Global Health Governance Post-Pandemic: Did International Cooperation Fail During COVID-19?

Source: Luba Ertel 

Introduction

The COVID-19 pandemic represented the most significant challenge to global public health in a century. While the development of effective vaccines in record time was an unprecedented scientific achievement, their distribution exposed deep fractures in the international order. The promise that "no one is safe until everyone is safe" collided with the reality of vaccine nationalism, structural inequality, and the failures of multilateral mechanisms. This paper examines whether international cooperation failed during the pandemic by analyzing the role of the WHO, the consequences of unequal vaccine access, the TRIPS waiver debate, and the ongoing negotiations surrounding a new international pandemic agreement.

The WHO and the "Catastrophic Moral Failure"

From the earliest stages of the global vaccination campaign, the World Health Organization warned of the dangers of unequal access. Director-General Tedros Adhanom Ghebreyesus repeatedly cautioned that an uneven pace of inoculations would lead to more contagious mutations — a warning that proved prophetic with the emergence of the Delta and Omicron variants.

At a WHO executive board meeting in early 2021, Tedros reported that just 25 vaccine doses had been administered in the world's poorest countries, compared with more than 39 million shots in at least 49 wealthy nations. "Not 25 million, not 25 thousand. Just 25," he stated, warning that "the world is on the brink of a catastrophic moral failure."

Tedros later described the situation as "vaccine apartheid" — a term that came to define global disparities in COVID-19 vaccine access, and which he had already flagged in late 2020 as an imminent consequence of wealthy-country hoarding.

COVAX: The Promise That Failed

The primary multilateral mechanism created to prevent this scenario was COVAX (COVID-19 Vaccines Global Access), co-led by Gavi, the WHO, and the Coalition for Epidemic Preparedness Innovations (CEPI). Its stated goal was to ensure that all countries, regardless of income level, would have equitable access to COVID-19 vaccines.

COVAX failed spectacularly in its mission. By July 2021, it had shipped only 138 million vaccines to 136 countries — a tiny fraction of what was needed — accounting for merely 3.8% of the over 3.79 billion doses administered worldwide at that time.

Bilateral Hoarding

The fundamental flaw was that COVAX allowed participating countries to also pursue bilateral deals with pharmaceutical companies. Within days of Pfizer-BioNTech announcing promising results in November 2020, the company had sold more than 80% of its projected 2021 production to governments representing only 14% of the global population.

Wealthy nations entered into numerous bilateral agreements with manufacturers: the EU finalized a deal for up to 300 million doses; the US ordered 100 million with options for 500 million more — an approach criticized as cornering the market; and the UK reserved 40 million Pfizer-BioNTech doses alone.

Structural Inequities in COVAX's Design

COVAX's operational structure divided participants into two groups: high-income self-financing countries could secure doses for up to 50% of their populations, while low-income countries were limited to 20%. Furthermore, self-financing countries could choose their preferred vaccines, leaving lower-income countries to accept whatever remained. As one BMJ analysis noted, the "opaque nature of secret agreements with vaccine manufacturers ruled out transparency and reduced public trust."

Supply Chain Collapse

COVAX's supply was heavily dependent on the Serum Institute of India, described as the "lifeline" of the facility. When India imposed export controls during its devastating third wave, COVAX faced major procurement and supply disruptions, exposing the fragility of the entire model.

The Scale of Vaccine Inequality

Stark Statistics

By September 2021, just over 3% of people in low-income countries had received at least one dose, compared to 60.18% in high-income countries. By early 2022, only 1% of the 10.7 billion doses administered worldwide had gone to low-income countries, leaving 2.8 billion people still waiting for their first shot.

Research published in the International Journal of Health Policy and Management found that this disparity reflected "not just logistical constraints such as production delays but systemic inequities in a health architecture where public health priorities were treated as secondary to commercial interests."

A study in Global Public Health examined the determinants of "vaccine apartheid," concluding that intellectual property rights constrained affordability and availability in ways inadequately addressed by COVAX, with any waiver compromise ultimately "thwarted by political, corporate, and philanthropic interests."

Geographic Concentration

Inequality was most pronounced in Sub-Saharan Africa, where countries including Burundi, the DRC, and Chad had less than 1% of their populations vaccinated. Paradoxically, vaccines like Oxford-AstraZeneca had been trialed in countries such as Kenya, yet Kenya's fully vaccinated population remained at just 1.2%.

Economic Consequences

According to UNDP analysis, if low-income countries had achieved the same vaccination rate as high-income countries (~54%) by September 2021, they would have increased their combined GDP by $16.27 billion in 2021 alone. Joint research by UNDP, WHO, and Oxford University further revealed that COVID-19 vaccine programs were expected to cost low-income countries an additional 56.6% on health budgets, compared with just 0.8% for high-income countries.

Intellectual Property: The TRIPS Waiver Debate

In October 2020, India and South Africa proposed a temporary waiver of certain TRIPS provisions to allow manufacturers worldwide to produce generic versions of COVID-19 vaccines. The proposal garnered support from more than 100 countries, including a surprising reversal from the United States, but was systematically blocked by the EU, UK, and Switzerland.

Proponents argued the waiver was necessary to overcome "manufactured barriers" prolonging the pandemic. As one commentator wrote in African Arguments, Africa's AIDS epidemic demonstrated that "charity is not a public health plan" and that blocking the waiver amounted to "colonial gatekeeping of big pharma's supply chains."

Opponents, primarily pharmaceutical companies and their home governments, argued that patents incentivize innovation and that manufacturing complexity meant waiving them would not automatically create production capacity. The final compromise fell far short of the original proposal and was widely criticized as inadequate, demonstrating the immense power of pharmaceutical industry lobbying in shaping global health policy.

The WHO Pandemic Agreement: A New Hope?

The catastrophic failures of pandemic response prompted member states to negotiate a new international instrument. The WHO Pandemic Agreement was adopted by the World Health Assembly on May 20, 2025, endorsed by 124 countries, after more than three years of negotiations.

Key Provisions

•      One Health approach: for the first time in a multilateral treaty, it enshrines the balance between human and animal health and environmental protection.

•      PABS System: the Pathogen Access and Benefit-Sharing mechanism requires manufacturers participating in the system to reserve 20% of their pandemic-related production for WHO allocation — half as donations and half at affordable prices.

•      Articles 10 and 11 introduce structured commitments for diversifying manufacturing capacity, promoting non-exclusive licensing, and WHO-led technology pools.

Limitations and Criticisms

Despite these advances, the agreement fell short of initial ambitions. Key provisions on supply chain transparency, technology transfer, and intellectual property were diluted during negotiations. The final text only requires parties to "promote and facilitate" technology transfer on "mutually agreed terms" — well short of binding obligations.

The agreement also revealed deep divisions between the Global North and South, "with inflexible negotiating positions partly fed by resentment at the hoarding of COVID-19 vaccines by developed countries."

Critically, the agreement cannot enter into force until its PABS annex is finalized. Negotiations began in July 2025 with an initial target of May 2026, though most observers anticipate a longer timeline. Even once finalized, as one Chatham House analysis noted, "the history of global governance has shown, time and again, that the mere development of agreements is not sufficient in the absence of strong compliance and enforcement mechanisms."

Geopolitics and Alternative Models

The pandemic revealed how geopolitical forces shape health outcomes. Vaccines became diplomatic tools, with China using medical goods trade to expand influence in the Global South. The US announced withdrawal from WHO in January 2025, cutting billions from the organization's budget and creating additional uncertainty. Geopolitical tensions also manifest through conflicts that destroy health infrastructure, sanctions that undermine health resource-building, and diplomatic standoffs that weaken global frameworks.

Yet geopolitics also offers opportunities. Regional institutions such as the African Union and ASEAN could strengthen data sharing, epidemic preparedness, and procurement mechanisms. Some Global South countries demonstrated alternative approaches: Cuba developed its own vaccine, Abdala, working to make its technology accessible to other states. Experts argued that African states must insist on the right to fully manufacture — not just "fill and finish" — vaccines, and called for implementing the Abuja Declaration, the AU's 2001 pledge to spend at least 15% of national budgets on health.

Conclusion

International cooperation failed during the COVID-19 pandemic. This was not a technical failure — vaccines were developed at unprecedented speed — but a political and ethical one. The global health governance system, with a weakened WHO dependent on state goodwill, proved incapable of countering vaccine nationalism. Dose hoarding, the prioritization of patents over human lives, and COVAX's collapse are clear evidence that national and corporate interests prevailed over the global common good.

The consequences were devastating: millions of preventable deaths, a prolonged pandemic, and a two-track economic recovery. As UNDP Administrator Achim Steiner noted, this unequal recovery demanded "swift, collective action."

The Pandemic Agreement represents a foundational, though incomplete, step toward reform. Its success depends on sustained political will. As WHO Director-General Tedros stated, it is in all countries' best interest — "economically, epidemiologically, and morally" — to make lifesaving vaccines available to all.

The fundamental question remains: will the international community learn from this catastrophic failure, or, as one BMJ analysis warned, will the same actors who failed simply apply "cosmetic" fixes to maintain control during the next crisis? The answer lies in whether the Pandemic Agreement's aspirational goals can be transformed into enforceable obligations — and whether the world has truly absorbed the lesson that in an interconnected world, no one is safe until everyone is safe.