Pandemic Preparedness Infrastructure: WHO Reform and National Readiness Gaps

Executive Summary

The WHO Pandemic Agreement, adopted by the World Health Assembly on 20 May 2025, marked the most significant structural reform to global health governance since COVID-19. Yet adoption is not implementation. The agreement cannot be opened for signature until a critical annex, the Pathogen Access and Benefit Sharing (PABS) system, is finalized, and in May 2026 WHO member states decided that a final negotiated outcome will not be presented to the World Health Assembly until May 2027. Simultaneously, the United States, United Kingdom, France, Germany, and others reduced their global health and research and development funding in 2025, according to the International Pandemic Preparedness Secretariat. The architecture of reform is being built while its financial foundations are being removed. A live test arrived when Doctors Without Borders warned in June 2026 that major gaps in surveillance, diagnosis, contact tracing, and community engagement are limiting efforts to contain the Ebola Bundibugyo outbreak in the DRC. Reform has produced frameworks; the structural gaps are still producing outbreaks.

The Architecture Gap: Treaty Text Vs. Operational Reality

Two major developments now define the post-COVID era of global health governance: the 2024 amendments to the International Health Regulations and the 2025 WHO Pandemic Agreement. Both instruments were crafted through multi-year negotiations and aim to correct systemic failures revealed by the pandemic while embedding equity, transparency, and legal authority into global health responses. On paper, the architecture is substantial. On the ground, the picture is more mixed.

The IHR amendments, which entered force in September 2025, introduced genuine operational tools. Article 44 establishes a coordinating financial mechanism to support developing countries, while Article 54 forms a new advisory subcommittee to enhance multilevel implementation. The new Pandemic Emergency tier, sitting above the existing PHEIC, creates a clearer escalation ladder that health officials lacked during COVID-19's ambiguous early weeks. These are incremental but real improvements.

The WHO Pandemic Agreement goes further in ambition. A Global Supply Chain and Logistics Network, coordinated by WHO, will be established to ensure pandemic-related health products are distributed rapidly and equitably; the Agreement also establishes a Coordinating Financial Mechanism to support strengthening pandemic preparedness capacities in countries. Taken together, these provisions address the two most glaring COVID-19 failures: supply chain fragmentation and inequitable product access.

But the treaty text describes commitments, not capabilities. The WHO's own Pandemic Fund has, per WHO statements, supported disease surveillance and training in 98 countries and established the Global Health Emergency Corps. Yet the WHO also observed, as PBS Frontline reported in March 2026, that it has witnessed a funding shift from health to defense, a shift that the WHO itself described as problematic given that pandemics represent national security threats. The interplay between treaty ambitions and national-level funding retrenchment creates a widening implementation gap that no amount of legal text can bridge.

The Pabs Impasse And Its Strategic Consequences

The most consequential unresolved question in post-COVID reform is the PABS system, and its failure to date to reach agreement is a case study in how geopolitical interests override public health logic. A major complication is the role of digital sequence information, essentially the genetic code of pathogens stored as data, which allows researchers and companies to work with a pathogen's genome without needing the physical virus or bacteria. The ability to exploit genomic data without triggering benefit-sharing obligations has become the central point of contention.

The gap between developed and developing blocs remains substantial and progress has been slow: a bloc of approximately 100 LMICs calls for mandatory benefit sharing, including guaranteed access to vaccines, therapeutics, and diagnostics as the price of rapid sharing of novel pathogen information, while high-income countries remain focused on protecting the pharmaceutical innovation ecosystem and ensuring open pharma access to pathogen sequence data. Neither position is irrational from the perspective of the respective bloc, which is precisely why resolution is proving so difficult.

The opacity of the process compounds the problem. Following calls for more transparency, the IGWG decided on a pilot basis to invite stakeholders to observe discussions, but this openness was quickly revoked at IGWG3 in November 2025, and in January 2026 participation was further limited to virtual attendance. As Health Policy Watch reported, other critical topics, including financing, have yet to be meaningfully addressed. This spills into broader governance risk: a PABS system that high-income countries reject, or that LMICs refuse to operate under, collapses the entire equity premise of the 2025 Agreement.

The US bilateral strategy further fragments the multilateral foundation. These US bilateral agreements with developing countries, 15 in all, offer aid and commercial deals in exchange for access to pathogen samples, competing directly with the multilateral PABS framework. If the US succeeds in locking in bilateral access arrangements before the PABS annex is ratified, the 20 percent production-sharing commitment in Article 12 becomes hollow, because manufacturers with bilateral sample access will have little incentive to operate under a different set of obligations.

The Surveillance Erosion Problem

The single most dangerous structural gap in global pandemic preparedness is not treaty text, it is the real-time intelligence layer that enables early outbreak detection. The CDC's surveillance infrastructure includes case tracking, wastewater surveillance to detect early signs of infectious disease spread, and environmental monitoring; without adequate funding, significant gaps in disease monitoring could reduce the nation's ability to identify and contain outbreaks before they escalate.

What makes this a global, not merely American, problem is the architecture of international disease surveillance. Eight former CDC directors warned, as reported by AVAC, that many laboratory systems, surveillance networks, trained health workers, and community engagement capacity used in current outbreak responses were built through decades of HIV and PEPFAR investment, and that requiring countries to purchase CDC technical assistance through new bilateral agreements risks weakening the surveillance and response systems and undermining long-standing relationships of trust with ministries of health.

These dynamics compound the existing economic and public health uncertainty. The National Academies of Medicine, writing after the DRC Ebola declaration, stated plainly that this is the seventeenth, not the first, Ebola outbreak in the DRC; more outbreaks are inevitable, and risks are increasing; preparedness is not an option, it is a requirement for national security. Daily Trust, reporting from Nigeria in May 2026, observed that the cycle of outbreaks continues unabated, with rodent-control measures remaining weak, hospital infection-prevention practices inconsistent, and laboratory capacity limited, leaving communities vulnerable year after year.

The result is a pattern the NAM labeled "panic, neglect, repeat" — crisis spending replacing sustainable infrastructure investment. The TFAH found that this year's termination of already-approved funds clawed back over $12 billion in COVID-era grants, funding that was intended to strengthen public health infrastructure beyond the pandemic, including infectious disease monitoring, laboratory capacity, and emergency preparedness. That clawback is not neutral: it directly shrinks the surveillance capacity that feeds into WHO's Global Outbreak Alert and Response Network, translating a domestic fiscal decision into a global detection gap.

The Equity Financing Paradox

The interplay between global health financing and pandemic preparedness creates a reflexive problem that treaty analysis tends to underweight: the countries most likely to be the source of the next pandemic are precisely those whose surveillance and laboratory capacity is most dependent on high-income country aid. Sharp declines in official development assistance are affecting disease surveillance, vaccination campaigns, maternal care, and emergency preparedness; between 2023 and 2025, health aid from high-income countries fell from over US $25 billion to around US $15 billion, disrupting services and declining vaccine coverage, particularly in rural and conflict-affected areas.

The broader systemic implications include a compounding feedback loop: weaker surveillance in low-income countries means later detection, later detection means wider spread before international response is triggered, and wider spread means higher global response costs and more economic damage to the very high-income countries that withdrew the upstream investment. These frameworks directly influence how quickly a country can access vaccines during an outbreak, how fast a novel pathogen is detected and reported, and how well local health systems can respond without being overwhelmed; from a national interest perspective, they help stabilize geopolitical relationships, protect economies from pandemic shocks, and ensure national responses are informed by global data.

Both economic and political dimensions of this withdrawal demand attention from risk managers. The Clalit Health Services consortium, joining a major European AI research project in early 2026 to predict future pandemics, represents the kind of private-multilateral innovation that partially fills the gap left by receding government funding, but innovation at the research frontier does not substitute for the ground-level community health workers and laboratory technicians whose positions are being eliminated.

Counterarguments

1. The assessment may be overstated because the 2025 Agreement represents genuine structural progress that takes years to operationalize by design. A fair challenge to the primary assessment is that treaty-making timelines of five to ten years between adoption and full implementation are normal for complex international instruments. The IHR itself was adopted in 1951, revised in 2005, and amended again in 2024, a 70-year iterative process. Critics of the pace of PABS negotiations may be applying an inappropriate urgency . If the PABS annex is adopted by the 79th WHA in May 2027, the Agreement could be open for signature and accumulating ratifications before 2028, a timeline that, while imperfect, is not historically unusual for binding multilateral health law. The European Commission's Health Security Committee, which issued a coordinated opinion on Ebola response within days of the 2026 PHEIC declaration, suggests that institutional reflexes have in fact improved since 2020.

2. The surveillance erosion argument assumes that the CDC is an irreplaceable node, but the 2020-2025 period has seen meaningful capacity building at Africa CDC, the ECDC, and regional health bodies that partially distributes detection risk. The Africa Centres for Disease Control and Prevention has grown substantially since its founding in 2017, and the European Centre for Disease Prevention and Control assessed the 2026 Ebola risk in the EU/EEA rapidly and competently. If African and European surveillance capacity has genuinely improved, the loss of US global health presence may be less consequential than public health advocates warn, not irrelevant, but not the single point of failure the evidence pool emphasizes. This assessment rests largely on US and multilateral sources with an institutional interest in highlighting US withdrawal; the independent evidence on Africa CDC capacity to substitute is thinner.

3. The bilateral pathogen-access agreements that the US is negotiating with developing countries could in theory accelerate information sharing faster than the multilateral PABS framework, creating a parallel system that is imperfect but functional. Health Policy Watch noted that US bilateral agreements, 15 in total, offer aid and commercial deals in exchange for pathogen access. If these arrangements produce faster sample-sharing than a negotiation process that has now extended to at least 2027, the multilateral ideal may be sacrificed for a more pragmatic speed-access model. The counterargument has merit in narrow operational terms; its weakness is that bilateral arrangements structurally exclude the benefit-sharing obligations that prevent vaccine hoarding, leaving low-income countries with faster sample extraction but no guaranteed product return.

Securitization Theory Analysis

Securitizing Actor: The WHO, its Director-General Dr. Tedros Adhanom Ghebreyesus, and a coalition of health-oriented heads of state and scientific institutions have been the primary securitizing actors, framing pandemic preparedness as an existential threat to state and global order. The WHO explicitly stated that "pandemics are national security threats" in its critique of the shift from health to defense spending.

Referent Object: The primary referent object is global population health and, in a secondary register, economic stability. The framing progressively shifted post-COVID from a narrowly epidemiological concern to a geopolitical and economic security issue, as evidenced by the 2025 US "America First Global Health Strategy" acknowledging pandemic prevention as a national security goal.

Existential Threat Construction: The WHO and the Independent Panel for Pandemic Preparedness and Response constructed the threat through multiple speech acts: COVID-19's death toll (over 7 million confirmed, per KFF), the economic cost projection of US $6 trillion for unmitigated pandemics cited in the National Academies of Science analysis, and the framing of the 2026 Ebola outbreak as evidence that the "panic, neglect, repeat" cycle remains operational despite reform efforts.

Target Audience: Member states of the WHO, the G7 and G20, and, critically, the pharmaceutical industry, whose cooperation on PABS is indispensable. The IGWG's struggle to maintain transparency (civil society access was revoked at IGWG3) suggests the target audience shifted from the general public to a narrow set of state and corporate negotiators.

Extraordinary Measures: The 2024 IHR amendments created a Pandemic Emergency tier specifically designed to trigger extraordinary international cooperation beyond normal PHEIC mechanisms. The 2025 Agreement's requirement that pharmaceutical manufacturers share 20 percent of production represents an extraordinary obligation on private entities that would be politically unthinkable outside a securitized health context.

Classification: SECURITIZED

The pandemic preparedness issue has moved fully from politicized debate into securitized territory, the IHR Pandemic Emergency declaration tool, the binding commitment language of the 2025 Agreement, and the invocation of national security framing by states across the political spectrum all indicate that extraordinary measures are now institutionalized, not merely discussed.

Process Tracing Analysis

Cause and Outcome: The cause is the COVID-19 pandemic's exposure of structural governance gaps (inequitable access, slow escalation, fragmented coordination). The outcome being traced is the adoption of the 2025 WHO Pandemic Agreement and IHR amendments as corrective reforms.

Causal Mechanism Chain:

1. COVID-19 pandemic (2020-2022) caused global failures in vaccine distribution, declaration speed, and inter-state coordination.
2. The Independent Panel for Pandemic Preparedness and Response issued recommendations identifying systemic failures and calling for a binding international instrument.
3. WHO member states launched the Intergovernmental Negotiating Body in December 2021, mandating a legally binding agreement.
4. Three years of negotiations produced a consensus text, adopted at the 78th WHA on 20 May 2025, alongside the IHR amendments that entered force in September 2025.
5. The 2026 Ebola PHEIC invocation tested the new declaration architecture within twelve months of the IHR amendments entering force.

Evidence Assessment:

• The causal link from COVID-19 failures to treaty negotiations is confirmed by smoking gun evidence: the WHA resolution text explicitly cites COVID-19 inequities as the rationale, peer-reviewed scoping review literature from the American University confirms this causal chain, and the Swiss Federal Council's June 2025 formal approval of the IHR amendments traces directly to the post-COVID reform process.
• The link between treaty adoption and improved outcomes is currently only hoop-test level: the PHEIC was declared for Ebola in May 2026 using the new architecture, which passes the hoop test of institutional use, but whether speed or equity of response improved remains indeterminate pending longer observation.
• The link between PABS negotiations and eventual equity in medical countermeasures is straw-in-the-wind level: divergences remain too large to confirm this mechanism will operate as designed.

CAUSAL_MECHANISM_STRENGTH: MODERATE

The mechanism from COVID failures to treaty adoption is well-evidenced. The mechanism from treaty adoption to improved pandemic outcomes remains unconfirmed and depends critically on PABS resolution and sustainable financing, neither of which is settled.

Constructivism Lens Analysis

Actor Identities: The WHO projects a norm entrepreneur identity, framing pandemic preparedness as a collective obligation of sovereign states rather than a voluntary charity. Low- and middle-income country blocs project a "historically wronged partner" identity, invoking COVID-era vaccine hoarding as a legitimizing grievance. High-income countries project an "innovation guardian" identity, framing intellectual property protection as a public good that incentivizes the R&D pipelines pandemics require.

Operative Norms: The norm of rapid and transparent pathogen data sharing, embedded in both the original IHR and the new PABS framework, is enabling the Agreement's core logic. Simultaneously, the norm of pharmaceutical intellectual property protection constrains the mandatory benefit-sharing obligations that LMIC blocs demand. These two norms are in direct tension, and that tension is precisely why the PABS annex remains unresolved.

Intersubjective Meaning: There is no shared meaning on the central equity question. High-income countries read "benefit sharing" as a voluntary complement to commercial markets; low-income countries read it as a mandatory corrective to market failure. The US bilateral pathogen agreements further contest shared meaning by proposing a commercial framing for sample access that the multilateral framework explicitly sought to replace.

Norm Lifecycle Stage: The norm of binding multilateral pandemic governance is in cascade: it has been adopted by a supermajority of WHO member states and embedded in legal text, but it has not yet reached internalization because it cannot enter into force until PABS is resolved. The benefit-sharing norm is still contested between competing interpretations.

Norm Lifecycle: CASCADE

Indicators To Watch

The table below identifies observable signals that would confirm or challenge the primary assessment.

Decision Relevance

Scenario A (~55%): Treaty architecture remains imperfect but functional, PABS annex adopted by 2027, US cuts partially reversed, Ebola contained. The WHO Pandemic Agreement eventually enters into force with weakened but present equity provisions. The IHR Pandemic Emergency mechanism demonstrates incremental improvements in declaration speed. US public health capacity is diminished but not gutted. Recommended action for risk managers: assume a 10-15 year runway before the new multilateral architecture is fully operational; treat the 2025-2027 period as a governance transition with elevated outbreak risk; stress-test supply chains for medical countermeasures against a 3-6 month equitable access delay scenario rather than the COVID-era 12-18 month gap.

Scenario B (~30%): PABS negotiations fail or are indefinitely deferred; US bilateral strategy displaces multilateral equity norms. The Agreement remains legally dormant. Vaccine and therapeutic access in the next pandemic is governed by a patchwork of bilateral deals weighted toward high-income country interests. The WHO retains operational surveillance functions but loses normative authority on equitable access. Recommended action: organizations dependent on global operations should build medical countermeasure stockpile strategies that do not rely on WHO equitable allocation; engage directly with pharmaceutical manufacturers on contractual priority-access arrangements; and support CEPI and Gavi as the most resilient multilateral vaccine access mechanisms remaining.

Scenario C (~15%): Cascading surveillance failures, triggered by US cuts, aid withdrawal, and the Ebola response straining Africa CDC, produce a delayed detection event for a high-consequence pathogen. The "panic, neglect, repeat" cycle identified by the National Academies of Medicine produces a new pandemic with a COVID-comparable detection lag. The 2026 Ebola Bundibugyo outbreak, with its documented delayed detection, is a harbinger. Recommended action: trigger business continuity and pandemic response plan reviews immediately; engage government-affairs teams on opposing the full FY 2026 CDC budget cuts; and expand investment in AI-assisted environmental and wastewater surveillance as a partial substitute for the receding government-funded surveillance layer.

Analytical Limitations

• The PABS negotiation dynamics involve closed-room deliberations; reporting from Governing Pandemics and Health Policy Watch provides real-time snapshots but cannot capture the full range of positions or side arrangements being discussed.
• The 2026 Ebola outbreak is still in early stages as of this writing; outbreak trajectory data cited (1,000+ cases, 100+ deaths) reflects late-May reporting and will have changed substantially by the time this assessment is read. Readers should check WHO situation reports directly.
• The causal link between US CDC funding cuts and global surveillance capacity degradation is plausible based on structural analysis, but the specific magnitude of capability loss is difficult to quantify in real time; the full impact of FY 2025 cuts may not be visible in surveillance data for 12-24 months.
• This assessment draws primarily on government, academic, and international organization references, with limited visibility into pharmaceutical industry internal planning on benefit-sharing compliance, a significant blind spot given that industry behavior is central to whether PABS works in practice.
• Potential anchoring bias exists toward the multilateral reform narrative: the evidence pool skews toward WHO, academic, and NGO perspectives that favor treaty-based solutions; perspectives from actors skeptical of multilateral governance constraints are underrepresented.