Intended for healthcare professionals


Pandemic treaty: a chance to level up on equity

BMJ 2022; 377 doi: (Published 20 May 2022) Cite this as: BMJ 2022;377:o1279
  1. Clare Wenham, associate professor of global health policy1,
  2. Rebecca Reisdorf, policy associate2,
  3. Sumegha Asthana, co-founder, postdoctoral fellow23
  1. 1London School of Economics
  2. 2Women in Global Health
  3. 3Center for Global Health Science and Security, Georgetown University
  1. Twitter: @clarewenham @becca_reisdorf @SumeghaAsthana

The Intergovernmental Negotiating Body (INB) is in the midst of developing a blueprint for the proposed pandemic instrument: a political framework to prevent, detect, and respond to emerging infectious diseases and pandemics in the future. While the International Health Regulations 2005 (IHR) already exist to govern this transnational challenge, it has proven insufficient for government compliance during covid-19 where we have seen widespread contraventions of the obligations placed on states.1 Such contraventions have in turn contributed to the scale of the spread of covid-19 globally. Consequently, some governments have championed the idea of a pandemic instrument to ensure political commitment and adherence to public health and evidence based recommendations, know how and international legal requirements.23

One of the key principles which has underscored the pandemic instrument discussions—at the World Health Assembly Special Session, the 150th World Health Organisation Executive Board Meeting, and the INB’s public hearings—has been that of equity. Yet, in practice equity has not been related to access to and distribution of medical countermeasures, such as vaccines, in future pandemics.4 The failures of the patent based system and advance market commitments has undermined the success of global public goods approach such as COVAX. Many states, particularly those low and middle income countries that have suffered from being unable to purchase covid-19 vaccines, are demanding that equitable access and distribution is included into the pandemic instrument.

A more comprehensive equity must also be central to pandemic governance in the future, especially gender, racial, geographical, and socio-economic equity. These intersectional areas of policymaking have been widely ignored in previous infectious disease protocols, to the detriment of marginalised communities that are most affected by downstream effects of inequitable and neutral policies, based on assumptions that all people experience health emergencies in the same way.

The gendered effects of covid-19 are by now well established; women, who make up 70% of the health and care workforce, have borne the brunt of the pandemic on the front lines. Violence, harassment, unequal pay, and lack of recognition have led women health and care workers to leave their professions at disproportionate rates, with some estimates showing one in three planning to transition out. The world was facing an 18 million health worker shortage at the start of the covid-19 pandemic, and this situation has worsened significantly over the past two years. Women are the cornerstone of the health systems in which they work, yet they are currently not present equitably in pandemic preparedness, response, and recovery discussions or leadership.

In addition, women have lost their jobs at a greater rate than men since 2020, with women disproportionately being employed in sectors of the economy that suffered shutdowns (such as retail, hospitality, and tourism), and in other areas of the economy women have lost jobs as they have absorbed the additional care burden associated with school closures. At the same time, many women lost access to sexual and reproductive health services, deemed “non-essential” in the first waves of the pandemic, and global trends of domestic violence have soared as women have been exposed to danger when lockdown orders were issued.567

These effects are not uniform; we know that women earning lower incomes were more likely to have lost their jobs than those who earn more; we know that single mothers were especially vulnerable to school closures; black, asian and minority ethnic women are disproportionately employed in the health and care sector and thus have suffered considerable health, mortality, and mental health burdens associated with working on the front line of the pandemic.

Furthermore, these effects are not new; we saw similar trends during Ebola, Zika, pandemic influenza, and before this, yet they had not been recognised by global policymakers when crafting previous governance frameworks for epidemics, such as the IHR. The IHR is particularly gender blind, and efforts have subsequently been made by the WHO to overcome this, such as the creation of a gender working group within the Health Emergencies Programme.8 However, in light of the widespread evidence now available as to the unequal effects of the pandemic, ensuring gender and racial equity must be prominently included into the pandemic instrument negotiations. Women cannot afford for the same mistakes to be made again by gender neutral or gender blind policies.

While governments are in the process of determining substantive content for the pandemic instrument we suggest the following would go a long way to towards recognising and addressing the disproportionate impact of pandemics on women:

  1. Adopt feminist principles of equity, equality, autonomy, empowerment, meaningful participation, and inclusion as central to both the content of the treaty, and the process by which the treaty is negotiated and will be implemented.

  2. Ensure that a rights based approach is central to the treaty, ensuring equity for all peoples.

  3. Ensure participation of Civil Society Organisations are taken into the process and they are able to meaningfully contribute to the INB and negotiation process.

  4. Ensure that any governance body, decision making body, or expert and advisory committee have gender parity, including women health workers, with a particular focus on women participants from low and middle income countries.

  5. Ensure that a gender and equity adviser is brought into the process of the treaty negotiations to ensure that women’s needs are identified and championed during the process.

  6. Recognise that most of the healthcare workforce required to prevent, detect, and respond to a pandemic are women (70% and 90% on the frontlines), and ensure that they receive equal and decent pay, especially community health and frontline workers; safe and decent working conditions, are free from violence and harassment at work, have access to adequate health services, including mental and psychosocial health services, and that provision of support for their domestic care work are made available to them during future pandemics.

  7. Consider the mechanisms by which gender has been mainstreamed into other treaty processes, such as that of the ​​Intergovernmental Panel on Climate Change (IPCCC), to understand how best to do this, and what pitfalls may exist.

  8. Consider mechanisms to ensure that risk assessments / equality impact assessments are required at different stages of an epidemic curve requiring a whole of government approach to identify and mitigate the potential impact of an epidemic across vulnerable sectors of society


  • Competing interests: none declared.


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