Historic negotiations for a pandemic treaty or other international instrument on Pandemic Prevention, Preparedness and Response (PPPR) have just started [1]. Areas and provisions under consideration are both complex and broad [2]. Strengthening national health systems, which Member States labelled as “foundational” for PPPR [2] have an important place in that spectrum. Indeed, health systems and services, including those of high-income countries, suffered heavy burden during the COVID-19 pandemic. Health systems which had been under-resourced and fragmented prior to the pandemic were the least resilient [3]. Delivery of essential services were interrupted, health workforce disproportionally affected and over-stretched, and treatment of other diseases delayed or cancelled to ensure system capacity for COVID-19 care [4]. Emergency care services faced particular challenges. Emergency visits generally declined during lockdowns, and some services (emergency dentistry for example) were available for very serious cases only [5], with potentially negative consequences on disease outcomes. At times however, intensive care units had to operate at 200-300 percent of capacity and health personnel from other areas be reallocated to emergency services to meet the demand [3,4]. Both chronic and pandemic-induced shortages in critical supplies - oxygen, ventilators, lifesaving medicines and personal protective equipment [6] - only aggravated the crisis.

Overall, health systems in most countries were not prepared for a health emergency of such magnitude and length a key lesson to learn when preparing for future pandemics. Although health systems are widely considered as a domain of national responsibility, international implications are clear. Failures and shortages in addressing diagnostic and treatment needs of a huge influx of patients in a timely manner, and major interruptions of essential health services contribute, undeniably, to the spread of disease across borders. It is also widely acknowledged that resilient health systems and international coordination to strengthen them will be critical in preventing and mitigating the risk of pandemics. Solutions therefore are needed at national and international levels alike. In the same time, the existing regulations concerning health emergencies of international concern only marginally address capacities of and response by healthcare institutions. The current International Health Regulations (IHR 2005) [7] focus strongly on surveillance and other public health capacities (detection, notification, information, border measures, quarantine etc.) but much less on healthcare capacities and response, including those in relation to emergency care. While this aspect didn’t expose significantly in recent international outbreaks of relatively limited scale and geographical spread, including SARS and Ebola, it did manifest acutely during the COVID-19 pandemic due to its exceptional magnitude. As the world braces for next potential pandemics, we think the new international health security framework should address public health and healthcare capacities alike. Both primary care and hospital capacities, including health workforce, technologies, governance and supplies deserve attention in ensuring adequate pandemic preparedness and response. It would therefore be important for the future pandemic treaty or other international instrument to establish, as part of the global pandemic preparedness and response, minimal compulsory requirements for national healthcare service capacities by analogy with - and at the expansion of – requirements for public health capacities contained in the current International Health Regulations (2005) [7]. Such requirements would encompass technology, supply, coordination, financial and health workforce capacities alike. The requirements then to be reflected in national pandemic preparedness plans – and in universal periodic reviews of implementation of such plans - in line with renewed internationally agreed targets and benchmarks, as recommended by the Independent Panel for Pandemic Preparedness and Response [3]. Emergency care capacities would comprise important part of such requirements, with several provisions – such as for simulation exercises, secured supplies of life-saving products, rapid deployment of health workforce, and special measures such as establishing oxygen plants [6] – gaining particular relevance. The requirements could also take into account lessons learned during the COVID-19 pandemic concerning access to, and utilization of, emergency services in selected countries [5]and facilities [8,9]. Finally, the prospective treaty requirements would utilize relevant features of existing international frameworks [10], such as the health system related provisions of the Sendai Framework for Disaster Risk Reduction [11] and the WHO’s Health Emergency and Risk Management Framework [12]. As the process for a pandemic treaty or other international instrument is now at its early stage, taking into account the above aspects during negotiations would contribute to strengthening health systems resilience in pandemic preparedness and response, both at national and global levels.

1. (2021) The World Together: Establishment of an intergovernmental negotiating body to strengthen pandemic prevention, preparedness and response. Decision of the Second special session of the World Health Assembly, Switerland.
2. (2021) Report of the Member States Working Group on Strengthening WHO Preparedness and Response to Health Emergencies to the special session of the World Health Assembly, Switzerland.
3. (2021) COVID-19: make it the last pandemic. Report of the Independent Panel for Pandemic Preparedness and Response.
4. Haldane V, De Foo C, Abdalla SM, Jung AS, Tan M, et al. (2021) Health systems resilience in managing the COVID-19 pandemic: lessons from 28 countries Nature Medicine 27: 964-980.
5. (2021) Impact on essential health services. Background paper 8. The Independent Panel for Pandemic Preparedness and Response.
6. (2021) Access to Essential Supplies. Background paper 7. The Independent Panel for Pandemic Preparedness and Response.
7. (2005) International Health Regulations. World Health Organization, Switzerland.
8. Reschen ME, Bowen J, Novak A, Giles M, Singh Sudhir, et al. (2021) Impact of the COVID-19 pandemic on emergency department attendances and acute medical admissions. BMC Emergency Medicine 21: 143.
9. Hautz W, Sauter T, Exadaktylos AK, Krummrey G, Schauber S, et al. (2020) Barriers to seeking emergency care during the COVID-19 pandemic may lead to higher morbidity and mortality – a retrospective study from a Swiss university hospital. Swiss Med Wkly 150: w20331.
10. Nikogosian H (2021) A Guide to a Pandemic Treaty . Graduate Institute of International and Development Studies, Geneva.
11. Sendai Framework for Disaster Risk Reduction (2015). United Nations.
12. Health Emergency and Disaster Risk Management Framework (2019). World Health Organization.