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[Research Reports] Prospects for Post-Pandemic Health Cooperation

Kayo Takuma (Professor, Tokyo Metropolitan University)
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Research Group on 'Global Issues' FY2021-# 4

"Research Reports" are compiled by participants in research groups set up at the Japan Institute of International Affairs, and are designed to disseminate, in a timely fashion, the content of presentations made at research group meetings or analyses of current affairs. The "Research Reports" represent their authors' views. In addition to these "Research Reports", individual research groups will publish "Research Bulletins" covering the full range of the group's research themes.


Two years have already passed since the World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern (PHEIC) on January 30, 2020. Numerous other PHEICs have been declared since 2000, but the COVID-19 epidemic has been the longest PHEIC among them. The 2009 H1N1 influenza was declared a PHEIC in April 2009 and this designation ended one year and four months later in August 2010. During the 2014 Ebola outbreak in West Africa, a PHEIC was declared in August of the same year and lasted for one year and seven months until it was lifted in March 2016. In February 2016, a PHEIC was declared for the Zika outbreak in the Americas, which lasted for nine months before being lifted in November of the same year. The ongoing COVID-19 outbreak has been unusually long compared to such precedents. At the end of 2021, a new mutant Omicron strain was identified. By mid-February 2022, the cumulative number of infections in Japan had exceeded four million. The difficult fight against DOVID-19 continues in many countries.

Unlike recent outbreaks such as Ebola and H1N1, which were localized, COVID-19 has spread all over the world. As a result, countries are doing all they can to deal with the pandemic within their own borders, making competition and conflict over resources such as vaccines and treatments more likely. Since the pandemic affects economic and social activities in every corner of society, one misstep in the way politicians deal with it can be fatal to their governments. Their responses are thus naturally very political. However, that is not the only reason the fight against the virus has dragged on. In the first place, there were structural problems in the framework supporting cross-border health cooperation. Countries have also actively engaged in health diplomacy in recent years as a means of increasing their own influence, and responding to COVID-19 has itself become an arena for health diplomacy.[*]1 In this article, I would like to consider the current status and future prospects of health cooperation from this perspective.

1. Characteristics of health governance and its impact on COVID-19 responses

Global governance in the field of health and medical care (health governance) refers to a system of cooperation that includes not only states but also non-state actors in addressing global human health issues in a variety of formal and informal ways. In recent years, the issues of decentralization of health governance and reduced unifying power have arisen due to the diversification of actors and the declining centrality of the WHO.[*]2 These trends have also cast a shadow over the coronavirus response. The main concerns pertain to the existing International Health Regulation and the authority of the WHO. The International Health Regulation has its origins in the International Sanitary Convention established in 1903. It stipulates various obligations in responding to infectious diseases, such as conducting surveillance in the territory, imposing border measures, and reporting to the WHO within a certain period of time. For example, the Regulation states that a country must inform WHO of a PHEIC in its territory within 24 hours after assessment. It was not until New Year's Eve 2019 that China informed the WHO about COVID-19. In fact, it is said that various abnormalities had been confirmed from around the autumn of 2019, so the rules of the International Health Regulation were not followed correctly. When South Africa reported the emergence of the Omicron strain at the end of 2021, the WHO recommended that countries lift travel restrictions in accordance with the existing rules, but this advice was not followed correctly. There is no provision to enforce the rules, and compliance relies on the voluntary cooperation of individual countries.

2. Vaccine diplomacy

The state, a traditional actor in health governance, remains an important actor, although its role has been relativized amidst the diversification of actors in governance. In the past it was common practice to engage through national health ministries, but in recent years there has been an increase in engagement through foreign ministries and international cooperation and development agencies, aimed at improving health systems in specific countries or globally. In many cases, countries concurrently seek to expand their own political influence or pursue some subsidiary political purpose.

This aspect of health diplomacy was also highlighted in the COVID-19 response. Disparities in access to medicines between developed and developing countries are nothing new, and the COVAX Facility, the first-ever framework for equitable supply of COVID-19 vaccines, was established to prevent disparities. While COVAX is a global partnership that aims to provide a safe and effective COVID-19 vaccine with about $20 billion co-financed by member countries and a lock-in of candidate vaccines, establishing the system did not mean that vaccines were distributed equitably. The delivery of vaccines through COVAX began in February 2021, but it is difficult to say that the delivery of vaccines has progressed smoothly. Even now, COVAX is distributing only about half as many vaccines as originally planned, affected by vaccine procurement and funding shortfalls.

As if to fill the niche, "vaccine diplomacy" has been actively deployed on a bilateral basis or through frameworks of willing countries. As noted above, there is much uncertainty as to whether COVAX will work, and China and Russia have made up for that by exporting their own vaccines to developing countries. Vaccines, which have more rarity value than face masks, are also said to be intended by China to serve as a diplomatic tool in exchange for support for its actions in the South China Sea.[*]3 China is supporting the local manufacturing of vaccines in Morocco and Indonesia in addition to Egypt, which is expected to have an impact not only on the response to COVID-19 but also over the medium to long term.

Since around April 2021, when the domestic injection of vaccines progressed enough, the US has engaged in vaccine diplomacy in competition with China through multiple channels, including bilateral routes, donations to COVAX and donations through the Quad, a diplomatic and security policy framework comprising India, Japan, the United States and Australia. However, this is not necessarily support based on necessity. According to data released by the Council on Foreign Relations, vaccine diplomacy efforts by the US, Europe, China, Japan and Australia are concentrated in the Asia-Pacific region rather than in sub-Saharan Africa, which has the lowest vaccination rate in the world. It is clear that vaccine diplomacy is driven not by necessity, but by strategic considerations.[*]4

3. Future issues at the global level

The decline in the centrality of international organizations, the continuing conflict between the United States and China, and the battle for hegemony between the United States and Europe are expected to hinder efforts to reach a consensus on transnational health issues at the global level. In fact, there are some specific issues on which agreement has been difficult. The first concerns the investigation of the origins of COVID-19. Understanding the origins and routes of transmission of infectious diseases that have rocked the world is also important in preventing the next pandemic. In the wake of the 2014 Ebola outbreak in West Africa, researchers from Germany's Robert Koch Institute took a close look at the circumstances surrounding the first deaths shortly after the pandemic was declared, and by the end of that year published an article in a scientific journal suggesting that the source of the outbreak was likely insectivorous bats living in tree holes in a village in the remote area of Guinea. On the other hand, in response to a resolution of the World Health Assembly in May 2020, an assessment of the origins of COVID-19 was conducted in China from the end of January to the beginning of February 2021, but the source of the outbreak is still far from clear. In 2021, the United States took the position that the virus had leaked from a virology laboratory in Wuhan and moved to carry out an investigation on its own, and the WHO established a working group in the fall of 2021 to conduct a new review. However, it will not be easy to move forward without China's voluntary cooperation.

The second issue concerns a pandemic treaty. European Council President Charles Michel proposed a treaty in 2020 with the aim of preparing countries for pandemics by increasing national responsibilities and international cooperation. At present, there is the International Health Regulation that describes the obligations of countries in addressing infectious diseases, but there are no penalties for failing to meet these obligations. The proposed pandemic treaty is intended not to replace the International Health Regulation, but rather to strengthen the WHO's mandate and the responsibilities of states in areas of cooperation not covered by existing frameworks, to include sharing clinical trial data and ensuring stable supply networks for medicines and medical supplies during pandemics.

The agreement reached at the Special Session of the WHO in November 2021 to establish a pandemic treaty can be seen as a tentative step forward. On the other hand, there are many who urge caution in imposing sanctions on countries that fail to comply with their obligations under the pandemic treaty, or in giving the WHO coercive authority. Therefore, there remains uncertainty whether a pandemic treaty will really reinforce the existing framework.

As of early 2022, about 30 countries mainly in Africa and Europe had expressed their support for WHO Director-General Tedros Ghebreyesus, who will begin a second term in 2022, but there are countries that have not expressed such support, most notably the United States and China, leading to a division among states concerned. There have also been no signs of financial reform. In FY2021, half of WHO's funding came from the top six actors, and the challenge has been to build a stable financial mechanism that can withstand political changes. At the end of 2021, a report on sustainable financial resources was submitted by several WHO member states, but this was derailed by opposition from the United States and China. Under these circumstances, continued challenges are expected in bringing COVID-19 under control, preventing the next pandemic, and addressing other health challenges such as polio and AIDS.

4. Future Challenges: How Can a Multilayered Cooperation Framework Be Developed?

(1) Importance of multilayered cooperation

Even in this difficult international environment, we must continue to look for concrete measures to improve the situation. What should we do? In concrete terms, frameworks for cooperation at the regional level should be reviewed while strengthening the response framework at the global level. Six regional bureaus were established under the World Health Organization following World War II and regional health cooperation developed. However, these regions tended to close themselves off from each other, causing problems that they were unable to help each other when needed. Nevertheless, the significance of health cooperation at the regional level lies in its ability to complement cooperation at the global level. The unravelling of global cooperation in responding to COVID-19 has galvanized efforts to rethink regional cooperation. In the past, the EU had not been active in regional cooperation in the field of public health. But having experienced the inability to coordinate responses to COVID-19 and procure COVID-19 vaccines, the EU began in autumn 2020 to move toward establishing a European Health Union whose aims would be to strengthen regional preparedness and responses to public health crises by monitoring supplies of medicines and medical devices in the region, coordinating information and research on vaccine trials and vaccine efficacy/safety, developing surveillance systems at the EU level, and sharing data such as hospital bed availability and the number of healthcare workers within member countries.[*]5 Building information-sharing systems and signing memorandums of understanding on emergency responses with neighboring countries can complement the global response framework.

In Latin America, the WHO's Americas Regional Office announced in September 2021 the establishment of Regional Platform to Advance the Manufacturing of COVID-19 Vaccines and other Health Technologies in the Americas to promote the manufacture of COVID-19 vaccines within the region. In Africa, the importance of intra-regional cooperation was reaffirmed amid the COVID-19 pandemic, and the Africa CDC has been playing a central role in surveillance, testing, and procurement of necessary supplies and vaccines. The Africa Medical Supplies Platform has also been established as a regional framework for the procurement of medicines and medical supplies within the continent. Through partnerships among regional organizations such as the AU, the Africa CDC, and the United Nations Economic Commission for Africa, the Platform has also played a major role in Africa's procurement of COVID-19 vaccines from outside the region. Efforts within Africa to increase vaccine self-sufficiency have been spurred by COVID-19. Africa has a vaccine import rate of 99%, and the director-general of the Africa CDC declared in April 2021 that the organization would aim to reduce the import rate to 40% no later than 2040 by increasing local production capacity. Criticism and skepticism in Africa about the global framework have led to moves to reinforce regional frameworks.

(2) Potential for regional health cooperation in Asia

In Asia, unlike in Europe and Africa, it is difficult to say that progress has been made in putting in place a comprehensive regional health cooperation system that encompasses the entire region. Japan, China and South Korea have held health ministers' meetings every year since 2007 (except in 2012, when Japan-China relations soured over the Senkaku Islands issue). A special meeting of health ministers from Japan, China and South Korea was held in May 2020, and a joint statement was adopted on the importance of enhancing the sharing of information, data and knowledge among the three countries, promoting further exchanges and cooperation among technical and professional organizations, and sharing information and experiences to combat COVID-19. On the other hand, there has been growing distrust of China's response since then, and relations between Japan and South Korea have become strained due to trade issues and the issue of wartime forced labor, so there has been no progress at all in the Japan-China-ROK Health Ministers' Meeting.

Against this backdrop, a fragmentary framework of cooperation is developing in Asia. In 2020, the Japanese government announced its intention to support the establishment of an ASEAN Centre for Infectious Diseases in order to conduct surveys and analyses of trends in infectious disease outbreaks and to develop medical personnel. It is considered that this center will lead to raising the medical treatment level in the region and promoting Japanese companies' advance in ASEAN countries. The center will also have the potential to serve as a base for clinical trials and other cooperation in developing Japanese-made pharmaceuticals in the future. We have already seen progress in vaccine assistance and health cooperation through the Quad.

Regional health cooperation in Asia has thus been making headway on a piecemeal basis, reflecting heightened tensions in Japan-ROK relations, US-China rivalry, and differences in political systems. On the other hand, the importance of cooperation at the regional level remains high, as its history shows, and it would be desirable to establish a certain system of information sharing among neighboring countries, to jointly develop medicines and vaccines for possible infectious diseases, and to put in place mechanisms for emergency travel restrictions and supply networks for medical supplies and medicines. The National Institute of Infectious Diseases in Japan conducts regular research exchanges with the Chinese CDC and the Korea Disease Control and Prevention Agency. In parallel with Southeast Asia-Japan cooperation, which is seeing steady progress, building up informal cooperation with South Korea and China is expected to contribute in some way to combatting infectious diseases in the region.

In response to changes in the international environment, such as US-China confrontation and the decline of the liberal international order based on multilateral cooperation, cooperation at the global level will become increasingly dispersed and decentralized. A realistic approach to delaying this would be to reinforce the global framework while at the same time strengthening infectious disease preparedness and response capabilities at multiple levels, so that they will complement each other.

1 This point was also noted in "Coping with COVID-19 as a 'Domestic Crisis'" by Kayo Takuma in Geopolitics Changing Due to COVID-19: Japan under the Great Reset, Center for International Economic Collaboration (CFIEC), Sankei Shimbun Shuppansha, 2021, pp. 210 -218.

2 Ilona Kickbusch, et al., (eds.), Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases (Springer 2015).

3 Wall Street Journal, "China Seeks to Use Access to COVID-19 Vaccines for Diplomacy", August 17, 2020,

4 Council on Foreign Relations, "Visualizing 2022: Trends to Watch", Last updated December 6, 2021 3:00 pm (EST),