beta and Omicron (World Health Organization 2021; Pilling 2022).
Despite this prevailing narrative about Africa, the negotiations initiated in 2021 of two foundational international instruments for the global governance of health emergencies – the revision of the International Health Regulations (IHR) and the drafting of a new pandemic treaty – created an opportunity to begin shifting the prevailing perception of Africa’s role in health emergencies. The Africa Group, composed of the 55 Member States of the African Union, used these negotiations as a platform to advocate, as a proactive and coordinated bloc, for transformative changes aimed at embedding equity at the core of these multilateral health agreements.
Beginning with the IHR, it emerged in 1951 as the result of one hundred years of international health cooperation aimed at preventing specific diseases, such as plague, cholera, and smallpox, with the primary objective of minimizing the harm to trade caused by health protection measures (Fidler 2001; Kerouedan 2013). In 2005, a new version of the IHR created an abstract category, the Public Health Emergency of International Concern (PHEIC), which may be caused by a disease or any other threat, defined not by its lethality, harmful effects, or number of cases, but rather by its extraordinary nature, the risk of international spread, and the need for international coordination to address it.
Of the eight PHEICs declared to date, four had their epicentre in Africa: the Ebola virus disease epidemic in West Africa (2014-2015) and in the Democratic Republic of the Congo (2019-2020); and MPox outbreaks in the Democratic Republic of the Congo and other countries such as Burundi, Sierra Leone, and Uganda, with the first PHEIC occurring between 2022-2023 and the second between 2024-2025. None of these events experienced significant spread beyond the African continent. The remaining PHEICs originated in the United States and Mexico (H1N1 influenza, 2009-2010); Brazil (Congenital Zika Syndrome, 2016); multiple countries – particularly Afghanistan, Pakistan, and Syria – in the case of poliomyelitis, declared in 2014 and ongoing to this day; and China in the case of COVID-19, the only one that effectively achieved extensive international spread.
It was precisely the incipience of international cooperation during COVID-19 and the limits of WHO’s action that led the 196 States Parties to the IHR to recognize the need to strengthen the international legal regime for responding to PHEICs.
The revised IHR negotiation began in 2022 following a decision at the 75th World Health Assembly (WHA). Member States submitted amendments, and a Review Committee provided technical recommendations. The intergovernmental negotiations, conducted by the Working Group on Amendments to the IHR (WGIHR), led to the adoption of the revised IHR by the 77th WHA in June 2024 (Carmo et al. 2024).
In parallel, the Pandemic Agreement was proposed in 2021, under the leadership of the European Council, to also address the failings of the international COVID-19 response. The Intergovernmental Negotiating Body (INB), established by the WHO, was tasked with drafting the treaty. After thirteen meetings and limited civil society input (Ventura et al. 2024), amid significant difficulties in reaching consensus that required an extension of the negotiation deadline (WHO 2024), as well as the separate negotiation of an annex to the treaty – still ongoing at the time of the completion of this article –, the Pandemic Agreement was approved during the World Health Assembly in May 2025.
Equity became a central issue in both processes, especially in light of the unequal access to vaccines and other medical products during the COVID-19 pandemic. Low- and middle-income countries pushed for more equitable sharing of benefits, most notably health products, during emergencies, while high-income countries, particularly those that are home to pharmaceutical companies, sought to preserve unrestricted access to pathogens while limiting the scope of benefit-sharing (Spark Street Advisors 2024).
From the perspective of the African Union (AU) and the Africa CDC (Ndembi et al. 2024), equity in the pandemic agreement and the revised IHR must ensure that African countries, together with other low- and middle-income countries, receive a more equitable and timely sharing of health products and technologies, especially during public health emergencies. This vision is grounded in the reality and experience of the African continent, which has faced numerous outbreaks and other public health emergencies, with more than 160 reportable public health events annually (African Union 2024).
Although the negotiations on the Pandemic Agreement were structured around the six WHO administrative regions, most of them did not operate as cohesive negotiating blocs due to significant internal diversity. The Region of the Americas, and Latin American countries in particular, did manage to establish some joint positions, but the most significant outlier was the Africa Group, which – despite the diversity of national interests – remained cohesive and demonstrated a strong sense of mutual solidarity, thereby exerting significant influence throughout the negotiations (Fernández and Heinzel 2025).
Alongside the Africa Group, the Equity Group played a central role in the negotiations, driven by the informal efforts of a small number of geographically diverse countries, evoking the work of the Group of 77 at the United Nations. A third distinct bloc was formed by the so-called G7+ countries, including the G7 member states and the European Commission, which participated in the Pandemic Agreement negotiations on behalf of the 27 EU member states (Fernández and Heinzel 2025).
We understand that the Africa Group’s proposals for both instruments are not an exercise in declaratory diplomacy, but rather a call for a structural transformation in how equity is addressed in the governance of health emergencies. The content of the proposals related to equity aimed to bring about concrete changes in the lived realities of African countries. These included legally binding commitments to share benefits arising from pathogen access, ensure timely and affordable access to pandemic-related products, and establish mechanisms for accountability.
This article questions how – and with what objectives – the Africa Group’s proposals were articulated in the negotiations of the revised IHR and the Pandemic Agreement, as well as the extent to which these positions express an agenda oriented toward promoting equity in global health governance.
Considering the historical patterns of neglect and securitization, our hypothesis is that the Africa Group’s demands for equity in responding to health emergencies were not fully addressed in the final texts of the revised IHR and the Pandemic Agreement, reflecting the difficulty of transforming asymmetries that hinder the timely sharing of health products and technologies, especially during public health emergencies.
The objective of this article is to summarize, categorize, and ultimately analyse the Africa Group’s proposals that promoted equity during the negotiations of the revised IHR and the Pandemic Agreement, assessing whether the positions of African countries had been incorporated into the final versions of both instruments. Regarding the structure of the article, the first section presents a synthesis of the theoretical framework and the historical contextualization of the topic. This is followed by a presentation of the research methods, as well as the reporting and discussion of the results. Based on this analysis, we demonstrated that these emerging international regulations for epidemics and pandemics only partially addressed the Africa Group’s demands for equity in responding to health emergencies in Africa, when considered in light of the proposals they had put forward during the negotiations.
Historical context and theoretical framework
In the early years of the WHO’s operation, established in Geneva in 1948, African nations were still, for the most part, colonies or territories dominated by European countries, which assumed their representation in the World Health Assemblies (Pires Alves and Cueto 2006). Of all the WHO regions, the last to be formed was the one for Africa, in 1951, a continent that had formerly received scant attention from international health agencies but was, not accidentally, the leading site of European colonization and colonial medicine (Fee, Cueto and Brown 2016). Thus, the delay in creating a regional office was the direct result of complex negotiations with the European imperial powers.
With the process of decolonization, the international engagement of African countries acquired a new dimension. However, colonization left as its legacy agreements that maintained the economic and military domination of former colonies, local elites tied to the interests of former colonizers, and the political fragmentation of the continent, in a world divided by the Cold War (Makiadi 2016). Among the responses of African countries to this challenging context was the creation of the Organization of African Unity in 1963, which in 2002 was transformed into the African Union. Whether in a coordinated manner or not, African countries actively participated in crucial moments in the history of global health, such as the Alma-Ata Declaration of 1978 on the implementation and development of ‘Primary Health Care’ worldwide – considered a historic hallmark of twentieth-century public health – and the Bamako Initiative, launched in 1987 in an attempt to address the growing crisis of drug scarcity and reduced access to quality health care (Anaemene 2017).
According to Marcos Cueto (2015), since the nineteenth century, when social medicine and biomedical responses to health problems emerged, two perspectives have been in constant dispute in global health: one linked to social medicine, which considers public health physicians as agents of social change and health as a human right, promotes comprehensive interventions, and values community participation; and a technocratic perspective, oriented toward the economic development of a liberal society, implemented by an elite of specialists who view improvements in health as a means of controlling disease outbreaks and providing assistential, hospital-based care.
A North–South divide runs through these two perspectives, with a particularly strong presence in international health cooperation, in which wealthy countries and the philanthropic foundations linked to them are the primary funders. In this field, wealthy countries hegemonically control sites of intellectual production, decision-making, and action related to resource allocation, agenda-setting, academic training, research, and knowledge production practices (Meda et al. 2025). As a result, traditional global health approaches are often shaped by colonial legacies, neocolonial practices, and the dominance of Western-centric paradigms, perpetuating inherent biases, power imbalances, and structural inequities (Mehjabeen, Patel and Jindal 2025).
In light of that, our theoretical premises are fundamentally grounded in Critical Global Health Studies, a field that represents a critical and people-centred approach both to and within global health and challenges the dominant power structures and epistemological foundations of conventional global health practice (Biehl 2016; Burgess 2024). This approach recognizes that traditional global health interventions often operate through systems where the intended recipients of aid are frequently marginalized and rendered invisible, portrayed as either having no valuable knowledge to offer or as passive recipients who accept interventions without question, while biomedical perspectives continue to dominate the field, treating community participation as politically necessary but scientifically irrelevant (Biehl 2016).
Critical Global Health Studies provides a comprehensive framework that considers the social, political and ideological contexts in which health problems are framed and understood, moving beyond technical solutions to examine the complex power dynamics that shape global health discourse and practice (Nunes and Pimenta 2016).
Central to Critical Global Health Studies is the commitment to shed light on silenced issues that are systematically marginalized by dominant global health frameworks. This involves exposing how ‘global health becomes embedded within cycles of hearing but not listening,’ where people are ‘heard, and simultaneously ignored’ (Burgess 2022) because the stories and experiences of these individuals are processed through research approaches and theoretical frameworks selected by those who aim to assist them, organized according to knowledge frameworks that reflect the concerns and values of distant societies rather than these individuals’ local contexts (Burgess 2022).
Critical Global Health Studies reveals how global health’s knowledge practices are constructed for a powerful audience that is ‘typically foreign,’ leading to ‘unfair knowledge practices’ and ‘epistemic injustice’ that privilege certain forms of knowledge while silencing others (Abimbola 2024). Through examining cases like the Zika epidemic for example, this field demonstrates how framing health crises in narrow technical terms systematically neglects crucial issues including for example ‘reproductive rights and abortion problems, maternal health, social determinants of disease, infrastructural issues of health systems and city management’ (Nunes 2016), revealing how seemingly objective approaches actually perpetuate negligence as ‘a political process through which a certain issue is separated from mechanisms conducive to effective resolution’ (Nunes 2023).
We believe that the contribution of the Critical Global Health Studies to this research is to shed light on the African Group’s role in the negotiations of the IHR and the pandemic agreement by applying analytical frameworks that move beyond superficial assessments of diplomatic success. Drawing on Critical Global Health Studies’ commitment to illuminating ‘what is silenced, ignored or left at the margin’ (Nunes 2016), this analysis reveals how the Africa Group’s equity-promotion objectives challenge dominant global health governance structures that typically operate where ‘the supposed beneficiaries of interventions are too often hidden from view, and appear either as having nothing to contribute or as unabashedly, uncritically receptive’ (Biehl 2016).
By examining the Africa Group’s contributions through the lens of how ‘global health becomes embedded within cycles of hearing but not listening’ (Burgess 2022), we can understand how African proposals were acknowledged in the negotiation of both instruments yet systematically weakened in the final versions of these documents.
This critical approach helps us understand how African states’ political flexibility in these negotiations – which enabled consensus on the documents’ approval – actually reflects the constraints imposed on peripheral voices in global health governance when they attempt to challenge systems designed to perpetuate negligence toward the needs of people in countries that seek equitable access to health products. The result is the adoption of politically significant agreements that remain separated from implementation mechanisms capable of addressing the equity-related problems they target.
Critical Global Health Studies are equally important to this research in light of the shifts underway in global health governance during the second term of President Donald Trump, particularly following the launch of the America First Global Health Strategy (US Department of State 2025). These shifts include a move from multilateralism toward bilateral agreements between the United States and other countries, including African nations, occurring in parallel with the withdrawal of the United States from the WHO. This change represents a fundamental departure from collaborative international frameworks toward arrangements that privilege the more powerful partner.
In the ongoing negotiations of health agreements between the United States and African countries, it is natural that an emphasis on direct government-to-government relations would rely primarily on bilateral agreements, which invariably favour the stronger partner. The strategic nature of this shift becomes evident when examining the specific terms being proposed: the recent release of a model for one such agreement reveals an intention to bind African countries to share pathogen data and other types of data – without guarantees of access to the benefits arising from that sharing – for 25 years (Ventura 2025).
From an African perspective, this situation exposed the fragility of health systems heavily dependent on external support, revealing that global health governance rests more on political discretion than on durable assurances (Okereke 2026). Furthermore, this recent bilateral approach in global health governance deliberately undermines existing multilateral processes where African nations have demonstrated significant agency, precisely because multilateralism helps peripheral and semi-peripheral countries amass collective bargaining power within international institutions, making them more protected from agreements that seek to extract valuable health-related resources while offering fewer reciprocal benefits.
These recent bilateral agreements seek to circumvent the advances achieved in the negotiation of the international pandemic agreement, whose annex on access to pathogens and benefit-sharing is currently being negotiated within the WHO, where member states of the African Union have played a recognized leadership role in resisting the interests of wealthy countries (Ventura 2025). This strategic circumvention of multilateral forums represents exactly the kind of power dynamics that Critical Global Health Studies seek to expose and challenge. In this sense, the recent shift toward bilateralism creates conditions under which African countries could become isolated from the collective bargaining power they have exercised within multilateral institutions until very recently.
Thus, African countries have demonstrated – and we share this view – that global health governance of health emergencies must go beyond formal declarations and take tangible steps to redress health inequities (Ventura et al. 2024). To date, there has yet to be a comprehensive analysis of the Africa Group’s equity-related proposals in the negotiations of the revised IHR and of the Pandemic Agreement.
Methods
We searched the WHO and the African Union’s websites for all instances where the Africa Group made proposals during the negotiations of the amendments to the IHR and the pandemic instrument.
During this review, we identified a total of 14 proposed amendments to the IHR and nine proposals for the pandemic instrument, as summarised in Table 1. From these proposals, we included in the analysis nine proposals for the pandemic agreement and 13 for the revised IHR. As a criterion for inclusion, we considered the Africa Group’s mention of equity promotion in the justifications for submitting the proposals during the negotiations of the instruments.
After the selection process, as shown in Figure 1, we identified a total of 22 proposals made by the Africa Group for both instruments which are directly related to its objective of promoting equity, as detailed in Supplementary Tables 1 and 2.
We grouped the selected proposals into four general categories, naming them after topics that stood out as key to assessing whether the Africa Group’s objectives of advancing equity were achieved, and to what extent, and then divided them into subcategories to address specific objectives.
Based on the analysis of these proposals, we presented the following general categories: i) equitable access to health products and technologies; ii) financing; iii) strengthening research and development (R&D), technology transfer and regional production in the pandemic agreement; iv) and improving implementation and cooperation under the IHR.
For the pandemic instrument, we present the following categories: Pathogen Access and Benefit Sharing (PABS), financing initiatives focused on developing countries’ needs, Research and Development (R&D) conditionalities, technology transfer, and regional production.
Regarding the IHR, the proposed categories are: cooperation, equitable access to health products, surveillance, financing, and implementation.
Under each general category, we examine whether topics of interest of the Africa Group were included in the pandemic agreement and the IHR and analyse the meaning of the presence (or absence) of the Africa Group’s proposals in the documents.
Results
The Africa Group advocates that all provisions of the pandemic agreement and the revised IHR be founded on equity (South Centre 2024). Notwithstanding this holistic approach, African countries understand that equity in these instruments will be effectively achieved through the prioritization of themes that specifically impact Africa’s capacity to address health emergencies.
Of the 22 proposals made by the Africa Group that are directly related to promoting equity (Supplementary Tables 1 and 2), most were incorporated into articles of both the IHR and the pandemic agreement. Seven proposals were not transformed into articles during the negotiation of these instruments. Thus, we infer that these suggestions were not accepted or were not sufficiently considered by negotiators.
Six articles in the pandemic agreement address the equity-based proposals made by the Africa Group in the following categories: the Pathogen Access and Benefit-Sharing (PABS) System (article 12), financing (articles 19 and 20), R&D conditionalities (article 9), technology transfer (article 11), and regional production (articles 10 and 11).
Ten articles and one annex in the revised IHR relate to the Africa Group’s main proposals to advance equity, considered under the following categories: equitable access to health products (articles 1, 2, 13 and 43), cooperation (articles 6, 12, 13, 44 and 45), surveillance (annex 1), financing (article 44bis), and implementation of the IHR (article 54bis).
Pandemic agreement
Using the general categories we advance in this paper, we identified the following proposals of the Africa Group in the final text of the pandemic agreement:
Equitable access to health products and technologies: Pathogen Access and Benefit Sharing (PABS) System
Under the subcategory PABS System, the Africa Group advocated for two proposals to be included in article 12.
First, they support the adoption of an annex to operationalise the PABS System, to be approved alongside the main text. Despite the absence of a draft annex, article 12.2 (final) mandates the introduction of an annex in the agreement to operationalize the PABS System.
Secondly, the Africa Group asserted that sharing pathogen data must always be reciprocated with multilateral benefits. Hence, the Africa Group supported, in exchange for access to pathogens, either allocating a percentage of production to developing countries or providing financial contributions for capacity-building. Article 12.6 of the final text reflects the negotiators’ current preference for allocating a percentage of production as the multilateral benefit within the PABS System.
Financing: financing initiatives focused on developing countries’ needs
On the subcategory financing initiatives focused on developing countries’ needs, there are a total of four proposals.
First, the Africa Group advocated for the establishment of an international financing mechanism accountable to the Conference of Parties (COP) of the agreement. This suggestion is in the final version of article 20, establishing the mechanism will be the same approved in article 44bis of the IHR, operating under both instruments.
Secondly, African leaders wanted ‘explicit commitments’ to debt relief and debt restructuring mechanisms, including debt swaps to support country-level pandemic prevention, preparedness and response (PPPR) in the pandemic agreement. There is no reference to debt relief and debt restructuring mechanisms in the final text of the pandemic agreement.
Third, the Africa Group also wanted mention of new, sustainable, and increased funding support from developed countries to support country-level PPPR in developing countries. Article 19.1 provides that the Parties shall cooperate to sustainably strengthen the pandemic prevention, preparedness, and response capacities of all Parties, particularly developing country Parties. According to the text, this cooperation may take the form of financial assistance.
Finally, this group defended financial support for sustainable and geographically diversified production of countermeasures, a proposal that was not included in the final text of the pandemic agreement.
Strengthening research and development (R&D), technology transfer and regional production in the pandemic agreement: R&D conditionalities
The Africa Group advocated for one specific proposal on R&D in the pandemic agreement: the establishment of enhanced platforms to improve coordination on R&D conditionalities.
These platforms were intended to advance provisions in funded research of pandemic-related health products that promote timely and equitable access to such products, particularly for developing countries. These platforms should have contingent funding available from their inception to align funded research with public health priorities.
As of now the final version of article 9 (on R&D) of the pandemic agreement does not mention an international platform for coordinating R&D conditionalities. The commitment to tie R&D activities to public health priorities rests exclusively with the Parties at the national or regional level, without the establishment of binding multilateral policies or initiatives under the agreement.
Strengthening research and development (R&D), technology transfer and regional production in the pandemic agreement: technology transfer
The Africa Group made one specific proposal for placing several WHO-coordinated mechanisms, such as the WHO R&D Blueprint and the mRNA Technology Transfer Hub, under the authority of the Conference of Parties (COP) of the pandemic agreement. There is no reference to this suggestion in the final version of pandemic agreement, however, article 11.5 recognizes the possibility of establishing WHO-coordinated mechanisms where appropriate.
Strengthening research and development (R&D), technology transfer and regional production in the pandemic agreement: regional production
The one proposal of the Africa Group on this subcategory was the creation of a section in the pandemic agreement with measures aimed at promoting regionally distributed production of pandemic related health products.
Article 10 sets out measures for ‘Sustainable and Geographically Diversified Local Production,’ whose implementation is the sole responsibility of the State Parties. The Africa Group agrees with the measures listed in article 10, which encourage States to promote technology, skills and knowledge transfer via WHO, and procurement contracts between international organizations and facilities, especially from developing countries, for the production of pandemic-related health products.
Additionally, article 11.1 caput establishes that one of the purposes of the section on technology transfer is to promote a geographically diversified production of pandemic-related health products (thus, regional manufacturing is considered a result of actions taken on technology transfer within the agreement.)
There were no proposals under the category of improving implementation and cooperation under the pandemic agreement.
Revised International Health Regulations
Under the general categories we present in this paper, we found that the Africa Group made the following proposals in the revised IHR:
Equitable access to health products and technologies: equitable access to health products
On the category equitable access to health products, the Africa Group made four proposals to the final text of the IHR.
First, as an extension of article 13, the Group advocated for more detailed articulated measures to ensure equitable access to relevant health products, which were partially incorporated in the revised IHR. The suggested measures included: i) exemptions and limitations on intellectual property rights to facilitate the production and distribution of health products; ii) support for diversified geographical production of health products; iii) mandatory obligations under the IHR for manufacturers and IP holders to comply with WHO recommendations; iv) information sharing, including about availability of health products; and v) a WHO mechanism to coordinate initiatives to ensure equitable access to health products .
Second, the Africa Group advocated the need for establishing a platform to review unilateral health measures adopted by States, which was not incorporated in the revised IHR. The Group proposed amendments to make article 43 operational, considering that the IHR Review committee has noted that lack of enforcement of this provision, which led to several excessive travel measures during Covid-19 response, many of them being also discriminatory on a racial basis, as described in the amendments to the IHR proposed by the Group (World Health Organization 2024).
Third, the Africa Group proposed amendments in article 2 to clarify that the mandate for countries to ‘avoid unnecessary interference with international traffic and trade’ applies to those measures that affect equitable access to and supply of health products required for the response to the international spread of disease as well. The amendments were not adopted in the revised IHR.
Finally, the Group defended that the use of language regarding definitions should be in accordance with WHO Resolutions and UN Documents. In article 1, the Africa Group advanced definitions for many terms related to the equitable access to health products. The suggestions were partially incorporated such as the definitions of ‘vaccines,’ ‘diagnostics,’ ‘assistive products,’ ‘cell- and gene-based therapies’ and ‘technologies.’ The suggestion on ‘health technologies and know-how’ was not incorporated in the proposed terms but is briefly mentioned in the final text.
Financing: Financial Mechanism for Equity
There is one proposed amendment related to financing in the IHR. The Africa Group presented a paragraph proposing the creation of a Financial Mechanism for Equity in Health Emergency Preparedness and Response exclusively for developing countries. Although the paragraph was not adopted as originally proposed, the approved article 44bis provides for the establishment of a financing mechanism with more general contours, open to the needs of both developed and developing countries.
Improving implementation and cooperation under the IHR: surveillance
The Africa Group proposed several amendments in annex 1 of the IHR, which detailed support measures for core capacities in disease detection, surveillance, and health emergency response in developing countries. The suggestions were partially incorporated, in more generic terms, for example, regarding WHO’s responsibility to support the building and maintenance of essential capacities.
Improving implementation and cooperation under the IHR: implementation of the IHR
Regarding the implementation of the IHR, the Africa Group proposed one amendment.
The Group suggested an extension to article 53, aiming to establish an Implementation Committee composed of all Member States, which would meet annually to discuss the implementation and functioning of the IHR. The proposal is equivalent to an annual Conference of the Parties and would serve to monitor and review the implementation of both the IHR (2005) and any eventual pandemic instrument, thereby ensuring greater coherence and complementarity between the two frameworks. The final text adopts the suggestion partially, without following the capacities and governance structure proposed by the Africa Group.
Improving implementation and cooperation under the IHR: cooperation
The Africa Group made six proposals on cooperation, which relate to five articles and one annex in the IHR.
First, the Group proposed amendments in article 13 to address the weakness of provisions which are capable of addressing equity challenges. The Africa Group understands that article 13(5) of the IHR is one of the most promising provisions of the IHR 2005 in terms of advancing equity. In this sense, the Group recommends provisions (article 13 (5)) to enhance the possibility of having an internationally coordinated public health response to PHEIC. In this context, the African leaders proposed a series of WHO-coordinated response activities, including supply of health products and technologies to be adopted by State parties. In case any State party would be unable to fulfil such activity, that should be informed to the WHO and the Director general. This proposal was partially incorporated into the final text.
Secondly, the African Group advocated for the need to address the duty to cooperate as an explicit obligation of the State parties, which was essentially incorporated in the revised IHR. This suggestion – advanced in article 44 – includes not only the recognition of the duty, but also the creation of mechanisms and follow-up structures to guarantee support to developing countries, such as the mobilization of financial resources to support developing countries and the formulation of legal provisions for the implementation of the IHR. In this article, African countries also proposed the establishment of a proper linkage on reporting and the financial mechanism, to be monitored by the implementation committee.
Thirdly, the Group presented a new annex 10 to bring more consistency in the discharge of obligations under article 44, providing a list of activities in which WHO and States Parties may collaborate, regarding surveillance capacities, response capacities and legal assistance. However, the proposed annex was not incorporated in the final text.
Fourth, the Africa Group proposed, in paragraph 12, measures to enhance accountability of WHO’s response to a Public Health Emergency of International Concern (PHEIC). Although these suggestions were not incorporated in the revised IHR, the objective was to keep WHO’s activities related to such PHEIC, including through partnerships or collaborations, as well as engaging with non-State actors, in accordance with the provisions of the IHR.
Fifth, the Group presented a provision, in article 6, defending that the sharing of genetic sequence data or information shall not be required unless a fair and effective access and benefit-sharing mechanism is agreed upon, as described in the amendments to the IHR proposed by the Group (World Health Organization 2024). This proposal was not incorporated in the final text.
Finally, the African Group acknowledges the responsibility of data protection, proposing the addition of a new article 45 (4) to bring in responsibility of recipient States Parties to handle personal data in accordance with national sovereignty more than the data of its nationals. This amendment was not adopted in the revised IHR.
There were no proposals under the category of ‘strengthening research and development (R&D), technology transfer and regional production’ in the IHR.
Discussion
In this section, we examine (1) whether the Africa Group’s objectives for advancing its equity perspective in the Pandemic Agreement and the revised IHR have been achieved, and consequently, (2) whether these new international regulations for epidemics and pandemics address the Africa Group’s claim for equity during health emergencies in Africa.
By design, this study only reviewed the proposals made by the Africa Group during negotiations of the revised IHR and the Pandemic Agreement. Based on the analysis of the general categories of articles presented in the results, four topics stand out as key to assessing whether the Africa Group’s objectives of advancing equity were achieved, and to what extent: i) equitable access to health products and technologies; ii) the establishment of a shared financing mechanism for these two instruments; iii) strengthening research and development (R&D), technology transfer and regional production in the pandemic agreement; iv) and improving implementation and cooperation under the IHR.
Equitable access to health products and technologies
Regarding equitable access to health products and technologies, the Africa Group placed significant emphasis on operationalizing the Pathogen Access and Benefit-Sharing (PABS) System in article 12 of the pandemic agreement.
While equity remains a core principle of the agreement, the final text risks perpetuating inequalities, as developed countries continued to try to limit the scope of benefit sharing derived from access to pathogens worldwide during the negotiations of the text, while pushing for continued access to these pathogens (and other materials) that are used to develop health products with minimal restrictions.
Given Africa’s recent experience of unequal access to vaccines and pandemic products during COVID-19, the Africa Group views an operational PABS System that ensures rapid sharing of pathogens and sequence data, coupled with equitable access to countermeasures, as critical. To achieve this goal, the group’s proposals during negotiations included allocating a percentage of production to developing countries and facilitating financial contributions and technology transfers.
The result in paragraph 12 is positive for the Africa Group since article 12.6 partially reflects these objectives by allocating 20% of their real time production of safe, quality and effective vaccines, therapeutics, and diagnostics for the pathogen causing the pandemic emergency, provided that a minimum threshold of 10% of their real time production is made available to WHO as a donation, and the remaining percentage, with flexibility based on the nature and capacity of each participating manufacturer, is reserved at affordable prices to WHO. The allocated percentage demonstrates a concrete multilateral commitment to the multilateral benefits claimed by the Africa negotiators.
Moreover, the Africa Group’s proposal of a binding annex to operationalize the PABS System was approved under article 12.2. The final text establishes that provisions governing the PABS System shall be developed and agreed in an instrument in accordance with Chapter III (hereinafter the ‘PABS Instrument’) as an annex, which shall also define the terms for the administration and coordination of the PABS System by WHO. This proposal of binding annex is important to ensure that the agreement does not merely offer guiding principles without establishing enforceable commitments.
Article 12 represents one of the key gains for the Africa Group in the agreement, as it increases the availability of health products on the African continent during a pandemic, driven by the Parties’ compliance with the pandemic agreement.
Within the revised IHR, the Africa Group submitted proposals to strengthen article 13 regarding equitable access. However, major proposals – such as mandating exemptions and limitations on intellectual property rights, enforcing donations by manufacturers, and obligatory technology transfer – were not incorporated. Instead, the final text encourages States Parties to ‘engage and encourage stakeholders,’ significantly softening the original ambitions. Some proposals were partially accepted: WHO is tasked with assessing the availability of health products and facilitating regulatory information sharing, and mechanisms to coordinate equitable access were included, albeit conditioned on State Party consultations. The sharing of regulatory dossiers now depends on prior manufacturer consent, further softening initial requirements. The Group’s suggestion to create a formal platform to review unilateral health measures was also not adopted; instead, a consultation mechanism through the WHO was included, emphasizing confidentiality and consensus.
A shared financing mechanism for the IHR and the pandemic agreement
On financing, the Africa Group advocated for a shared financing mechanism to support pandemic prevention, preparedness, and response (PPPR) under both the pandemic agreement and the IHR.
With the conclusion of negotiations in April 2025, the establishment of this shared financing mechanism was confirmed in the approved article 20.3 of the pandemic agreement. In the IHR the mention of this mechanism is already in article 44bis.
One of the main advantages of this approach is that it would establish a financing mechanism mandated by an already approved legally binding instrument – the IHR.
This joint financing mechanism emerges in a crucial geopolitical context marked by declining state funding for the WHO. In this scenario, the mechanism represents an opportunity to ensure that state investments prioritize multilateral PPPR arrangements, which may lead to more equitable outcomes in terms of access to health products.
Regarding the mechanism’s scope, article 20.3 of the pandemic agreement includes a financing mechanism under the authority of the Conference of Parties (COP), aligning with the Africa Group’s interests. However, the language remains broad, offering general support commitments without concrete obligations. Notably, debt relief or restructuring mechanisms as proposed by the Africa Group were excluded, and commitments to funding support for developing countries for country-level PPPR were reduced to statements of intent.
In the revised IHR, the Africa group initially proposed two ideas: creating a financing mechanism for PPPR exclusively for developing countries and explicitly linking that mechanism to the promotion of equity. However, neither proposal was accepted. The approved article 44bis envisages a financing mechanism not exclusively dedicated to developing countries and that does not explicitly mention equity, reflecting a significant gap in the Africa Group’s aspirations. Given the more generic language of the final text, no longer exclusively aimed at developing countries – provisions to promote financial assistance for R&D and production at the regional and local level were not included.
R&D, technology transfer, and regional production in the pandemic agreement
The Africa Group proposed establishing a mechanism to coordinate R&D conditionalities to ensure that research funded by public money prioritizes public health objectives and equitable access to health products. This proposal was not incorporated. Instead, article 9.5 of the pandemic agreement leaves the alignment of R&D with public health goals to national jurisdictions, offering only a recommendation without binding commitments. The omission of a coordinated R&D mechanism represents a missed opportunity to ensure that public investments in research are directly tied to equitable health outcomes.
Improved implementation and cooperation in the IHR
On the implementation of the IHR, the African Group proposed the creation of an implementation committee composed of all Member States to discuss the implementation and functioning of the IHR on an annual basis. The idea of such a mechanism, embraced by the WHO Working Group on Amendments to the IHR (WGIHR), is similar to that of the Universal Periodic Review (UPR) of the UN Human Rights Council. The proposal aligns with the WHO’s efforts to introduce a mechanism that fosters government accountability by assessing, reporting, and improving compliance with IHR requirements (Foster 2024). This proposal was partially incorporated: while the committee was created, it was assigned only a consultative role, not the monitoring and accountability functions originally envisioned. Furthermore, the committee will meet biennially rather than annually, and no requirement was included for annual reporting to the World Health Assembly. Consequently, the mechanism focuses more on sharing best practices than on monitoring compliance.
On cooperation in the IHR, the Africa Group aimed to strengthen the duty to cooperate under the IHR (article 44) by inscribing explicit obligations for the State parties and creating proper linkage to provision on reporting, financial mechanism, and implementation to make the article operational. Although provisions for cooperation on equitable access to health products were included, they were considerably softened, and key proposals of the Africa Group – such as a new annex 10 on the duty to cooperate, enhanced WHO accountability for PHEIC responses, and enhanced cooperation provisions on sharing of genetic sequence data and handling of personal data – were not incorporated. Mechanisms for ensuring effective cooperation and accountability thus remain weak.
Specifically on cooperation on surveillance, the Africa Group’s proposals were partially incorporated. The proposed provisions establishing that States and the WHO should support the development and maintenance of essential capacities (article 4 of annex 1) were accepted but diluted by the phrase ‘to the extent possible.’ Proposals for logistical and infrastructure support were included in general terms, while specific proposals for vaccine production, hospital infrastructure, health care worker protection, family medical costs, scientific research, and medical team coordination were not adopted.
The Africa Group’s suggestions for support at the local level were also partially incorporated and restructured. article 2(c) summarizes this contribution by reducing the emphasis on labour support and introducing a reference to misinformation and fake news in risk communication. In addition, proposals urging States to ensure access to health products and to expand vaccine and diagnostic production were softened: the final version of article 3(h) omits requirements for affordable pricing, broad distribution, and obligations to produce or develop related technologies. Thus, although some progress was made, the final text falls short of fully realizing the Africa Group’s vision for a strengthened and equitable surveillance system.
The analysis of the above four general categories – equitable access, financing, R&D and production, and implementation and cooperation – suggests that the Africa Group’s demands for equity in responding to health emergencies have been only partially met in these new international regulations.
In the Pandemic Agreement, the Africa Group’s importance for the negotiations was especially evident in the final stages of the pandemic agreement, where the Group made significant concessions from its original position in order to secure consensus by the World Health Assembly (WHA) in May 2025. Despite the outcome falling short of the Group’s full aspirations, it was widely recognized, including by the WHO Director-General, that the Africa Group’s flexibility ‘saved the day’ (Health Policy Watch 2024).
In the Pandemic Agreement, the Africa Group strongly promoted the operationalization of the Pathogen Access and Benefit-Sharing (PABS) System under article 12. It is of utmost importance that the agreement be legally binding, with firm legal obligations, so these provisions shall be translated into concrete results during future pandemics. As emphasized by African negotiators, converting the agreement into an international treaty was a necessary step to ensure its effective implementation. The Intergovernmental Negotiating Body (INB), responsible for drafting and negotiating the agreement, advocated that the new international instrument be legally binding in July 2022 (World Health Organization 2022).
In the revised IHR, proposals related to equitable access focused primarily on cooperation and information sharing rather than enforceable obligations. While the inclusion of WHO-led coordination mechanisms and regulatory information sharing is notable, the absence of legal obligations again highlights a pattern where developing countries are encouraged to rely on cooperation and voluntary measures rather than legal guarantees, limiting the transformation in PPPR sought by the Africa Group.
The Africa Group’s proposals on financing aimed not only at securing resources for implementation but also at correcting structural imbalances by linking equity to financial mechanisms. In the pandemic agreement, a financing mechanism under the authority of the Conference of Parties (COP) is a notable gain, as it provides an institutional platform for ongoing funding of PPPR activities. However, the current language lacks specificity on resource allocation and equity priorities.
Regardless of the financing modalities adopted (countries’ assessed contributions to the agreement or donations to this WHO mechanism), adopting the pandemic agreement as an international treaty is preferable to ensure Parties’ commitment to financing. This would enable the proper development of the treaty’s activities, including R&D, one of the Africa Group’s stated priorities.
The revised IHR frames financing as a general support mechanism for all States Parties, without prioritizing the needs of developing countries or including equity as an objective. The lack of mention of equity as an objective of the mechanism is offset by its clear mandate to promote timely and sustainable financing for the implementation of the IHR. However, the absence of equity wording could leave room for future debates on which issues are worth considering under article 44bis, particularly in the current geopolitical context of declining state funding for global health, potentially weakening developing countries’ pledge for addressing health inequities in financing matters.
The revised IHR provides a partial but meaningful response to the Africa Group’s demands for stronger implementation and cooperation mechanisms. While the implementation committee was established, it was granted a consultative rather than monitoring role, with biennial meetings and no reporting obligation to the World Health Assembly. Although this limits its ability to ensure robust accountability, the creation of the committee nonetheless represents a step toward more structured governance.
On cooperation, the revised IHR maintains a general commitment to cooperation and includes language that can support future developments. While the instruments do not yet ensure balanced accountability across States, they open space for continued engagement on equitable implementation. In surveillance, more ambitious proposals – such as obligations for affordable pricing, local production, and health worker protection – were not included. Thus, while progress is evident in the inclusion of cooperation and implementation structures, significant gaps remain in operationalizing equity on the ground.
The Africa Group’s view on implementation of the IHR demonstrates that each State parties’ responsibility and obligations might not yet be fully accountable considering the duties agreed in the Regulations. The Group’s proposals on this topic imply that the mechanisms established are not adequately addressing the specific measures and how those obligations should be operational and accountable under the international order, in a way to guarantee the effective implementation of the IHR.
In sum, the new international regulations – the Pandemic Agreement and the revised IHR – represent progress in acknowledging equity as a core value of global health governance. The Africa Group achieved important gains, including the creation of financing mechanisms, improved language on cooperation, and institutional structures for monitoring implementation. However, many of their proposals were either softened, partially included, or left out entirely. The lack of enforceable commitments and the reliance on voluntary cooperation weaken the transformative potential of these instruments.
Therefore, while the new international regulations partially address the Africa Group’s claims for equity, they fall short of the structural reforms required to overcome long-standing disparities in pandemic preparedness and response. The approval of both instruments – within roughly the agreed timelines and with African support – strengthens their legitimacy. But their long-term value will depend on future implementation efforts, political will, and continued advocacy to turn principles of equity into binding global commitments.
Conclusion
This first comprehensive analysis found that the final texts of the revised IHR and pandemic agreement partially reflect the Africa Group’s demands for equity in responding to health emergencies. While advances were made, such as the approval of article 12 on the Pathogen Access and Benefit-Sharing System and the establishment of a shared financing mechanism, several proposals were either softened, partially included, or excluded. The lack of enforceable commitments also weakens the transformative potential of these instruments. Therefore, operationalizing equity requires strong political will and continued advocacy for binding global commitments. Strengthening accountability and implementation mechanisms will be essential to ensure that future global health governance effectively addresses long-standing inequities faced by African and developing countries during health emergencies.
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Editor-in-Chief Responsible
Roberto Vilchez Yamato
All data generated or analysed during this study are included in this published article.
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