Developing and Validating a Global Governance Framework for Health: A Delphi Consensus Study

TL;DR

This study creates a governance framework to improve global health coordination and pandemic preparedness by addressing gaps in leadership, equity, and accountability.

Contribution

The study introduces a validated Global Governance for Health (GGFH) Framework to complement and strengthen the WHO Pandemic Agreement.

Findings

All seven governance domains achieved consensus among experts by Round 3 of the Delphi study.

High agreement was reached on strengthening WHO leadership and equitable financing mechanisms.

Financing, equity, and legal frameworks were identified as core enablers for effective treaty implementation.

Abstract

Public health relevance—How does this work relate to a public health issue?
The study addresses persistent global governance failures exposed during COVID-19, including inequity, weak coordination, and limited accountability mechanisms that undermine global health security.It evaluates the WHO Pandemic Agreement through an evidence-based governance lens, identifying operational gaps that directly affect preparedness and public health protection.

The study addresses persistent global governance failures exposed during COVID-19, including inequity, weak coordination, and limited accountability mechanisms that undermine global health security.

It evaluates the WHO Pandemic Agreement through an evidence-based governance lens, identifying operational gaps that directly affect preparedness and public health protection.

Public health significance—Why is this work of significance to public health?
The GGFH Framework shifts pandemic preparedness from a health-sector focus to an integrated governance-for-health model, enabling coordinated action across health and non-health sectors.The GGFH Framework attempt to complement the implementation of the WHO Pandemic Agreement by addressing partially resolved areas, providing practical governance solutions to gaps in financing, accountability, equity, and cross-sectoral coordination.

The GGFH Framework shifts pandemic preparedness from a health-sector focus to an integrated governance-for-health model, enabling coordinated action across health and non-health sectors.

The GGFH Framework attempt to complement the implementation of the WHO Pandemic Agreement by addressing partially resolved areas, providing practical governance solutions to gaps in financing, accountability, equity, and cross-sectoral coordination.

Public health implications—What are the key implications or messages for practitioners, policy makers and/or researchers in public health?
The GGFH offers policymakers a validated governance alternative that replaces fragmented, market-driven responses with a model based on global public goods, enforceable obligations, and shared accountability.A phased implementation approach is recommended, prioritizing foundational legal, leadership, and financing reforms to enable effective rollout of subsequent equity, accountability, and cross-sectoral measures.

The GGFH offers policymakers a validated governance alternative that replaces fragmented, market-driven responses with a model based on global public goods, enforceable obligations, and shared accountability.

A phased implementation approach is recommended, prioritizing foundational legal, leadership, and financing reforms to enable effective rollout of subsequent equity, accountability, and cross-sectoral measures.

Background: The COVID-19 pandemic exposed major deficiencies in global health governance, including fragmented authority, inequitable resource distribution, and weak compliance mechanisms. Although the WHO Pandemic Agreement (2025) addresses several of these gaps, significant operational and institutional challenges remain. This study aims to develop and empirically validate a Global Governance for Health (GGFH) Framework that strengthens leadership, financing, equity, and legal accountability across global, regional, and national levels. Methods: A three-round Delphi study was conducted. Thirty-one experts from diverse sectors, including public health, international law, economics, environment, and diplomacy, evaluated 32 structured governance statements across seven domains. Experts rated all statements using a 7-point Likert scale. Consensus was determined using a strict threshold median ≥ 6; SD ≤ 1.35; ≥75% agreement. Open-text comments were systematically reviewed through thematic analysis. All statements were systematically mapped to the WHO Pandemic Agreement articles to identify areas lacking operational clarity or enforceability. Results: All seven governance domains achieved consensus by Round 3. High agreement emerged on strengthening WHO leadership, implementing sustainable and equitable financing mechanisms, embedding LMIC representation, establishing legal preparedness and capacity-building, and integrating independent accountability tools. Correlation and interdependence analyses demonstrated that governance goals form an integrated, mutually reinforcing system, with financing, equity, and legal frameworks identified as core enablers of effective treaty implementation. Conclusions: The Delphi process validated a comprehensive and operational Global Governance for Health Framework. The GGFH complements the WHO Pandemic Agreement by addressing its unresolved governance, financing, and equity limitations and offers a structured roadmap to guide global pandemic preparedness and treaty implementation.

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