The health crisis of COVID-19 has provoked a pivotal moment of global health law reform that comes against larger shifts against international law, democracy, and human rights. In this light, it is perhaps not surprising that state-led amendments to the International Health Regulations (IHR)—international law’s primary instrument governing state responses to public health crises—and a prospective Pandemic Agreement—designed to remedy the former’s defects—have shifted away from the language of human rights and toward the sweeping principle of equity. While these changes appear to herald an important normative and legal shift in international law, they also raise longer-standing questions about coherence and fragmentation in international law, and about the future of human rights within international law. In this essay, I first explore larger concerns around coherence and fragmentation in international law, and the practical manifestation of these threats in disparities in access to COVID-19 vaccines. Second, I consider the legal and political implications of the shift to equity in both instruments. I conclude by considering what this move may mean for coherence and human rights in international law.

The entry into force of the amendments to the International Health Regulations 2005 (IHR 2005), on September 19, 2025, represents a pivotal moment in global health emergency governance history.1 The COVID-19 crisis revealed the inability of both developed and developing nations to protect their populations from the pandemic. Developing nations experienced disproportionate impacts due to insufficient financial resources and manufacturing capacity to obtain necessary health products for pandemic response.2 The neoliberal emphasis on economic efficiency and enforced trade liberalization through the World Trade Organization (WTO) framework, particularly mandatory product patent protection under the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) widened inequities in access to vaccines, therapeutics and diagnostics (VTDs), and increased dependency of developing countries on developed countries for this access.3

COVID-19 starkly exposed the systemic frailties of global health governance, particularly concerning the functioning and utility of the International Health Regulations (IHR). Multiple independent reviews declared that the existing framework was designed to constrain rapid global action, and recommended concrete transformational reforms for the global health legal regime.1 Most notably they recommended the negotiation of a new instrument to govern future pandemic prevention, preparedness, and response (PPPR). The appetite for a new instrument was cemented by a statement of support from twenty-six other world leaders and the director-general of World Health Organization (WHO).2 From the start, there was a lack of clear unified vision for what a new treaty ought to achieve. This ideological rift generally fell along the North–South divide, something that continued throughout the negotiations of the treaty. Low- and middle-income countries (LMICs), suffering from the stark inequalities in vaccine access during the COVID-19 pandemic demanded embedding equitable distribution of life-saving health products into legally binding commitments. Meanwhile high-income countries (HICs) sought greater prevention and surveillance activities, determined to prevent spillover events from occurring and spreading in the first place.

For Global South countries who faced vaccine inequity during the COVID-19 pandemic, the development of an equitable Pathogen Access and Benefit Sharing (PABS) system is considered to be “at the heart of the political bargain”1 of a pandemic agreement, and is critically important to prevent a repetition of vaccine inequity in future pandemics. These countries want to ensure that they have equitable access to pandemic products developed using genetic sequence data (GSD) or digital sequence information (DSI) from their geographies. A repeat of pandemic history, where GSD was uploaded from the Global South (such as from China, and from Botswana in the case of the Omicron variant), with Global South countries receiving a lower proportion of vaccine supply, would be abhorrent.

The current trend of growing state disengagement from global governance institutions—seen as a threat to the World Health Organization—is not unfamiliar to the World Trade Organization (WTO). Over the past two decades, multilateral trade negotiation channels have increasingly given way to more selective partnerships, built around preferential alliances and strategic markets outside established global platforms. These alliances have taken shape through Regional Trade Agreements (RTAs)—treaties negotiated outside the WTO umbrella between two or more countries that facilitate trade and economic integration between them.1 Between 2015 and 2022, the number of RTAs in force rose from 290 to 385, both through major blocs—already formalized in large-scale regional trade integration, such as the European Union—and through bilateral arrangements between individual states or regional markets.2 Examples include, among others, the Comprehensive and Progressive Agreement for Trans-Pacific Partnership, recently expanded to twelve countries with the accession of the UK, and the new UK-India free trade agreement.

On August 14, 2024, the upsurge of mpox across more than a dozen African countries was declared a public health emergency of international concern (PHEIC).1 As is often the case, the World Health Organization’s (WHO) director-general made this determination on the basis of advice tendered by an expert committee convened under the International Health Regulations (IHR)—the world’s only international agreement on public health emergency prevention, preparedness, and response.2 The timing of this declaration, however, differed in one crucial respect from past PHEIC declarations: just one day earlier, the Africa Centres for Disease Control and Prevention (Africa CDC) had issued its own regional alert, designating the outbreak a “Public Health Emergency of Continental Security” (PHECS).3

In the field of “global health,”1 a sense of discomfort with the status quo and the systems and practices it upholds persists.2 This unease stems from the lopsided nature of power and resources to address health issues across the world.3 The authors accept the view that a system is what it reproduces, regardless of its best intentions.4 The concentration of disease and death amongst those with the least power to address them reflects clearly established causal links between inequitable systems and health outcomes,5 which have precipitated agitations for rectification of global health injustice. This has culminated in the clamor to “decolonize” global health,6 which has ranged from interrogations of the training practices of global health students and practitioners,7 to recommendations of better practices within the field,8 decentralization of power, and challenge to assumptions of expertise in the sites of practice and intervention.9 Given that power is largely a function of means, some have made suggestions to fundamentally address how the flow of resources shape the global health agenda, while prioritizing certain voices over others.10

Civil registration and vital statistics (CRVS) systems comprise two interdependent components: civil registration (CR) and vital statistics (VS). Civil registration records the occurrence and characteristics of vital events in a population, including births, deaths, fetal deaths, and cause of death information.1 Vital statistics compile and process the data derived from civil registration to analyze mortality trends, and track demographic patterns, such as birth and death rates.2