Sweeping modifications to the International Health Regulations have come into effect from September 19, marking a turning point in the governance of global health. The reforms, born of hard lessons from the COVID-19 pandemic, signal a renewed international commitment to collective action in the face of public health emergencies. The IHR is a set of binding global rules that define the rights and responsibilities of 196 states parties — covering all 194 WHO members, plus Liechtenstein and the Vatican — on how to respond to cross-border health risks. The principle is straightforward: diseases travel faster than borders can stop them, and only coordinated global action can contain them.
The most striking change in the new International Health Regulations is the introduction of a new alert category—a “pandemic emergency.” It raises the alarm beyond a Public Health Emergency of International Concern (PHEIC), the mechanism used during outbreaks such as Ebola and COVID-19. A pandemic emergency applies when a communicable disease spreads widely across multiple states, overwhelms health systems, disrupts economies and societies, and demands urgent global coordination. The new category is designed to push governments towards earlier and more decisive cooperation, avoiding the costly delays seen during COVID-19. Governments will also designate National IHR Authorities to oversee implementation and coordination.
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Equity and access to health products
Equity is the second major theme of the amendments. The revised regulations commit member states to improving access to vaccines, diagnostics, treatments, and financing during emergencies. A new Coordinating Financial Mechanism will pool resources and direct them to developing countries, which often struggle to build and maintain the core health capacities demanded by the International Health Regulations.
This marks a departure from past practice, when financial assistance was routed through donor channels outside the IHR framework and often reflected donor priorities rather than recipient needs.
To strengthen implementation, the revisions establish a states parties committee to promote cooperation and resolve issues in applying the rules. The creation of National IHR Authorities in each country should also streamline coordination between governments and the WHO. These changes, though technical, are crucial to bridging the persistent gap between rule-making in Geneva and action on the ground.
A legacy of weakness and criticism
The International Health Regulations has deep roots in the 19th century, when the spread of cholera and plague through expanding trade routes prompted quarantine rules. Successive iterations — the International Sanitary Regulations of 1951, their renaming as IHR in 1969, and the overhaul after SARS in 2005 — sought to balance public health safeguards with minimal disruption to trade and travel.
But the 2005 rules revealed limitations. They gave the WHO little authority beyond information-gathering and lacked mechanisms to deliver aid or guarantee access to health products. Critics argued that the IHR preserved a colonial legacy and did little to address the divide between developed countries and the Global South, which struggled to access vaccines and medicines during Ebola, Mpox, and COVID-19.
The pandemic treaty and pathogen sharing
Alongside the amended International Health Regulations, WHO member states in 2024 also adopted a draft pandemic agreement and are negotiating an annex on Pathogen Access and Benefit Sharing (PABS). The annex aims to ensure that in exchange for rapid access to pathogens and genetic data, companies and countries provide fair access to vaccines and treatments.
This remains contentious. Pharmaceutical interests and some governments resist binding commitments, and drafts have been watered down under lobbying pressure. At a time when WHO budgets are under strain, effective leadership will be required to push the treaty through ratification and implementation.
Sovereignty and rejections
Not all countries are on board. Eleven of the 196 IHR parties rejected the 2024 amendments. Slovakia formally disassociated itself; New Zealand, Russia, and Iran raised sovereignty concerns; and Argentina, Switzerland, and the Holy See also voiced objections. The United States, under its current policy stance, has withdrawn from WHO membership and stopped funding the agency.
The sovereignty issue is central. While the IHR sets global rules, national governments retain the right to legislate on health policy. The WHO serves as secretariat but has no enforcement power. This tension—between global coordination and national autonomy—has shadowed the IHR since its inception.
The amendments adopted in Geneva reflect both pragmatism and compromise. They acknowledge that “no one is safe until everyone is safe,” yet fall short of giving the WHO the authority or resources needed to enforce equitable outcomes. Whether the reforms succeed will depend on how seriously governments integrate them into national frameworks and whether they match solidarity with funding.
The pandemic era has unearthed a stark truth: global health is only as strong as its weakest link. The revised International Health Regulations offers a sturdier framework, but without political will and equitable financing, it risks becoming another well-meaning but underpowered set of rules.
Dr Joe Thomas is Global Public Health Chair at Sustainable Policy Solutions Foundation, a policy think tank based in New Delhi. He is also Professor of Public Health at Institute of Health and Management, Victoria, Australia. Opinions expressed in this article are personal.