Unpacking the package of amendments to the International Health Regulations at country level

PDF version

Hanan Balkhy ¹

¹Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.

Citation: Balkhy H. Unpacking the package of amendments to the International Health Regulations at country level. East Mediterr Health J. 2024;30(9):597–600. https://doi.org/10.26719/2024.30.9.597.

Copyright: © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

The WHO Eastern Mediterranean Region (EMR) is home to 745 million people, of whom 107 million (14%) need humanitarian assistance (1-5). EMR is the source of 55% of the world’s refugees and has 33.7 million people who have been forcibly displaced (1,4). Of the region’s 22 Member States and territories, 13 are directly or indirectly affected by conflicts, 9 are classified by the World Bank as in ‘fragile or conflict-affected situations’ and 6 rank among the lowest globally on the World Bank’s political stability and absence of violence indicator (3,4).

The year 2023 was particularly difficult for the EMR. As of October, WHO had responded to 71 disease outbreaks (excluding COVID-19) in the region, up from 61 outbreaks during 2022, and in November WHO was responding to 19 graded emergencies across the region, including 7 complex humanitarian emergencies (6,7). Nine of these emergencies were classified as Grade 3 acute and protracted crises: the COVID-19 pandemic; the global cholera outbreak; complex emergencies in Afghanistan, Somalia, Sudan, Syrian Arab Republic, and Yemen; the earthquakes in Syrian Arab Republic and Türkiye; the food security crisis in the greater Horn of Africa; and the recent escalation of violence in the occupied Palestinian territory (OPT) (1,6). Five of the emergencies affected multiple countries in different WHO regions (7).

In the third quarter of 2023 alone, EMR responded to 6 new emergencies: the escalation of a cholera outbreak in Sudan, in addition to an ongoing conflict; flooding in Libya; and major earthquakes in Morocco and Afghanistan (8). The conflict in the OPT will be remembered as one of the most challenging crises in the region's modern history, with over 40 000 killed, 90 000 injured, and 1.9 million displaced (9,10).

The disproportionate impact of climate-related disasters, for example, the El Niño-fueled seasonal Deyr rains in Somalia, have further exacerbated the challenges (11), and the consequences of all these crises on health, lives and livelihoods are severe.

Despite documented progress in strengthening public health systems and infrastructure across EMR countries during the COVID-19 pandemic – including in fragile settings – there has been no improvement in the annual States Parties Self-Assessment Reports (SPAR) for the International Health Regulations (IHR)-required capacities (12,13). During the last 3 years, the average regional score has fluctuated slightly but has generally remained stable at 65% in 2021, 67% in 2022 and 66% in 2023. Despite continuous efforts to enhance IHR across the region, progress has been incremental but slow, and the overall preparedness and response capacity has remained relatively consistent. This trend reflects insufficient investment in health security measures and a failure to build on and sustain the gains obtained during COVID-19. It also highlights a critical gap in the region's ability to protect public health and respond to emergencies effectively.

IHR (2005) is a set of legally binding regulations adopted by WHO Member States to help countries prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. It aims to enhance national, regional and global public health security by providing a framework for the coordination and management of public health emergencies (14).

During the COVID-19 pandemic, the IHR and global health security review panels identified the need for some amendments that would improve IHR implementation and compliance. They recommended the development of new international instruments that would enhance pandemic preparedness and response. Thereafter, WHO Member States agreed, through Executive Board Decision EB150 (15) (2022) (16) and WHA75(9) (2022) (17), to make amendments to the IHR through the Working Group on Amendments to the IHR (2005) (WGIHR) (18).

The IHR Review Committee was established to technically review proposed amendments based on such criteria as appropriateness, clarity, consistency, and feasibility, and to make recommendations to the WHO Director-General. Within the context of IHR (2005), more than 300 proposed amendments were considered (18). Pursuant to decision WHA75(9) (17) and considering the Review Committee's report on the amendments, WGIHR (18) proposed a package of amendments, which were approved by the 77th World Health Assembly in 2024 (20).

The amendments to IHR (2005) focus on several key areas (20). A new National IHR Authority will be established to coordinate and enhance implementation of, and compliance with, the IHR by each State Party. To facilitate equitable access to health products and enhance WHO support, and in addition to Public Health Emergencies of International Concern (PHEIC), the scope of IHR public health response was expanded to include pandemic emergencies.

An important concept, which emphasizes solidarity and equity in access to medical products and financing, was introduced as a guiding principle. The concept recommends the establishment of a coordinating financial mechanism that will identify and secure funding needed to "equitably address the needs and priorities of developing countries" (20), including developing, strengthening and maintaining core capacities, and enhancing pandemic-related prevention, preparedness and response capabilities.

To ensure effective implementation of the IHR, a States Parties Committee will be created, which will operate in a consultative, non-punitive manner, to promote cooperation and best practices among States Parties (20). The committee will involve intergovernmental organizations in pandemic and PHEIC response and seek to enhance WHO recommendations, including non-binding advice for current public health risks (20).

The amendments related to Annex 1 (20), particularly, emphasize the critical importance of preparedness in global health security and enhancement of the core capacities of States Parties to detect, assess, notify, and respond to public health emergencies effectively.

These new additions aim to minimize disruptions during public health emergencies, strengthen digitalization of health records and enhance engagement with non-state actors for tailored responses (20). To improve clarity, the amendments standardized terminologies and introduced new definitions, such as "National IHR Authority" and "pandemic emergency", while expanding the scope of IHR to include healthcare in humanitarian emergency settings.

WHO will provide technical assistance towards the realization of the objectives of the revised IHR, including those related to equitable access to healthcare products, ensuring that States Parties have timely and equitable access to essential healthcare products, as highlighted in Article 13: “WHO shall facilitate, and work to remove barriers to, timely and equitable access by States Parties to relevant health products.” The WHO Director-General will facilitate a review of the implementation of the revised IHR during the 80th World Health Assembly, in accordance with paragraph 2 of Article 54.

The amendments to the IHR, if consistently adopted, have the potential to significantly enhance health security in the EMR and globally (21). By facilitating access to adequate financing, better infrastructure and trained personnel for public health emergencies, countries will be better equipped to handle crises more efficiently (22). And by improving surveillance systems and communication, the amendments should enable timely detection and response to health emergency alerts and prevention of disease transmission. They are expected to enhance the effectiveness of public health measures at points of entry and within communities, thus preventing the introduction and spread of infectious diseases.

Unpacking the package of amendments to IHR (2005) for implementation at country level will involve a series of strategic actions, to ensure that all relevant sectors understand and consistently comply with the updated regulations (25). Implementing the amended IHR at country level is a multifaceted process that will require coordination, collaboration and commitment from all sectors of society.

EMR countries can meet international health standards and foster accountability and continuous improvements by promoting compliance with the IHR through enhanced readiness and timely reporting (23,24). It is essential for each EMR country to establish a National IHR Authority as a centralized and authoritative body responsible for coordinating implementation of the revised IHR (25). This will include forming a national task force or committee, designating an official national IHR focal point, and ensuring that the IHR Authority has adequate resources, authority and political backing to operate effectively.

Conducting a legal and policy review at country level is crucial to align national laws and policies with the revised IHR (26). This will include reviewing existing public health laws and regulations to identify gaps, drafting new legislation or amending existing laws as needed, and engaging legal experts and policymakers.

Developing a strategic implementation plan is critical for outlining how each country will meet the requirements of the revised IHR, including setting clear objectives and milestones, assigning roles and responsibilities, establishing timelines, and allocating budget and resources (27). It is important to foster multisectoral coordination by establishing intersectoral coordination mechanisms, engaging various sectors in planning and implementation, and developing standard operating procedures for collaboration during health emergencies.

EMR countries need to adjust their monitoring and evaluation systems to align with the amendments, including developing new indicators, conducting regular reviews and using the feedback for adjustments, and reporting progress (28). They should facilitate international collaborations by participating in international forums, sharing best practices, engaging in joint training, and harnessing technical assistance from WHO and other partners. Countries should establish IHR financing mechanisms by developing financing plans that will help identify and secure domestic funding and establish financial coordination mechanisms (22).

Countries can enhance their public health capacities and better protect their populations from local and global health threats if they implement the amended IHR comprehensively and consitently.

References

1. World Health Organization. WHO’s Health Emergency Appeal 2024. Cairo: WHO Regional Office for the Eastern Mediterranean, 2024. https://cdn.who.int/media/docs/default-source/documents/emergencies/2024-appeals/emro---who-2024-health-emergency-appeal.pdf?sfvrsn=87255e2d_1&download=true#:~:text=The%20Eastern%20Mediterranean%20Region%20(EMRO,who%20have%20been%20forcibly%20displaced.
2. Al-Mandhari A. Achieving "Health for All by All" in the Eastern Mediterranean Region. East Mediterr Health J. 2019 Oct 13;25(9):595-596. doi: 10.26719/2019.25.9.595.
3. Elnosserrya S, Bulivaa E, Elkholya AA, Mahbooba A, Koyab SF, Abubakar A. Rapid response teams in the Eastern Mediterranean Region: Results from the baseline survey of country-level capacities, operations and outbreak response capabilities. Global Public Health 2024;19(1):2341404. https://doi.org/10.1080/17441692.2024.2341404.
4. Al-Mandhari A, Hajjeh R. Health and healing in the Eastern Mediterranean Region: Progress on Vision 2023 and the priority health targets. East Mediterr Health J. 2024;30(7):467–469. https://doi.org/10.26719/2024.30.7.467.
5. United Nations Office for the Coordination of Humanitarian Affairs. Global Humanitarian Overview 2024. Geneva: OCHA. https://www.unocha.org/publications/report/world/global-humanitarian-overview-2024-enarfrsp#:~:text=In%202024%2C%20nearly%20300%20million%20people%20around%20the,need%20humanitarian%20assistance%20in%20East%20and%20Southern%20Africa..
6. Al Mandhari A. Earthquakes as triggers for public health disasters: WHO and health systems response. East Mediterr Health J. 2023;29(3):165–167. https://doi.org/10.26719/2023.29.3.165.
7. World Health Organization. WHO’s work in health emergencies: Public health emergencies, preparedness and response. Report by the Director-General. Geneva: World Health Organization, 2023. https://apps.who.int/gb/ebwha/pdf_files/EB154/B154_14-en.pdf.
8. Balkhy H. Increasing access to healthcare in the Eastern Mediterranean Region. East Mediterr Health J. 2024;30(2):91–92. https://doi.org/10.26719/2024.30.2.91.
9. World Health Organization. oPt Emergency Situation Update, Issue 41. Sitrep_-_issue_41b.pdf (who.int).
10. Balkhy H. Gaza cannot wait any longer. East Mediterr Health J. 2024;30(4):253–254. https://doi.org/10.26719/2024.30.4.253.
11. United Nations Office for the Coordination of Humanitarian Affairs. Deyr Rainy Season 2023. Flash Update No.5, 24 January 2024. https://reports.unocha.org/en/country/somalia/card/2kRpDKNEAs/.
12. World Health Organization. IHR States Parties Self-Assessment Annual Report (SPAR). Geneva: World Health Organization, n.d. https://www.who.int/emergencies/operations/international-health-regulations-monitoring-evaluation-framework/states-parties-self-assessment-annual-reporting.
13. Haji-Jama S, Moen A, Khan W, et al. Turning crisis into opportunity: sustaining COVID-19 gains in resource-constrained and fragile settings. BMJ Glob Health 2024;9:e015048. doi:10.1136/bmjgh-2024-015048.
14. World Health Organization. International Health Regulations (2005). Geneva: World Health Organization, 2005. https://www.who.int/publications/i/item/9789241580496.
15. WHO Executive Board Decision 150(3) (2022). https://apps.who.int/gb/e/e_eb150.html
16. World Health Organization. Review Committee on the Functioning of the International Health Regulations (2005) during the COVID-19 Response. Geneva: World Health Organization, 2021. https://www.who.int/teams/ihr/ihr-review-committees/covid-19/
17. World Health Organization. World Health Assembly Decision WHA75(9). Geneva: World Health Organization, 2022. https://apps.who.int/gb/e/e_wha75.html
18. World Health Organization. Working Group on Amendments to the International Health Regulations (WGIHR). (2022). https://www.who.int/teams/ihr/working-group-on-amendments-to-the-international-health-regulations-%282005%29
19. World Health Organization. Article-by-Article compilation of proposed amendments to the International Health Regulations (2005) submitted in accordance with decision WHA75(9) (2022). Geneva: World Health Organization, 2022. https://apps.who.int/gb/wgihr/pdf_files/wgihr2/A_WGIHR2_7-en.pdf.
20. World Health Organization. International Health Regulations (2005). Resolution A77/A/CONF./14 on amendments. Geneva: World Health Organization, 2024. https://apps.who.int/gb/ebwha/pdf_files/WHA77/A77_ACONF14-en.pdf.
21. World Health Organization. Strengthening health security by implementing the International Health Regulations (2005). Geneva: World Health Organization, 2020. https://iris.who.int/bitstream/handle/10665/359833/9789240048218-eng.pdf?sequence=1
22. World Health Organization. Proposal for a Coordinating Financial Mechanism under the IHR. Geneva: World Health Organization, 2023. https://www.who.int/news/item/01-06-2024-world-health-assembly-agreement-reached-on-wide-ranging--decisive-package-of-amendments-to-improve-the-international-health-regulations--and-sets-date-for-finalizing-negotiations-on-a-proposed-pandemic-agreement
23. Think Global Health. The new amendments to the International Health Regulations: The passage of a new IHR marks a key moment for global health governance. Governance, 4 June 2024. https://www.thinkglobalhealth.org/article/new-amendments-international-health-regulations.
24. United Nations. At World Health Assembly, countries agree on efforts to boost pandemic preparedness. UN News, 2 June 2024. https://news.un.org/en/story/2024/06/1150546.
25. World Health Organization. International Health Regulations: Implementation. Geneva: World Health Organization, n.d. https://www.who.int/health-topics/international-health-regulations#tab=tab_2.
26. Inter-Parliamentary Union. Strengthening health security preparedness: The International Health Regulations (2005). France: Inter-Parliamentary Union and the World Health Organization, 2022. https://iris.who.int/handle/10665/359833.
27. World Health Organization. Emergencies: Ten things you need to do to implement the International Health Regulations. Geneva: World Health Organization, 2014. https://www.who.int/news-room/questions-and-answers/item/emergencies-ten-things-you-need-to-do-to-implement-the-international-health-regulations.
28. World Health Organization. International Health Regulations Monitoring and Evaluation Framework (IHR MEF). Geneva: World Health Organization, n.d. https://www.who.int/emergencies/operations/international-health-regulations-monitoring-evaluation-framework.