Functioning of the International Health Regulations During the COVID-19 Pandemic

The International Health Regulations (IHR), which entered into force in 2007, were designed to strengthen global capacity to prevent, detect, and respond to public health threats. Framed as a legally binding agreement among the World Health Organization (WHO) Member States, the IHR aims to support national preparedness while enabling coordinated international alert and response to health emergencies.

During the prolonged and unprecedented COVID-19 pandemic, the effectiveness of the IHR has been widely questioned. Critics argued that the Regulations constrained rapid action and failed to keep pace with the scale and speed of the crisis. However, findings from the Review Committee on the Functioning of the IHR (2005) during the COVID-19 Response offer a more nuanced assessment, shifting the focus from regulatory design to implementation failures.

This article reflects on those findings and the implications for strengthening global health governance, drawing on the work of the IHR Review Committee, which brought together 20 experts with diverse public health expertise from around the world.

International Health Regulations and COVID-19: What Went Wrong in Practice

The IHR Review Committee found that the Regulations themselves remain fundamentally sound and appropriate for managing public health emergencies. Rather than structural deficiencies within the IHR, the COVID-19 response revealed persistent shortcomings in how the Regulations were applied by Member States and operationalized by the WHO.

Many countries implemented the IHR only partially, lacked sufficient awareness of their obligations, or chose to disregard specific requirements. At the same time, the WHO did not consistently make full use of the authority granted under the IHR, both in letter and in spirit. These combined gaps significantly weakened the global response during the early and most critical phases of the pandemic.

Within its mandate, explicitly focused on IHR-related aspects of the COVID-19 response, the Review Committee identified a collective failure across three interrelated domains:

Compliance, Accountability, and Empowerment

Inadequate compliance with IHR obligations, particularly those related to preparedness and core public health capacities, contributed to COVID-19 evolving into a protracted global crisis. The Committee underscored that IHR implementation must be elevated to the highest levels of government and embedded within a whole-of-government approach to health security.

Central to this effort is the strengthening of IHR national focal points. These entities must be institutionally positioned, adequately resourced, and granted sufficient authority to engage across sectors during emergencies. Without robust national legal frameworks aligned with the IHR, effective preparedness and response remain out of reach.

To address persistent gaps, the Committee highlighted the need for stronger review and accountability mechanisms. Periodic, obligatory assessments of national IHR capacities, similar in spirit to universal periodic reviews in other international governance frameworks, could play a critical role in improving compliance and transparency.

Early Alert, Notification, and Response

Timely alert and response are essential to triggering meaningful global action. Yet during COVID-19, early warning systems did not function as intended. Initial reporting from several countries was incomplete, and delays in recognizing human-to-human transmission, including asymptomatic and pre-symptomatic spread, undermined early containment efforts.

Despite the WHO issuing risk assessments, technical guidance, and early warnings, including the declaration of a Public Health Emergency of International Concern, many national responses were slow or insufficient. The Review Committee concluded that introducing additional alert levels would not have resolved these challenges. Instead, more consistent adherence to existing IHR obligations could have enabled faster, more decisive action.

The Committee also emphasized that trust, collaboration, and routine engagement between countries and the WHO, outside crisis periods, are essential to improving early alert and response. Strengthening established networks and information-sharing mechanisms remains a priority.

Political Will and Sustainable Financing

Effective implementation of the International Health Regulations depends on sustained political commitment and predictable financing at national and international levels. The Review Committee noted that resources allocated to IHR implementation, including within the WHO itself, remain limited and inconsistent.

As of early 2021, the WHO’s IHR-related functions were supported by approximately 200 full-time staff equivalents, fewer than the staffing levels of some national public health institutes. This imbalance highlights the need for Member States to provide the WHO with a stronger mandate and more stable funding to fulfil its global health protection role.

Strengthening the IHR for Future Health Emergencies

In April 2021, the Review Committee issued 40 recommendations across ten thematic areas to strengthen IHR implementation. These include enhancing legal preparedness, improving data sharing and risk assessment, clarifying responsibilities related to travel measures, advancing digitalization and communication, and reinforcing compliance and accountability frameworks.

The Committee also recognized the potential value of developing a global, legally binding convention on pandemic preparedness and response. Such a framework could complement the IHR by addressing gaps related to equitable access to countermeasures, global supply chains, and the management of zoonotic risks.

Moving from Lessons to Action

The COVID-19 pandemic demonstrated that global health security is only as strong as the collective commitment to uphold shared rules and responsibilities. The functioning of the International Health Regulations during the COVID-19 pandemic shows that the challenge lies not in the absence of guidance but in the failure to fully implement what is already agreed upon.

The evidence is clear, the recommendations are well established, and the path forward is known. What is now required is decisive action by Member States and by the WHO to translate the lessons of COVID-19 into a more resilient, accountable, and effective global health system.

Reducing Maternal Mortality in Low- and Middle-Income Countries Through Skilled Birth Attendants

Maternal mortality remains one of the most urgent and preventable global health challenges. Despite decades of international commitments, women in low- and middle-income countries (LMICs) continue to face an unacceptably high risk of death during pregnancy and childbirth. Increasing access to skilled birth attendants (SBAs) is one of the most effective and evidence-based strategies to reduce maternal mortality and advance global health equity.

Maternal Mortality as a Global Health Priority

The World Health Organization (WHO) has long identified maternal mortality as a global priority for improving global health outcomes. Maternal mortality is defined as the “death of a woman while pregnant or within 42 days of the end of pregnancy…from any cause related to or aggravated by the pregnancy.”

The United Nations Millennium Development Goal 5 (MDG5), which aimed to reduce the global maternal mortality ratio (MMR) by three-quarters, was not met by its 2015 deadline. As a result, the burden of avoidable maternal deaths persists in many low-resource countries, rural areas, and disadvantaged communities.

Current trends show a global maternal mortality ratio of 211 maternal deaths per 100,000 live births. In low- and middle-income countries, as defined by the World Bank, this ratio exceeds 800 maternal deaths per 100,000 live births. This unacceptable death toll highlights the urgent need for further action in resource-poor countries to address the major causes of maternal death and end avoidable maternal mortality by increasing investment, access, and equity in skilled birth attendants for all.

Background: Causes of Maternal Mortality in LMICs

According to the World Health Organization, the leading global causes of maternal death include hemorrhage, hypertension, and sepsis. A WHO systematic analysis identifies post-partum hemorrhage as the leading cause of maternal death in LMICs and worldwide, accounting for 21.7% of all maternal deaths.

Post-partum hemorrhage is preventable mainly with access to appropriate resources and timely care. However, when it occurs, hemorrhaging can lead to death in less than two hours. This makes it both one of the most preventable and most emergent maternal health complications. Focusing on this specific cause allows policy efforts to narrow their scope and target areas where intervention can have the most significant impact.

Global Commitments and Sustainable Development Goal 3.1

This policy statement is informed by the call to action outlined in Sustainable Development Goal (SDG) 3.1. Developed by the United Nations to extend and deepen the Millennium Development Goals, SDG 3.1 commits member states to reducing global maternal mortality and achieving a more sustainable and healthier future by 2030.

While global improvements have been achieved, maternal mortality declined by 38% over 17 years, with an average annual reduction of 3%. Progress remains uneven. These improvements are likely due to increased awareness, technological advancements, and improved access to healthcare resources in certain regions. However, maternal mortality continues to be a significant cause of death in LMICs, underscoring the continued relevance and urgency of SDG 3.1.

The Role of Primary Prevention and Health Systems Strengthening

Primary interventions addressing family planning, including contraception use, education, and access to legal and safe abortion services, have contributed significantly to reductions in maternal mortality. Research published in the Maternal and Child Health Journal indicates that the indirect effects of contraception use have saved one million lives in high-risk areas.

The Indonesian Family Planning Program demonstrates the impact of primary prevention. If similar programs were implemented in low-income areas, unmet family planning needs could be reduced from 10% to 7%, preventing more than 37,000 maternal deaths.

Despite these gains, achieving SDG 3.1 requires addressing unmet needs within health systems to reduce risks during pregnancy and childbirth. Improvements in skilled delivery and healthcare environments alone could reduce maternal mortality ratios by an additional 19–20%.

Skilled Birth Attendants and Maternal Mortality Reduction

While global progress has been made, LMICs (particularly in Sub-Saharan Africa) continue to experience disproportionately high maternal mortality rates. Sub-Saharan Africa accounts for nearly two-thirds of all maternal deaths worldwide. These regions face persistent challenges related to inadequate, inaccessible, and inequitable healthcare resources.

Skilled delivery is a critical intervention for reducing preventable maternal complications. The World Health Organization defines skilled birth attendants as accredited health professionals, such as midwives, doctors, or nurses, who have been educated and trained to a high level of proficiency. Evidence shows that where 100% of births are attended by skilled health staff, maternal mortality ratios fall to fewer than five deaths per 100,000 live births. This strong correlation underscores the life-saving impact of skilled birth attendance.

Purpose and Scope of the Policy Statement

The purpose of this policy statement is to bridge the gap in maternal mortality outcomes between high-income and low- and middle-income countries, in alignment with Sustainable Development Goal 3.1. The goal aims to reduce the global maternal mortality ratio to fewer than 70 deaths per 100,000 live births by 2030, using indicators such as MMR and the proportion of births attended by skilled health personnel.

Women in high-income countries face a 1 in 5,400 chance of dying from a maternal complication, compared to a 1 in 45 chance in low-income settings. These disparities must be addressed by expanding access to quality care, reducing avoidable maternal deaths, improving MMR outcomes in LMICs, addressing urban-rural inequities, and strengthening future healthcare resources. According to the United Nations, investing in health systems could save up to 5 million mothers’ lives.

Target Areas for Intervention

Low- and middle-income countries account for 94% of all maternal deaths globally. Sub-Saharan Africa contributes two-thirds of these deaths, while South Asia accounts for one-fifth, together representing 86% of global maternal mortality.

High-priority countries include South Sudan, Somalia, the Central African Republic, Yemen, Syria, Sudan, the Democratic Republic of Congo, Chad, Afghanistan, Haiti, Guinea, Nigeria, and Ethiopia. Maternal mortality ratios in these countries range from 31 to 1,150 per 100,000 live births.

Within these regions, rural and Indigenous populations face an 80-percentage-point gap in skilled birth attendance and a 25-percentage-point gap in antenatal care and education. Similar disparities exist in high-income countries, including the United States, where socioeconomic and racial inequities drive higher maternal mortality rates in low-income and Black communities.

Policy Context and Precedents

This policy builds on prior international efforts, including the American Public Health Association’s 2011 Call to Action to Reduce Global Maternal, Neonatal, and Child Morbidity and Mortality. That policy emphasized political commitment, targeted funding, professional competency, and program evaluation to address stalled progress toward MDG5.

It also aligns with the World Federation of Public Health Associations’ policy statement Reducing Maternal Mortality as a Human Right, which calls for stronger government accountability, improved health systems, enhanced policy research, and the promotion of gender equity. This statement advances those recommendations explicitly by focusing on skilled birth attendants, training, and access to essential equipment in low-resource settings.

Recommendations to Reduce Maternal Mortality Through Skilled Birth Attendance

To address the ongoing maternal mortality crisis in low-resource areas and close gaps in achieving the Millennium and Sustainable Development Goals, it is recommended that governments and advocacy organizations:

• Increase skilled birth attendance to more than 90% in areas where coverage is currently below 50%.
• Expand healthcare utilization in the poorest LMIC regions with the highest maternal mortality ratios.
• Improve access to essential supplies, medications, and hygienic clinical practices.
• Promote and support maternal healthcare training programs in low-resource districts.
• Strengthen primary prevention contraception programs.
• Require national antenatal care and skilled birth attendance guidelines, including licensing and regulation.
• Develop comprehensive strategies for skilled attendant provision, including clinic locations, staffing, monitoring, and training.
• Enhance capacity building and cultural competency in maternal healthcare settings.
• Leverage UN agencies, the WHO, the World Bank, and other multilateral organizations to inform stakeholders.
• Ensure access to life-saving medications such as Misoprostol and simple blood-loss management tools to prevent deaths from post-partum hemorrhage.

Advancing Equity in Maternal Health

Reducing maternal mortality in low- and middle-income countries is both a public health imperative and a matter of human rights. Expanding access to skilled birth attendants, strengthening health systems, and addressing inequities across populations are essential steps toward ending preventable maternal deaths and achieving Sustainable Development Goal 3.1.

Climate Change and Public Health: Why the Climate Emergency Is a Health Emergency

Climate change is no longer a distant threat. It is a present and accelerating crisis undermining health, safety, and well-being worldwide. As extreme weather intensifies, global temperatures rise, and environmental systems destabilize, the consequences for human health grow more severe. The World Federation of Public Health Associations (WFPHA) issues this call to action to highlight the urgent need for governments, institutions, and health leaders to confront the accelerating climate emergency with decisive, health-centered policies.

The Climate Crisis: A Global Failure With Human Consequences

Since the adoption of the Sustainable Development Goals (SDGs) in 2015, progress has been significantly hindered by accelerating climate change. Although solutions exist, global action has been too slow, fragmented, and insufficient to safeguard population health. Scientific evidence shows that:

• Global warming is accelerating, driving extreme heat, catastrophic fires, severe storms, droughts, and flooding.

• Disruptions across land, water, and ecosystems are worsening faster than anticipated.

• Opportunities for meaningful intervention are narrowing, as climate extremes become more frequent and intense.

The health risks are profound. Climate change affects food security, water quality, air quality, housing stability, and economic livelihoods, all of which are critical determinants of health.

Children: The Most Vulnerable Victims of Climate Change

UNICEF calls climate change the defining challenge for children’s rights. Nearly 1 billion children live in areas at extremely high risk from climate impacts. Many face overlapping threats such as:

• Flooding

• Heatwaves

• Water scarcity

• Disease outbreaks

• Poor air quality

Because children will experience climate impacts for longer and more intensively than adults, climate inaction constitutes severe intergenerational injustice.

Scientific Consensus: Human Influence Is Unmistakable

Despite decades of warnings, global emissions continue to rise. The IPCC confirms:

• Each of the last four decades has been warmer than the one before.

• Global temperatures have already increased by about 1.1°C above pre-industrial levels.

• Warming over land is even higher, posing heightened threats to health and safety.

Recent climate disasters, including heatwaves, fires, and severe storms, would be nearly impossible without human-induced warming.

The Mounting Toll: Water Scarcity, Disasters, and Economic Loss

Freshwater scarcity, already affecting billions, is expected to worsen dramatically. Extreme weather events have increased fivefold in the past 50 years, causing:

• 2.06 million deaths

• $3.6 trillion USD in economic losses

• Disproportionate impacts on developing nations

These inequities represent a profound moral and public health failure.

A Clear Path Forward: Mitigation and Adaptation

Even if emissions stopped today, warming would continue due to high atmospheric CO₂ levels. Therefore, climate resilience requires:

• Mitigation – drastically reducing greenhouse gas emissions.

• Adaptation – preparing health systems, communities, and infrastructure for unavoidable impacts.

Renewable energy, sustainable food systems, water preservation, and reduced consumption are essential pathways to a healthier, more resilient world.

The Economic Case for Climate Action

Climate mitigation not only protects lives but also yields immense economic benefits. Research shows that limiting warming to 2°C could prevent trillions in GDP losses annually and save millions of lives through:

• Cleaner air

• Healthier diets

• Increased physical activity

• Reduced climate-related disasters

The cost of inaction vastly outweighs the cost of solutions already available.

Global Inequity: Those Most Affected Contribute the Least

Low-income and climate-vulnerable countries face the most significant climate risks despite having contributed least to global emissions. Wealthier nations must:

• Provide financial support

• Honor climate finance commitments

• Invest in research and adaptation

• Address climate-related loss and damage

Mechanisms like the Green Climate Fund were designed for this purpose, yet contributions fall drastically short.

Strengthening the Public Health Response

Evidence gaps persist, especially in mental health, maternal health, child health, and impacts in low-income countries. Increased funding and research are urgently needed to guide effective interventions and support the world’s most vulnerable populations.

Why Immediate Action Is Essential

Climate change is harming health today and threatens to undermine the prosperity, safety, and stability of future generations. Governments, public health leaders, and community organizations must prioritize:

• Strong emissions reduction targets

• Rapid decarbonization

• Climate-resilient health systems

• Protection for vulnerable populations

• Public health leadership at every level

The science is unequivocal: human activity is driving climate change, and political inaction threatens catastrophic outcomes.

A Call for Health-Centered Climate Leadership

Health must be at the center of climate policy. Governments hold a responsibility not only to their citizens but to the global community and to future generations. Climate change is a health emergency—and addressing it is both a moral and practical imperative.

The WFPHA reaffirms its commitment to advocate for a healthier future and urges all partners, organizations, and health professionals to join in the effort.

Who Must Act Now

This call to action is directed toward:

• National and multilateral policymakers

• Local and regional government officials

• Public health associations and agencies

• Health care leaders and emergency planners

• Community organizations and NGOs

• Urban planners, infrastructure specialists, and social service providers

• Educational leaders and private-sector partners

These groups play essential roles in designing and implementing climate-healthy policies, reducing emissions, strengthening resilience, and protecting vulnerable populations.

Key Recommendations for Immediate Progress

• Set and enforce ambitious emission-reduction targets.

• Increase commitments to the Green Climate Fund and ensure contributions are fulfilled.

• Hold governments accountable for policies affecting health.

• Support decarbonization across energy, transportation, food systems, and investment markets.

• Advocate for equitable compensation for climate-driven loss and damage.

• Engage communities in developing localized resilience strategies.

• Restore ecosystems critical to water, food, and mental well-being.

• Integrate health considerations into all public policies.

Moving Forward Together

Climate change and public health are inseparable.

Recognizing this connection is essential to protecting lives and shaping a healthier, more equitable future. The WFPHA stands with global partners to demand immediate, effective, and equitable climate action, because the climate emergency is unequivocally a health emergency.

Policy Statement on Polio Eradication: The Last Battle?

Understanding Poliomyelitis and Its Global Impact

Poliomyelitis (polio) is an infectious viral disease that predominantly affects children under 5 years old. The virus spreads through person-to-person contact, primarily via the fecal-oral route or, less frequently, through contaminated food and water. It multiplies in the intestines and can invade the nervous system, causing permanent paralysis.

Approximately 1 in 200 infections results in irreversible paralysis, and 5–10% of paralyzed individuals die due to respiratory muscle immobilization. Despite this, 90% of infected individuals remain asymptomatic carriers.

There is no cure for polio; it is preventable only through routine childhood immunization.

Global Progress Toward Polio Eradication

In 1988, the World Health Assembly adopted a resolution calling for the worldwide eradication of polio, leading to the creation of the Global Polio Eradication Initiative (GPEI). National governments, the WHO, Rotary International, the CDC, UNICEF, the Bill & Melinda Gates Foundation, and Gavi, the Vaccine Alliance support this effort.

Since then, global cases of wild poliovirus have decreased by over 99%, from an estimated 350,000 cases in 2019 to 175 in 2020, and just 2 cases reported by mid-September 2021.

Countries Where Polio Remains Endemic

Polio remains endemic in Afghanistan and Pakistan (wild polio type 1, WPV1).

• In Pakistan, 72 of 468 (15%) environmental samples tested positive in 2017. In 2020, 84 cases of WPV1 were reported, and by mid-September 2021, one case had been recorded.

• In Afghanistan, WPV1 cases increased from 21 (2018) to 29 (2019) and 56 (2020). By mid-September 2021, one wild polio case had been reported.

WHO estimates that successful polio eradication will save USD $40–50 billion, while failure could result in 200,000 new cases annually within the next decade.

Recommendations to Address Current Challenges in Polio Eradication

Strengthen International Relations with Pakistan and Afghanistan

Pakistan and Afghanistan function as a single epidemiological zone due to significant cross-border population movements. Both countries have collaborated through joint Technical Advisory Group (TAG) meetings and have agreed to vaccinate children under ten at border points on the same day.

Further strategic efforts should include:

• High-quality, large-scale vaccination campaigns targeting core reservoir areas.

• Policies are shaped through collaboration between government and public-private partners, such as the National Highway Authority and media networks.

• Support for ongoing WHO and partner engagement with the new Afghan government and authorities in Pakistan.

Reach Under-Immunized Children Using Innovative Approaches

Reaching under-immunized children remains a significant challenge due to vaccine refusals, operational gaps, difficulties in tracking mobile populations, and challenges in following up when children are not at home.

To strengthen reach and immunization quality:

• Use digital tools such as GIS mapping and mobile-based monitoring to track outbreaks.

• Redesign door-to-door campaigns to prioritize border entry and exit points.

• Expand vaccination efforts to include non-health workers and migrant populations.

Maintain Continuity of Operations Across the Pakistan–Afghanistan Region

Although GPEI operations in Pakistan are well funded, efficiency is hindered by gaps in documentation within the public health delivery system. A lack of electronic immunization records complicates accurate tracking.

Key steps include:

• Conduct all external reviews within the immunization indicator’s 28-day average lifespan.

• Supplement finger-marking with immunization cards and digital records.

• Integrate polio surveillance with broader health services across both countries.

• Provide community services (such as hygiene kits and maternal/child care supplies) during polio campaigns.

Address the Dual Challenge of Polio and COVID-19

In 2020, GPEI paused polio activities to redirect resources to the COVID-19 response, during which polio cases resurged (84 in Pakistan, 56 in Afghanistan).

To address this dual burden, revised operational procedures should include:

• Water, Sanitation, and Hygiene (WASH) promotion

• Non-pharmaceutical infection control (masks, sanitizers, thermometers)

• Enhanced staff training for safe campaign implementation

Summary

Eradicating poliovirus in Afghanistan and Pakistan requires unified action across military, religious, governmental, and social institutions. It demands trans-disciplinary leadership that ensures transparent processes and upholds both security and primary health objectives. Strong national capacity is essential to meet global commitments and to ensure every child receives lifesaving vaccinations.

Key Messages

• Polio is a highly infectious viral disease that attacks the nervous system and can cause irreversible paralysis and death.

• There is no cure for polio; it can only be prevented through immunization.

• Polio remains endemic in two countries: Afghanistan and Pakistan.

• Failure to stop polio could result in as many as 200,000 new cases every year, for up to 10 years, across the world.

• Eradicating polio will save lives and could save USD $50 billion in low-to middle-income countries.

• Continued coordination among international organizations, NGOs, philanthropists, religious institutions, and governments is essential to eradicate polio finally.

References

1. World Health Organization. (2019, July 22). Poliomyelitis.

2. Global Polio Eradication Initiative. (2021, May 25). Polio + Prevention.

3. Elhamidi, Y., Mahamud, A., Safdar, M., Al Tamimi, W., Jorba, J., Mbaeyi, C., Hsu, C. H., Wadood, Z., Sharif, S., & Ehrhardt, D. (2017). Progress Toward Poliomyelitis Eradication – Pakistan, January 2016-September 2017. MMWR. Morbidity and mortality weekly report, 66(46), 1276–1280.

4. Polio Eradication Initiative. (2021). National Emergency Action Plan 2021.

5. Shah, S., Saad, M., Rizwan, M., Haidari, A., & Idrees, F. (2016). Why We Could Not Eradicate Polio from Pakistan and How Can We? Journal of Ayub Medical College Abbottabad – Pakistan, 28(2), 423-425.

6. Hussain, S.F., Boyle, P., Patel, P. et al. Eradicating Polio in Pakistan: an Analysis of the Challenges and Solutions to this Security and Health Issue. (2016). Global Health 12(63).

7. Pakistan, Pakistan Polio Eradication Programme, National Emergency Operations Centre. (n.d.). National Emergency Action Plan for Polio Eradication 2020.

WFPHA Working Groups: Welcoming New Chairs/Co-chairs and Thanking Outgoing Chairs

At WFPHA, our mission is to protect people, prevent diseases, and promote health and wellbeing. Our 10 diverse Working Groups help us achieve our mission through advocacy, collaborative work, and support. We are constantly overwhelmed by the efforts they put forth to uphold our mission and reach our universal goals.

Recently, we have had to say goodbye to two of our valued working group chairs, Prof. Raman Bedi (Oral Health) and Dr. Florian Stigler (Tobacco Control) as they take on their next venture. They have served us exceptionally well over the years, and we would like to thank them for their contributions within the WFPHA. They committed their time supporting WFPHA working groups and provided assisting through collective work and implementation. We appreciate their efforts and wish them a fruitful journey ahead.

As we say goodbye to some of our previous working group chairs, we also would like to give a warm welcome to those who have just joined: Hannah Marcus (Environmental Health), John Gannon (Tobacco Control), Leanne Coombe (Public Health Professionals’ Education and Training), and Timothy Mackey (Global Health Equity and Digital Technology).

We are excited to see the difference our new working group chairs/co-chairs will contribute to in global health. We hope this experience brings jubilation and achievement to both them and us!