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The COVID-19 pandemic has highlighted profound weaknesses in the global governance of health; inadequate preparation, coordination, and accountability hampered the collective response of nations at each stage. Changes to the global health architecture are necessary to mitigate the health and socioeconomic damage of the ongoing pandemic, and to prepare for the next major global threat to health. Against this backdrop, on April 4, 2022, the London School of Economics and Political Science, London, UK, hosted a meeting on the topic, “Paying the Pandemic Piper: Global Health and Economic Security”. The cross-sectoral stakeholders who participated at the meeting arrived at several insights, including the key proposals captured here. We recommend international institutions focus on their core missions and unique capabilities to respond to global externalities—ie, policy areas and challenges where the actions or inaction of any one country affect all global actors.

Within the multilateral space there are many overlapping, fragmented efforts to improve global governance in response to COVID-19, with different actors leading each process. Examples of proposals to improve pandemic prevention, preparedness, and response are shown in the panel.^{1, 2, 3, 4,} 5

The 75th World Health Assembly in Geneva, Switzerland, on May 22–28, 2022 is an opportunity to turn these varied proposals into effective action. Success will require clear demarcations of responsibility with a parsimonious role for international institutions. Although a pandemic treaty or alternative new instrument or process cannot solve all that is wrong with global health, it can deliver targeted improvements if supported by effective and clear global governance. Such a new governance instrument should focus on responsibilities that are truly transnational in nature, meaning it addresses global challenges with causes and consequences that transcend national boundaries.

Importantly, the processes summarised in the panel need to unite these international actors and strengthen their collective efforts rather than reinforce historical silos in global health governance. This collective response means that WHO pandemic treaty negotiations should align with the G20 and World Bank proposals of a Financial Intermediary Fund and a Finance and Health Board. ⁶ Additionally, many countries are striving to increase domestic health spending, despite the economic damage from the impacts of the COVID-19 pandemic. ⁷ More should be done to align this momentum for increased health spending to make best use of national government resources.

Our core recommendation is for international institutions to focus on fulfilling their unique capabilities by sharing knowledge between countries; pooling resources and distributing benefits equitably between countries; monitoring the preparedness of health systems within and across countries; and convening national actors effectively and in real time.

First, international institutions should synthesise, create, and share knowledge of which health policies work and which do not, rather than trying to duplicate or mandate national actions. For example, different national lockdown policies have had widely divergent benefits and costs, yet there is no repository of global comparative data to analyse the impacts of lockdowns to date. ⁸ The lockdowns and economic impacts of the COVID-19 pandemic have underlined the interdependence between health and economic security. National decision makers need a common language of outcomes to compare the trade-offs within and across sectors. International institutions could support this reframing of interdependent outcomes, with health spending explicitly segmented into health maintenance and health investment so that new opportunities are easily identified.9

Second, international institutions can pool resources, since aspects of pandemic preparedness and response benefit from economies of scale. For example, platform technologies that enable vaccine research and development could be pooled under a clear global investment framework with guaranteed supply to contributors alongside global equity provisions—although the sustainability of these investments also requires attention on the demand side.¹⁰ Economies of scale are also relevant for public health assets, such as high complexity laboratories, regulatory harmonisation, and medical supplies procurement, with potential for mutually beneficial collaboration.

Third, shared monitoring of the preparedness of national health systems for crises is required, following the model of the G20 Financial Stability Board, which tests financial system resilience so that weaknesses can be addressed.¹¹ Such a role is suited to a single international body to ensure consistency and transparency, and could be attained by expanding the WHO pilot Universal Health and Preparedness reviews. ² The International Monetary Fund could also regularly analyse the economic and financial consequences of health challenges, as an input to the proposed G20 Finance and Health Board.

Finally, international institutions have the unique power to convene health, finance, and political actors, but this has not always been done well historically. The proposed G20 Finance and Health Board would strengthen coordination between finance and health, which would be a promising step.⁴ However, more could be done in regular forums to strengthen collaboration. One relevant model here is the UN Conference of the Parties, whereby countries make climate pledges and reassess them annually. Participants could then derive financial and non-financial support from parties with mutual benefit. Convening key global actors would also encourage these forums to act on unmet health and economic challenges. Given the potential for disease outbreaks and antimicrobial resistance (AMR) to spread across borders, collaborative action offers regional and global benefits.

Improvements to global governance structures for pandemic preparedness and response will also have benefits for other global health challenges, such as climate change and mass migration.¹² Prevention and detection activities are integral to tackling future pandemics and AMR, and global governance should maximise the shared benefits across these two areas. Health leaders must not squander this opportunity to build a renewed global and national architecture to meet current challenges and those yet to come.

The London School of Economics and Political Science, London, UK, hosted a meeting of cross-sectoral stakeholders on the topic, “Paying the Pandemic Piper: Global Health and Economic Security”. We declare no competing interests. The views expressed in this Comment are entirely those of the authors and do not necessarily represent the views of the organisations with which they are affiliated. Participants at the meeting also included Chikwe Ihekweazu,

Paul Johnson, Ilona Kickbusch, Connor Rochford, and Minouche Shafik. We thank George Wharton for his assistance with preparing this Comment.

Barts and the London School of Medicine and Dentistry, London E1 2AD, UK (AW); London School of Economics and Political Science, London, UK (RF, AM, CW, EM); WHO Regional Office for Europe, Copenhagen, Denmark (NA-M); Dr Evidence, Santa Monica, CA, USA (RB); Organisation for Economic Co-operation and Development, Paris, France (FC); Center for Global Development, Washington, DC, USA (AG); European Observatory on Health Systems and Policies, WHO European Centre for Health Policy, Eurostation (Office 07C020), Brussels, Belgium (JFM); European Bank for Reconstruction and Development, London, UK (BJ); Chatham House, London, UK (JO’N, RY); Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK (MMc); Bocconi University, Milan, Italy (MMo); Frontier Economics, London, UK (GO’D); Trinity College, University of Cambridge, Cambridge, UK (SD)

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