For the last year, reforming the global health architecture in the hopes of delivering health more equitably has been top of mind. From the Pandemic Fund launch, to post-mortems on the ACT-A (the global body convened to develop COVID-19 interventions and ensure access to them), to the call for a new Pandemic Accord, a strong consensus had finally emerged that things need to change. 
 
Accordingly, this theme ran throughout the health-related proceedings at the UN General Assembly in September where High-Level Meetings (HLMs) on universal health care (UHC), Tuberculosis (TB), and Pandemic prevention, preparedness and response (PPPR) took place. 
 
Four key takeaways from the week stand out to AVAC:
 
Multilateralism is threatened.
Tensions between countries are incredibly high. Each day’s proceedings made clear that the spirit of diplomacy from previous years has waned. Given that there have already been UN Declarations on UHC and TB, advocates went into this year’s process thinking that stronger declarations would be relatively easy to negotiate. But countries were at odds during negotiations for all three health-related HLMs. Country representatives disagreed on a host of issues that will impact access to medical products, financing, and who is responsible for addressing health crises. These disagreements upended usual procedure. Typically, the Declaration is finalized weeks before the actual HLM; this year, a final decision on all three Declarations hung in the balance until the minute before the meetings began. Advocates must work hard in the coming year to bring countries together on key issues in the Pandemic Accord.
 
Access is THE issue.
By far, the question of access to medical products and tools dominated all three HLMs. Tensions around this issue sparked the most heated disagreements during negotiations. During the PPPR HLM, Member States speaking from the UN floor all mentioned their commitment to building more equitable access to medical countermeasures, but richer countries are unwilling to alienate the pharmaceutical industry by including access commitments in international agreements. And lower-income countries are refusing to permit open access to data on new pathogens without access commitments to the products derived from that data. The issue is so fraught it almost derailed any health Declarations at all. Right before HLM week, eleven countries that have been the target of ‘unilateral coercive measures’ (sanctions) sent a letter to the President of the General Assembly refusing to sign on to the declarations because the sanctions prevent them from accessing medical countermeasures — tools, medicines and equipment, needed in a health crisis. The Declarations ended up moving forward anyway with very limited commitments on how best to ensure access to medical countermeasures. It will be imperative for advocates to keep the issue of access front and center and help to navigate toward agreements that all countries can stomach.
 
Civil society engagement is going backward.
The PPPR HLM had no civil society formal engagement mechanism, and the process suffered because of it. Civil society was left out of the loop. They didn’t receive information about the status of negotiations, or details on sticking points. These updates would typically be funneled through a formal mechanism. In addition, the HLM process usually includes two to three days of Multistakeholder Hearings for each HLM to allow civil society to state their priorities and views ahead of negotiations on the draft Declaration. This year, each HLM had just one half-day, significantly limiting the number of civil society organizations and advocates that could get their views in front of Member States. Approvals for registration for both the Multistakeholder Hearings and HLMs came less than a month before the actual event, leaving many advocates too little time to get visas to the US. To add insult to injury, during the HLM, many civil society advocates did not get to make statements from the floor even though time was reserved for civil society – agencies such as Gavi and the Global Fund and pharmaceutical corporations spoke during these slots. Engagement with UN staff is needed to better define what constitutes civil society, and to protect these rare points of access and influence for those who speak for communities. 
 
Policymakers are starting to understand the contributions HIV, TB, and malaria can make to pandemic preparedness.
As the furor to address huge gaps in pandemic preparedness and response capacities ramped up in 2021, it was a slog to get policymakers new to the space, who had not traditionally been involved in health negotiations, to understand the underlying infrastructure and movements that the global responses to HIV, TB, and malaria have built. However, this year’s UN General Assembly showed that advocates have made a lot of progress. The Coalition of Advocates for Global Health and Pandemic Preparedness, of which AVAC is a co-founder, pushed hard for inclusion of these ongoing pandemics in the Declaration on PPPR to great success – two clauses recognizing the existing infrastructure from these responses that can be leveraged for pandemic preparedness and committing to continue the fight to end these ongoing pandemics made it into the final Declaration text. Much more needs to be done to harmonize the PPPR and HIV/TB/malaria architecture, saving advocates and everyone involved in pandemic preparedness extensive time and resources, but the recognition of the interconnectedness of future and ongoing pandemics represents a huge win.

At AVAC, we have put a lot of hope in the processes of the Pandemic Accord, the UN High-Level Meeting (HLM) on Prevention, Preparedness, and Response (PPPR), and the development of a medical countermeasures (MCM) platform. To understand how these three efforts fit together, see AVAC’s Advocate’s Guide to PPPR. 

And check out these other important resources:

• AVAC’s Executive Director, Mitchell Warren along with partners from the Coalition of Advocates for Global Health and Pandemic Preparedness penned an essay to make the case of meaningful investment in Pandemic Preparedness while referencing continued failures of the COVID-19 pandemic. 
• Sam Rick authored a piece, Who’s Driving this Ship, which takes a critical look at the issues challenging Global North governments in creating a system that is equitable and aims to prevent health threats everywhere and prepare everyone.
• Our Take: Is the UN Declaration on PPPR and the Pandemic Accord going in the right direction? AVAC’s blog explored the drafts of the Pandemic Accord and the UN Declaration on PPPR—and their implications for equity in global health.
• PPPR Advocacy 101: Find out what it means to you: For a deep dive on the diverse initiatives aimed at preparing for the next pandemic. Learn what they commit to, how much they will spend, and how well these plans incorporate equity as a principle.
• The Shape of Pandemic Preparedness is Being Decided. Now is the Time for Collective Action: In this episode of Px Pulse, Chris Collins, the CEO and President at Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, talks about what’s at stake in efforts to re-think the global architecture of pandemic response, which policy-makers get it, why this year matters so much, and what advocates can do.