Pandemic Instrument Partner and Stakeholder Engagement Forum

Table of contents

• Executive summary
• Introduction
• Overview of attendees
• Thematic discussions
• Partner and stakeholder discussions
• Key takeaways
• Recommendations for further engagement
• Conclusion
• Annex: Discussion questions

Executive summary

In December 2021, the 194 World Health Organization (WHO) Member States, including Canada, agreed to launch an intergovernmental negotiating body to develop a new WHO convention, agreement or other international instrument on pandemic prevention, preparedness and response (a "pandemic instrument"). From March 21 to 22, 2023, the Office of International Affairs for the Health Portfolio hosted the Pandemic Instrument Partner and Stakeholder Engagement Forum to facilitate conversations with Canadian partners and stakeholders on issues that may be included in the Pandemic Instrument.

The Forum and attendees

The Forum took place in a hybrid format, welcoming 94 in-person participants in Ottawa and an additional 70 online. Attendees represented the following sectors:

• non-governmental organizations and not-for-profits (28%)
• academics, experts and researchers (27%)
• health and allied health services (14%)
• the private sector (13%)
• provincial, territorial, and Indigenous departments of health and health authorities (12%)
• youth (6%)

Attendees provided input on the following thematic issues in cross-sectoral breakout sessions:

• leadership and governance
• capacities to detect, understand, and act on public health emergencies
• health systems strengthening
• One Health
• equitable access to pandemic response products
• health equity and gender equality

Roundtable discussions were also held for each partner and stakeholder group to provide an opportunity for them to share their unique perspectives, priorities and concerns related to the Pandemic Instrument.

The Forum was just one step in Canada's engagement strategy and continues to inform how the federal government engages with partners and stakeholders, including how to ensure balanced representation and inclusive processes, as well as identifying the types of issues that are important to different stakeholder groups for future engagement. Canada will continue to engage with partners and stakeholders through a variety of mechanisms, as the development of the Instrument progresses.

Key takeaways

Several overarching messages emerged as key takeaways from the wide-ranging discussions that took place.

Embed equity in the process

Equity was part of nearly every discussion. Participants felt strongly that equity must be a primary consideration underpinning all aspects of the Pandemic Instrument and be central to its development process. Access to pandemic response products and services must be equitable and based on need, and equity must guide how pandemic preparedness and response measures impact marginalized groups and communities.

Ensure meaningful engagement from diverse voices

Meaningful, ongoing engagement throughout the development and implementation of the Pandemic Instrument will be necessary to ensure equity. All stakeholders, in particular marginalized groups and those most greatly impacted by pandemics and pandemic responses, must be represented. The voices of low- and middle-income countries (LMICs), Indigenous groups and frontline healthcare workers must be given prominence.

Be aware of colonial approaches

The Global North must work with LMICs, the Global South and Indigenous communities rather than do for them. Biased notions and practices must be avoided in areas such as health care recruitment, biosecurity, data extraction, intellectual property (IP) protection and the application of One Health principles.

Promote cooperation and collaboration

Jurisdictional boundaries are barriers to effective pandemic prevention, preparedness, and response (PPPR). The Instrument must promote the sharing of information, data, best practices, expertise and resources. Within Canada, provincial/territorial, federal agency and sectoral silos must be minimized to facilitate cooperation and cross-disciplinary research and collaboration.

Emphasize transparency, accountability and communication

Transparent processes and decision-making are key to building trust and ensuring equity. Stakeholder input must be represented in the document and acted on in its implementation. The Instrument must include common, measurable progress metrics to ensure accountability, status should be reported regularly and openly, and public education should be prioritized to improve the acceptance of public health measures and minimize the effects of disinformation.

Recognize the importance of data

Data and evidence must be central to future pandemic responses. Pathogen surveillance and monitoring must be conducted on an ongoing basis. Standards must be implemented to ensure data quality and global interoperability. Data must be shared with the international community without fear of negative repercussions and be used to inform policy making. Privacy must be protected and data sovereignty ensured.

Adopt a One Health approach

One Health requires collaboration and interdisciplinary cooperation among various sectors to tackle emerging and re-emerging zoonotic diseases. Prioritizing prevention, implementing recommendations, and addressing multisectoral issues are crucial for comprehensive surveillance and effective public health interventions. Tools, mechanisms, and resources are needed to help build capacity to implement a One Health approach.

Introduction

In December 2021, the 194 World Health Organization (WHO) Member States, including Canada, agreed to launch an intergovernmental negotiating body to develop a new WHO convention, agreement or other international instrument on pandemic prevention, preparedness and response (a "pandemic instrument"). Canada has been supportive of this process, as a stronger and better coordinated global health security architecture for disease outbreaks is essential to securing the health and safety of Canadians in a globalized world. Negotiations started in early 2023 and a progress report was presented at the 76th World Health Assembly in Geneva, Switzerland in May 2023. The development of a new pandemic instrument is expected to take until at least 2024.

Canada is taking a whole-of-government, whole-of-society approach in the development of the Instrument to ensure that Canadian priorities and values are reflected. Canada's partner and stakeholder engagement strategy aims to facilitate meaningful and inclusive engagement from provinces and territories, Indigenous organizations, academics and experts, civil society organizations, private sector, and youth.

From March 21 to 22, 2023, the Office of International Affairs for the Health Portfolio hosted the Pandemic Instrument Partner and Stakeholder Engagement Forum to facilitate conversations with Canadian partners and stakeholders on issues in the Pandemic Instrument. The Forum took place in a hybrid format, welcoming 94 in-person participants in Ottawa and an additional 70 online.

Attendees were welcomed by the Minister of Health and addressed by senior officials from the health and international development portfolios throughout the two-day event. They also heard from members of the Scientific Advisory Committee on Global Health (SAC-GH) on key issues including the impacts of COVID-19 on child health, lessons from the pandemic that will help protect the world from future emerging infections, applying a One Health approach, and the importance and application of equity in pandemic prevention preparedness and response (PPPR).

Breakout sessions were an opportunity for cross-sectoral dialogue on thematic issues, including:

• leadership and governance
• capacities to detect, understand, and act on public health emergencies
• health systems strengthening
• One Health
• equitable access to pandemic response products
• health equity and gender equality

Roundtable discussions were also held for each partner and stakeholder group to provide an opportunity for them to share their unique perspectives, priorities and concerns related to the Pandemic Instrument.

The Forum was just one step in Canada's engagement strategy and continues to inform how the federal government engages with partners and stakeholders, including how to ensure balanced representation and inclusive processes, as well as identifying the types of issues that are important to different stakeholder groups for future engagement. Canada will continue to engage with partners and stakeholders through a variety of mechanisms, as the development of the Instrument progresses.

Overview of attendees

Meaningful and inclusive engagement is important to Canada in the development of the Pandemic Instrument so that policy decision makers understand the needs, concerns, and perspectives of those that may be impacted by proposed measures and to ensure Canadian values and interests are reflected in any future agreement.

The Forum is one element of Canada's broader stakeholder engagement strategy and their first large multisectoral engagement. As a first step, Forum planners consulted relevant departments from across the Government of Canada, who had been regularly interacting with partners and stakeholders throughout the COVID-19 pandemic, to identify who might be interested in participating. Planners analyzed the list to ensure representatives from all relevant sectors and disciplines were included. As a result, over 600 invitations went out to a diverse range of partners and stakeholders. Invitees were also encouraged to recommend others who should be invited.

To promote balance among partner and stakeholder groups, a two-stage registration process was used, where an initial deadline was given with a set number of spots for each partner and stakeholder group. Following the initial deadline, spaces remained available, and registration continued on a first come-first served basis. Those who were unable to participate due to scheduling or space availability were invited to provide written input.

Out of the 200 registered participants, 164 participated in the event, with 94 attending in person and 70 joining virtually. The pie chart in figure 1 illustrates the breakdown of those who actively participated.

Provincial, territorial, and Indigenous departments of health and health authorities (12%) included chief public health officers, policy analysts, epidemiologists, health workforce managers, practitioners, and health emergency planners, among others.

Academics, experts and researchers (27%) came from 27 different institutions and organizations from across Canada, spanning a broad range of expertise, including but not limited to: health equity; gender and intersectionality; ethics; laboratory and clinical medicine; mental and psychosocial health; animal health and veterinary medicine; One Health; infectious diseases and antimicrobial resistance (AMR); health security; PPPR; global and public health; health systems; governance; health policy; international law; trade; supply chains; intellectual property (IP); and biomanufacturing.

Representatives from the health and allied health services sector (14%) were primarily composed of representatives from health professional associations representing physicians, nurses, paramedics, public health professionals, pharmacists, dental hygienists, long-term care, and Indigenous healthcare providers.

Private sector (13%) participants included representatives from biosafety, pharmaceutical, bio- and medical technology companies; environmental consulting; agriculture, agri-food, and livestock associations; and health insurance associations.

Participants from non-governmental organizations (NGOs) and not-for-profits (28%) included representatives from health, public health, animal health, and social services; health and global health policy and advocacy organizations; international development and humanitarian organizations; environmental organizations; research and research funding organizations; faith-based organizations; and organizations representing Indigenous peoples, women, black Canadians, and other marginalized populations.

Youth participants (6%) included representatives from youth organizations, youth working in global and public health, and youth in leadership positions.

Canada is taking a "responsive approach" to engagement and will use feedback received to guide their partner and stakeholder engagement strategy moving forward. The Office of International Affairs for the Health Portfolio thanks those who have submitted feedback on the Forum and welcomes constructive feedback as the development of the Instrument progresses.

Thematic discussions

Attendees were assigned to 1 of 4 groups to address questions on a series of 6 overarching themes, with each group addressing all of the themes. Themes included:

• leadership and governance
• capacities to detect, understand, and act on public health emergencies
• health systems strengthening
• One Health
• equitable access to pandemic response products
• health equity and gender equality

This report summarizes these discussions. Discussion questions are listed in the annex.

Leadership and governance

In addressing the complex challenges of PPPR, effective leadership and governance play a vital role. Participants discussed key approaches and mechanisms to encourage countries' long-term commitments, facilitate whole-of-government and whole-of-society approaches, and ensure the meaningful representation of low- and middle-income countries (LMICs) in decision-making processes.

Encouraging and supporting long-term commitments

To maintain and strengthen commitments on PPPR over the long term, including during inter-pandemic times, the following key strategies were recommended by participants:

1. Open communication and information sharing: Incentivize open communication and information sharing. This includes sharing data, best practices and lessons learned to facilitate collaboration and interoperability. Strategic communications plans should be developed and implemented and should include highlighting successes to maintain support for and interest in public health.
2. Transparency and accountability: Emphasize transparency and accountability to build trust, track and evaluate progress, and hold parties accountable, including through measurement and review mechanisms, such as audit tools.
3. Collaboration for enhanced PPPR: Foster better collaboration both nationally, among ministries and across stakeholder groups, and internationally, among states, NGOs, and the global research community. Multisectoral representation, including greater collaboration between the human health, animal health and environmental spheres, is imperative to promote a One Health approach to PPPR.
4. Funding and capacity building: Invest in capacity building at all levels and sectors, particularly in LMICs, to strengthen PPPR, with an emphasis on prevention. This includes preserving the systems and capacity developed in response to COVID-19. Adequate funding for LMICs, the WHO, civil society organizations, and social safety systems, are essential.
5. Ensuring firm commitments for a unified global response: Emphasize the necessity of a unified global response to effectively address pandemics. Strengthen language in the Instrument to ensure more binding commitments that prioritize public health.

Facilitating whole-of-government and whole-of-society approaches

To foster holistic approaches to PPPR, the following actions were recommended:

1. Communication and data sharing: Prioritize effective communication and data sharing to promote collaboration and coordination among stakeholders.
2. One Health approach: The importance of One Health should be recognized as it cannot be achieved without a whole-of-society approach.
3. Societal heterogeneity: Acknowledge the diversity of needs and perspectives within society to ensure inclusivity and equity in decision-making processes. Consider the overall health impacts beyond virus suppression, focusing on reducing mortality, morbidity, and societal damage.
4. Community engagement: Engage communities at the local level, including municipalities and public safety entities, and promote health literacy to enhance understanding of preventive measures.
5. Build on effective strategies: Learn from successful frameworks, such as those addressing AMR, to optimize efforts and streamline approaches.

Ensuring representation and expertise of LMICs

To empower LMICs and ensure their meaningful inclusion in decision-making processes, the following measures were recommended:

1. Avoiding paternalism: Acknowledge the valuable experience of LMICs in dealing with infectious diseases and avoid paternalistic approaches.
2. Inclusion of LMICs in decision-making: Include LMICs as participants, co-leaders, and co-designers in PPPR decision-making bodies; however, funding should be available to build capacity and ensure that participation is not a financial burden.
3. Inclusion of civil society organizations: Create better pathways for the inclusion of civil society organizations, amplifying their voices in shaping pandemic responses.
4. Supporting LMICs' unique challenges: Recognize the diversity of challenges across LMICs and provide support to address their specific needs, including the impacts of climate change.

Capacities to detect, understand, act on public health emergencies

This section explores key approaches recommended by participants to strengthen public health intelligence, integrate the One Health approach into public health surveillance and risk assessment, and improve data and information sharing for effective public health responses while safeguarding biosecurity and personal or confidential information.

Enhancing integration of public health intelligence

To better integrate public health intelligence for timely and appropriate response, several key strategies were identified:

1. One Health approach: Gathering of public health intelligence must integrate a One Health approach that employs both active and passive surveillance. Tools must be developed to efficiently connect veterinary, wildlife and human health data. The laboratory network for zoonotic diseases has little surge capacity, and its funding tends to be focused on research rather than ongoing support for public health.
2. Capacity building: Support should be provided to enable countries to rapidly collect and share data. Capacity must be enhanced through longitudinal rather than project-based funding. Community-based surveillance and the public health intelligence workforces need to be strengthened. Utilizing artificial intelligence (AI) technologies can aid in identifying signals in large datasets, improving early detection and response capabilities.
3. Collaboration and partnership: Foster collaboration between data collectors and interpreters to ensure accurate and comprehensive data analysis. Tools and platforms should be developed to promote collaboration among One Health sectors. Models such as the Global Public Health Intelligence Network and the Federal/Provincial/Territorial Public Health Response Plan for Biological Events can serve as valuable frameworks to build upon.
4. Data standardization and interoperability: Establish national and international data standards to enable interoperability across systems and facilitate the linking and amalgamation of datasets. Adhering to collection standards ensures data quality and the inclusion of relevant contextual metadata, enhancing the accuracy and usefulness of public health intelligence.
5. Eliminating disincentives and ensuring data sovereignty: Address disincentives for data sharing, including xenophobia and travel bans, by highlighting the benefits of data sharing for improved global health outcomes. Additionally, it is crucial to respect data sovereignty by recognizing ownership, control, access, and possession principles. This includes addressing concerns in LMICs regarding unauthorized data collection, commercial exploitation, and the equitable sharing of outputs.

Integrating a One Health approach

To better integrate a One Health approach into public health surveillance and risk assessment, the following strategies were highlighted:

1. Rethinking public health surveillance: Instead of imposing a One Health approach onto existing structures, there is a need for a more comprehensive and fundamental rethink of public health surveillance and risk assessment. This entails integrating fragmented data systems and enabling multidisciplinary analysis across human, animal, and environmental health domains. This undertaking may be complex but is necessary to effectively address emerging threats.
2. Leadership and coordination: Top-down leadership and coordination are essential to drive the integration of One Health into public health surveillance. This includes fostering collaboration between relevant sectors, agencies, and stakeholders to ensure a unified approach. Strong leadership will facilitate the alignment of policies, resources, and efforts towards a shared vision of One Health.
3. Addressing capacity challenges: Detecting signals and addressing gaps in low capacity settings, such as LMICs and remote areas, poses challenges.
4. Indigenous knowledge: Formal acknowledgement of Indigenous and locally-sourced knowledge will help, especially for animal and environmental health.
5. Monitoring of animal reservoirs: Improved monitoring of animal reservoirs will provide greater understanding of how diseases are amplifying or changing.

Improving data and information sharing

To improve data and information sharing for effective public health responses while safeguarding biosecurity and personal or confidential information, the following steps were identified:

1. Data governance and standardization: Establishing an international data governance structure that promotes integration, standardization, and interoperability is crucial. This framework should include provisions for de-identification of data to protect personal or confidential information. Mandating and auditing data collection and reporting processes can help ensure compliance and consistency.
2. Building capacity: Sharing best practices on health data governance and providing resources for data collection, especially in under-resourced settings, is essential. This includes promoting capacity building initiatives and technical assistance to enable effective data sharing practices across different regions and countries.
3. Transparency and public trust: Building transparency and public trust in how data is collected, stored, and shared is paramount. Engaging the public and stakeholders in discussions about data governance, privacy protection, and the benefits of data sharing can help foster acceptance and cooperation.
4. Clarifying the concept of biosecurity: There is a need to clarify the interpretation of the term "biosecurity" to avoid bias against LMICs and ensure that preserving public health is not compromised. It is important to strike a balance between biosecurity measures and principles of equity and solidarity.

Health systems strengthening

Discussions on health systems strengthening focused on the prioritization of specific health system building blocks, measurement of success in strengthening health systems, and critical supports necessary for LMICs to build response capacities and enhance health system resilience.

Priority areas to strengthen health systems

Health system building blocks are foundational elements for PPPR. However, it is difficult to identify which components should be prioritized as they are all interrelated and needs are context-specific so they must be assessed at the country level. However, there are a number of areas that could benefit from better global cooperation to further strengthen health systems, including:

1. Leadership and governance: Strong leadership and governance are essential for addressing system-level issues, such as improving the integration of services, enhancing frontline delivery of care, fostering partnerships with community organizations, and building public trust.
2. Health workforce: A healthy, robust, and well-trained workforce is important. Participants discouraged recruiting health professionals from other countries and suggested considering reimbursement to source countries facing a lack of capacity.
3. Building primary care capacity: Strong primary care serves as a necessary foundation for a well-functioning health system. Many people globally lack access to primary healthcare services, making it crucial to prioritize its development and accessibility.
4. Investing in public health systems: Investing in public health systems with a greater emphasis on prevention should be prioritized. This includes investing in health literacy; improving access to clean water, sanitation, and good nutrition; and better integrating data and health information systems.
5. Upstream determinants of health: Shifting the paradigm of health systems thinking to incorporate upstream environmental and social determinants of health is recommended. This broader perspective can help address the root causes of health disparities and improve overall population health.
6. Research and development: Incentivizing research and development, as well as building biomanufacturing capacities, plays a vital role in strengthening health systems and their ability to respond effectively to pandemics.

Measuring success

The measurement of success in strengthening health systems for PPPR requires a comprehensive approach that considers both quantitative and qualitative indicators. Participants emphasized the importance of contextual factors in defining and evaluating success.

1. Capacity of health systems: To assess the capacity of health systems, indicators such as staffing levels per population, measures of burnout among healthcare professionals, outpatient visit rates, hospital bed availability, laboratory capacity for diagnostic testing, field appointment capacities for rapid deployment of healthcare workers, and the effectiveness of health information systems in collecting, analyzing, and sharing data can be considered.
2. Preventative measures: Preventive measures are crucial in pandemic management. Indicators like compliance with public health protocols, surveillance systems for zoonotic diseases, and the level of trust-building within communities can provide insights into the success of prevention efforts.
3. Delivery of care: The delivery of care during a pandemic should be equitable, accessible, and responsive. Indicators to monitor include equitable access to healthcare services, vaccination rates, the availability and utilization of primary care, diagnostics, and treatment. Additionally, indicators such as patient satisfaction, quality of care measures, and the timeliness of response to disease outbreaks are valuable in assessing the effectiveness of health system responses.

In measuring success, it is essential to leverage existing indicators and evaluation frameworks, such as the Joint External Evaluation process under the International Health Regulations (IHR). Drawing from lessons learned during previous pandemics and conducting mock exercises to test preparedness can provide valuable data for assessing the effectiveness of health systems in preventing, preparing for, and responding to pandemics.

Strengthening LMICs response capacities and health systems resilience

Critical supports for LMICs to build response capacities for health crises and address systemic issues to increase health system resilience include:

1. Co-creation of solutions: Prioritization and risk assessment through collaboration and co-creation with LMICs are essential to ensure that responses are context-specific and aligned with the needs and capacities of each country. Building partnerships that involve local stakeholders and leveraging their expertise can lead to more effective and sustainable solutions.
2. Health systems strengthening: Support is needed to strengthen health systems and ensure universal access to quality healthcare services. This includes improving basic infrastructure, workforce development, PPE, health literacy, diagnostics, delivery of care, and addressing barriers to access.
3. Addressing social determinants of health: To increase health system resilience, it is important to address the underlying social determinants of health, such as poverty, inequality, education, and access to clean water and sanitation.
4. Mentorship programs: Establishing mentorship programs can facilitate knowledge and expertise sharing between countries. Stronger countries can provide support and guidance to address specific weaknesses in a given country, leveraging their strengths and experiences to build capacity and resilience in LMICs.
5. Financial assistance: Adequate financial resources are necessary to support the various efforts aimed at building response capacities and addressing systemic issues. Increased financial assistance from international partners, development agencies, and multilateral organizations can help LMICs strengthen their health systems and respond effectively to health crises.

Balancing aspirational and operational goals is crucial. While short-term operational focus is necessary to address immediate needs and build response capacities, setting aspirational goals can provide a long-term vision and drive progress towards achieving comprehensive and sustainable improvements in health systems and crisis response capabilities.

One Health

This section presents input on 3 key questions regarding Canada's role in enhancing cross-sectoral cooperation for the operationalization of a One Health approach to PPPR, and response, including ways to strengthen cooperation, address barriers, and Canada's role in bolstering One Health capacities globally, including in low- and middle-income countries.

Operationalization of One Health

To strengthen cross-sectoral cooperation and support the operationalization of a One Health approach in Canada, the following steps can be taken:

1. Build on existing partnerships and models: Learn from successful models and collaborations that have emerged from previous crises or initiatives, such as the AMR task force, Quadripartite structures, and climate treaties, to foster cross-sectoral cooperation.
2. One Health governance: Establish a One Health governance structure to facilitate a comprehensive and shared understanding of One Health across all sectors and develop a clear vision and goals for One Health initiatives, including mapping existing structures and resources and identifying gaps.
3. Establish inter-ministerial collaboration: Create formalized mechanisms for collaboration between different ministries and sectors to break down silos in funding, research, and programming.
4. Whole-of-society approach: Recognize and value the knowledge and perspectives of traditional, Indigenous, and LMIC communities in shaping One Health approaches, involving them in the process and ensuring their input informs decision-making. Include public engagement and education components in One Health initiatives to generate awareness and understanding of the concept.
5. Integration of animal health: Extend the scope of the Pandemic Instrument to include specific provisions for addressing animal health, including requirements for transfer of sequences, technologies, testing, and vaccines. There is a need for better collaboration in vaccine development between human and animal sectors.
6. Importance of data and surveillance: Threats of zoonotic diseases are not fully understood. Gaps in surveillance, particularly for domestic animals and wildlife, must be filled. Emphasize the importance of data sharing and interoperability while addressing industry concerns about IP risks.

Addressing barriers to One Health

To better manage the barriers to cross-sectoral cooperation in implementing a One Health approach, the following steps can be taken:

1. Clarify language and terminology: Clearly define the language and terminology used in the Pandemic Instrument to ensure a shared understanding across sectors. This will help avoid misunderstandings and facilitate effective collaboration.
2. Governance, leadership and collaboration: Establish a governance structure with a cohesive agenda, common goals, and standardized approaches. Foster a culture of collaboration and cooperation among different government departments and agencies, as well as with other sectors, breaking down silos and promoting shared ownership and leadership for One Health initiatives.
3. Ensure inclusivity: Expand the planning efforts to include rural, remote, and marginalized communities, ensuring that their specific needs and challenges are addressed in the implementation of a One Health approach.
4. Find a balance between private sector interests and public good: Develop mechanisms to address business interests and IP concerns that may hinder collaboration and information sharing. Finding a balance between commercial interests and the public good is crucial for effective cross-sectoral cooperation.
5. Facilitate information exchange: Establish mechanisms for cross-sectoral information exchange and collaboration, encouraging interactions between academia, industry, and government. This can be done through platforms, conferences, and partnerships that promote knowledge sharing and interdisciplinary research.
6. Increase funding for interdisciplinary research: Allocate more funding for interdisciplinary research, moving away from project-based funding and supporting long-term collaborations. This will encourage innovative solutions and promote cross-sectoral cooperation.
7. Improve data availability and accessibility: Address the lack of relevant data by investing in data collection, sharing, and interoperability. This will enable evidence-based decision-making and facilitate cross-sectoral cooperation.

Canada's role in strengthening One Health capacities internationally

While Canada has a role to play in strengthening One Health capacities internationally, it also has a lot to learn from others. It is also important to recognize how national contexts (for example, jurisdictional divisions) can affect the implementation of a One Health approach. Areas where Canada can contribute to strengthening One Health capacities internationally include:

1. Sharing expertise and best practices: Canada has research capacity, knowledge, and best practices that can be shared with other countries, particularly in the areas of surveillance strategies, data integration, and predictive modeling for pandemic prevention. Collaborative partnerships can be established to facilitate knowledge exchange and capacity building.
2. Mentorship and knowledge transfer: Canada can engage in two-way mentorship with low- and middle-income countries and Indigenous communities. This approach recognizes that while Canada has research capacity, other countries and communities have valuable on-the-ground experience and closer relationships between humans and animals. For instance, many African countries have created One Health platforms following Ebola. Canada can learn from the experiences of others while also providing guidance and support in strengthening One Health capacities.
3. Building community resilience and expertise: Canada can support initiatives that build resilience and expertise at the community level, particularly in low- and middle-income countries. This can involve capacity-building programs, training, and knowledge transfer to empower local communities to effectively address health challenges at the intersection of human, animal, and environmental health.
4. Standards and regulations development: Canada can contribute to the development and strengthening of global standards and regulations that support interoperability and the establishment of a globally unified pandemic data system. By sharing its expertise in regulatory frameworks, data governance, and information sharing protocols, Canada can contribute to the establishment of consistent and effective practices internationally.

Equitable access to pandemic response products

This section presents valuable insights on how the Pandemic Instrument can be leveraged to facilitate equitable access, with a focus on how to balance domestic and global interests. The section also explores opportunities, barriers, and lessons learned from promoting access to COVID-19 pandemic response products, offering valuable considerations for the development of an international instrument to address future pandemics.

Leveraging the Pandemic Instrument to facilitate equitable access to pandemic response products

Equitable access to pandemic response products is crucial for a fair distribution of limited supplies based on risk and need. The Pandemic Instrument plays a vital role in facilitating such access. Key steps and measures participants recommended include:

1. Determine risk and need at country and community levels: Regardless of income or geopolitical influence, equitable access requires evidence-based assessments of risk and need. A comprehensive approach should be adopted by considering factors beyond virus risk, such as social isolation and other health and social risks.
2. Strengthen access to knowledge and other forms of support: The language of the Pandemic Instrument should be more specific to effectively target equitable access to not only products but also knowledge and other forms of support.
3. Ensure continued access to healthcare products and services: While focusing on pandemic response, it is essential to consider the availability of other healthcare products and services. Ensuring continued access to essentials like cholera treatment and morphine during a pandemic response is crucial for comprehensive and equitable healthcare provision.
4. Foster transparent and culturally sensitive communication: Clear and transparent communication is essential to build trust and acceptance. Communicating the nature of the problem, decision-making processes, and the reasons behind them helps foster understanding and cooperation. Avoiding politicization of public health measures is crucial to maintain a focus on equitable access.
5. Support distributed manufacturing and technology transfer: Equitable access necessitates the distribution of vaccine manufacturing beyond the Global North. Supporting technology transfer and providing IP rights waivers can help accelerate the availability and distribution of pandemic response products, ensuring equitable access globally.

Balancing domestic priorities and global equity: Strategies for aligned interests

Achieving a balance between domestic priorities and global equity is crucial in addressing public health challenges. By recognizing the interconnectedness of national and global interests, countries can prioritize their citizens while promoting equitable access worldwide.

1. Acknowledge the interdependence: Recognize that protecting citizens and advancing global health security are mutually reinforcing objectives. Countries must avoid promoting racist or xenophobic attitudes by focusing on the global impact of health issues rather than national protectionism.
2. Link policies to equity principles: Policy frameworks must be linked to the principles of equity as articulated in the Zero Draft and allow for rapidly increasing the supply of pandemic response products and sharing of surplus products globally.
3. Foster collaboration and cooperation: Establish effective collaboration between national governments and international bodies to ensure coordinated responses and resource allocation. Strengthen collaboration among vaccine experts, policy experts, and manufacturers to enhance supply chain resilience and optimize pandemic response strategies.
4. Strengthen supply: Supply lines must be made more robust through collaboration among vaccine experts, policy experts and manufacturing, as well as through a strong WHO Global Pandemic Supply Chain and Logistics Network.

Barriers and opportunities in promoting access to COVID-19 Pandemic response products

As the world faced the COVID-19 pandemic, various opportunities and barriers were encountered in promoting access to pandemic response products. These experiences have provided valuable lessons and best practices that should be considered when discussing a potential international instrument to address future pandemics. Some key issues highlighted by participants include:

1. Collaboration: Governments, international organizations, industry, academia, and civil society must collaborate to accelerate research, development, and production of pandemic response products. Provinces and territories in Canada faced challenges due to the absence of a mandate for collaborative work, hindering effective coordination in promoting access to pandemic response products. Leveraging resources and expertise through public-private partnerships and streamlining regulatory processes can expedite the approval of safe and effective pandemic response products without compromising safety.
2. Misinformation and public trust: Misinformation and lack of public trust pose significant barriers worldwide. To overcome these challenges, targeted efforts in communication and education are necessary to address concerns and ensure accurate information dissemination. Strengthening communication and building trust is vital for encouraging widespread acceptance of pandemic response products. This involves transparent communication, addressing vaccine hesitancy, and developing strategies that connect national-level conversations with local knowledge and experiences to meet diverse needs.
3. Discrimination and vulnerable situations: Economic disparities exacerbated the difficulties in accessing pandemic response products among disadvantaged populations. Women and marginalized communities faced additional barriers due to discrimination, exacerbating inequities in accessing pandemic response products.
4. Lack of infrastructure: Limited access to a reliable cold chain infrastructure posed challenges in distributing temperature-sensitive pandemic response products in LMICs. Insufficient access to clean water impeded proper hygiene practices and affected the effectiveness of pandemic response interventions.
5. Maintaining research capacity: Maintaining research capacities during inter-pandemic periods enables swift response and effective surge capacity. By collecting and analyzing disaggregated data and vital statistics, policymakers can gain an accurate understanding of the specific requirements across countries and localities.
6. Learning from COVAX: Examining lessons from COVAX can provide insights into the need for accountability and enforcement mechanisms to ensure the success of future global initiatives. Canada should fulfill its promises and commitments for vaccine sharing, technology transfer, and financial support. Global manufacturing equity must be addressed to support the availability of vaccines in the Global South.

Health equity and gender equality

This section presents the valuable insights and perspectives of partners and stakeholders with respect to addressing systemic inequities, preventing gender inequities, and defining meaningful representation, engagement, and participation in decision-making processes within the context of the Pandemic Instrument.

Addressing systemic inequities

The Pandemic Instrument requires a comprehensive approach that addresses systemic inequities, embraces intersectionality, and prioritizes the needs of marginalized groups.

1. Intersectional approach and addressing root causes: The Pandemic Instrument should take an intersectional approach, recognizing the diverse needs of marginalized groups, and address the underlying systemic inequities that contribute to health disparities. Different pathogens will entail different issues of equity and equality.
2. Secondary impacts and social determinants of health: The Pandemic Instrument should address the secondary impacts of pandemics on education, mental health, and other areas, while also targeting the social determinants of health, such as poverty and discrimination.
3. Strong evaluation framework and accountability: The Pandemic Instrument should establish a robust evaluation framework with equity targets and prioritize human rights. The Pandemic Instrument must provide the greatest resources to those with the greatest need (proportional universalism) and include mechanisms for accountability.
4. Disaggregated data and analysis: The Pandemic Instrument should emphasize the collection and analysis of disaggregated data with contextual metadata on an ongoing basis, beyond pandemics, to inform decision-making and identify health disparities.
5. Representation and targeted outreach: The Pandemic Instrument should promote representation of women and marginalized groups in leadership positions and decision-making processes. It should also prioritize targeted outreach efforts to underserved communities, ensuring equitable access to testing, vaccines, and healthcare services. Understanding barriers and providing targeted solutions will strengthen health interventions (for example, providing intranasal vaccines to address low uptake of vaccines).

Supporting women, girls and gender diverse people

To effectively prevent women, girls, and gender diverse people from experiencing inequities in future pandemics, the Pandemic Instrument must prioritize key measures that address gender disparities, support caregivers, combat violence, mitigate the impact of school closures, ensure representation, and promote gender-sensitive budgeting and analysis.

1. Improved working conditions and support: The Pandemic Instrument should prioritize measures to enhance working conditions, including provisions for paid sick leave, flexible work arrangements, and adequate care support for women, girls, and gender diverse people who often shoulder caregiving responsibilities.
2. Addressing gender-based violence: The Pandemic Instrument should incorporate strategies to prevent and respond to the increased incidents of violence against women, girls, and healthcare workers during pandemics. This includes maintaining social protection structures, such as counselling, shelters, and maternal and reproductive care.
3. Mitigating the impact of school and daycare closures: Recognizing the disproportionate impact of school and daycare closures on women, the Pandemic Instrument should prioritize measures to address the challenges faced by women in balancing work, caregiving responsibilities, and education for their children. This could include expanding access to affordable childcare services and supporting remote learning options.
4. Intersectional approach and representation: The Pandemic Instrument should adopt an intersectional approach that considers the intersecting factors of gender, race, poverty, and other identities. It should ensure representation of women, especially from diverse backgrounds, in decision-making processes, leadership roles, and research associated with pandemic response, including vaccine development and clinical trials.
5. Gender-sensitive budgeting and analysis: The Pandemic Instrument should encourage gender-sensitive budgeting and analysis to identify and address the specific inequities experienced by women and children. This includes aligning funding priorities with PPPR, as well as promoting feminist budgeting practices among member states, as exemplified by Canada's Feminist International Assistance Policy.

Meaningful representation, engagement, and participation

Achieving "meaningful" representation, engagement, and participation in decision-making processes is crucial for inclusive and equitable governance. This entails involving diverse voices, ensuring active involvement, fostering accountability, engaging local communities, consulting relevant stakeholders, and adopting an early and participatory approach throughout the decision-making process.

1. Inclusive representation and consultation with diverse stakeholders: Meaningful representation involves ensuring that a broad cross-section of communities and diverse voices are included in decision-making processes. This includes representation from different genders, races, ethnicities, socio-economic backgrounds, ages, and other marginalized or underrepresented groups. Consultation with diverse stakeholders, including youth, healthcare workers, and representatives from marginalized communities, is essential to incorporate their perspectives and expertise.
2. Community-based engagement: Engagement opportunities should be available at the local community level, going beyond formal, centralized events. Actively reaching out to local communities and involving grassroots organizations, community leaders, and civil society groups ensures that meaningful engagement happens where people live, enabling the voices of those most affected by decisions to be heard.
3. Active engagement, ongoing involvement, and early participation: Meaningful engagement requires active participation in decision-making processes, allowing individuals to contribute their perspectives, insights, and expertise. It goes beyond providing opportunities for individuals to voice their opinions. Engagement must extend beyond opportunities to speak and involve ongoing involvement in the process. It should begin early in the development process, enabling stakeholders to shape policies and strategies from the outset.
4. Accountability and responsiveness: Meaningful representation and engagement necessitate accountability mechanisms to ensure that feedback and inputs from stakeholders are acted upon. Decision-makers should be accountable for the commitments made during the engagement process, and progress should be tracked and shared transparently.

Partner and stakeholder discussions

Roundtable discussions were organized to facilitate the exchange of diverse viewpoints, priorities, and concerns among various partner and stakeholder groups related to areas that implicate them in the Pandemic Instrument. The discussions revolved around key questions such as identifying priority issues and recommended measures for inclusion in the Instrument to address these concerns. Participants also examined potential concerns raised by the existing Zero Draft text and proposed ways to address or mitigate them. Furthermore, the discussions focused on defining meaningful engagement and establishing how Canada should engage with different sectors during the future development of the Pandemic Instrument.

Provinces and territories

Priorities that should be addressed in the Pandemic Instrument

1. Governance and leadership: Strengthening the governance and leadership of public health systems should be prioritized, particularly in the post-pandemic period when governments want to move on to other pressing issues.
2. Information sharing: Participants would like to see common indicators and dashboards developed to support information sharing at the provincial/territorial, national and international levels.
3. Addressing inequities: Access to pandemic products in Canada's North and unintended consequences stemming from measures taken to control the virus were specifically noted. Developing an ethical framework will help to address these issues.
4. Protection of human rights: Public health should be linked to the protection of human rights in the Instrument.
5. Accountability: The Instrument can be a tool to hold Canadian governments accountable for addressing the inequities and systemic issues that were exacerbated under COVID-19 and for strengthening nationally coordinated public health efforts across provinces and territories.
6. Supply of pandemic related products: To play a more influential role on the international stage, participants felt Canada needs to develop self-sufficiency in vaccines and PPE.
7. Gaps: One Health and approaches to dealing with intentionally released pathogens were also highlighted as needing greater priority.

Concerns with the Zero Draft

1. Framing: The Instrument must be viewed as more than a crisis-specific document. Issues such as basic health inequities, One Health and public health preparedness must be treated as ongoing concerns and be linked to broader initiatives and systems.
2. Language: As a legally binding document, the language must be tightened up and made more specific regarding accountability and obligations. The language around One Health also needs greater definition.
3. Unintended consequences: Concern was raised about WHO accountability and balancing public health with economic impacts (for example, impact of travel advisories on tourism). Representatives from the territories also highlighted the need to be mindful of context and balancing equity against One Health and climate concerns. For example, Northern localities are dependent on climate destructive transport for access to pandemic response products and public health supports.

Meaningful engagement moving forward

Participants indicated the need for ongoing engagement on the Pandemic Instrument. Other organizations within the provinces and territories will be looking to be informed on the progress of the Instrument. The scope of consultations should be broadened to include non-governmental stakeholders at provincial and community levels and specific groups within public health (for example, emergency response). Existing forums and tables could be leveraged to maintain engagement and disseminate information. There was also interest in making progress on common goals identified in the draft ahead of the international treaty. Operational and technical issues can be put on the agenda as consultations move forward. Some felt that the lack of detailed debriefings so far on Canada's COVID-19 response limit the ability to translate knowledge to the Pandemic Instrument development process.

Indigenous partners

Priorities that should be addressed in the Pandemic Instrument

1. Addressing systemic racism: Recognizing the trauma, racism and victimization inflicted on Indigenous Peoples and understanding how these impact PPPR and the Indigenous relationship to public health measures must be a priority. The Pandemic Instrument should explicitly acknowledge that historical colonial practices have made Indigenous communities wary and mistrustful of Western medical approaches and the Canadian healthcare system.
2. Indigenous rights: Consideration should also be given to how the following will inform the development of the Pandemic Instrument: the United Nations Declaration on the Rights of Indigenous Peoples; ownership, control, access and possession principles; and truth and reconciliation.
3. Culturally competent care: The Pandemic Instrument should address the need for culturally competent care and the importance of using nuanced approaches when working with marginalized communities to avoid further victimization. Factors such as public health restrictions, safety protocols, and vaccine education and availability must be looked at through this lens and given greater consideration than they were in the COVID response.
4. Social determinants of health: Particular focus should be directed towards addressing the social determinants of health, particularly those that are Indigenous-specific. These include: the quality of housing; health and community infrastructure; food and water insecurity; and access to digital connectivity.
5. Community-level capacity building: Capacity building in the context of PPPR must involve community leadership and agency. Investment of resources and support in healthcare sector recovery should be directed towards healthcare workers who have experienced the highest burden, especially women in healthcare.

Concerns with the Zero Draft

1. Infection prevention and control: The Zero Draft makes little mention of infection prevention and control. This is essential and must be directly addressed using an equity lens. Many centres in remote communities do not have the necessary safety infrastucture and resources required during a pandemic, including access to disinfectants and antibacterials.
2. Language: The tone of the draft is paternalistic and the language is stigmatizing, value-laden, and not inclusive. Greater cultural sensitivity is needed and the use of language that Indigenous communities are comfortable with is critical.
3. References to geographical variations: There is no mention of geographical locations other than small island developing states. In the Canadian context, the text should be expanded to include Northern and isolated regions where many Indigenous and Inuit communities are located.
4. Defining pandemic "preparedness": The parameters of "preparedness" should be more clearly defined. Topics such as testing and immunization are identified, but the document should also focus on basic safe infrastructure. Ignoring this is could be considered a form of discrimination.
5. Childcare for strengthening health workforce: When discussing strengthening human resource capacity and addressing gender disparity, child care must be considered. In order for women to be involved in descision making and healthcare provision, they need access to child care. The majority of healthcare providers are women, which makes this an important human resources consideration.
6. Vaccine infrastructure: When discussing vaccine availability, we need to be sure healthcare facilities have the proper refrigeration and back-up power systems to store vaccines.

Meaningful Engagement Moving Forward

Co-development and co-collaboration are important, and doing engagement well takes time. Engagement should have started before the development of the Zero Draft, with Indigenous Peoples taking leadership roles. Contact should be made with respected Elders and senior members of Indigenous communities prior to formal engagement to understand the key issues and so they can inform community members. Meaningful and culturally sensitive engagement should involve relationship building and should take place in safe spaces within the community. It should also involve a multi-step process of greeting, listening, and having reciprocal discussions that involve the bi-directional sharing of knowledge. Engagement should be ongoing throughout the duration of the Pandemic Instrument negotiations, with representation going beyond tokenism, involving all National Indigenous Organizations, and featuring the perspectives of Inuit and Metis voices as well.

Academics, experts, and researchers

Priorities that should be addressed in the Pandemic Instrument

1. Health systems resilience: The pandemic exposed weaknesses in health systems in countries of all income levels. Governance and leadership as well as infrastructure elements (surveillance of disease effects and treatments, lab capacity, diagnostics, etc.) need to be addressed to improve the global health security architecture. Training and knowledge transfer, particularly in remote and Indigenous communities, can make them more resilient and mitigate pandemic impacts (for example, local training for pathogen testing in wastewater). The Instrument should establish a floor for resources and funding for resilient health systems. High income countries need to reconcile the disparity of funding domestically with the amounts spent in LMICs.
2. Broader impacts of pandemics: The Pandemic Instrument should clearly address the broader impacts of pandemics, including mental health, social isolation and loneliness, domestic violence, racism, ageism, etc. Monitoring of these impacts is necessary and social science research must be included as a pillar of pandemic research.
3. Addressing inequality: Inequality must be prioritized. Women, marginalized communities and the poor are most affected in a pandemic. There must be equitable access to resources, support programs, and information, as well as direct support, at least temporarily, for these groups.
4. Protecting human rights: Human rights should be a fundamental consideration in the Pandemic Instrument. Protecting and respecting human rights is crucial, including during times of crisis. By prioritizing human rights, the Instrument can create a framework that respects and protects the dignity and well-being of every individual during pandemics.
5. One health: A One Health approach should be used with an emphasis on broadening the scope beyond human health. This includes addressing concerns related to AMR and reducing antibiotic use. Measures should be included to promote interdisciplinary collaboration among human health, animal health, and environmental sectors. This would facilitate comprehensive surveillance, research, and interventions to tackle emerging and re-emerging zoonotic diseases.
6. Addressing mis- and dis-information: The quality of public information and disinformation on social media must also be considered. Under COVID-19, we saw the emergence of self-appointed "public health experts" or groups that had no previous authority. Expert bodies must be established to maintain rigourous assessment of scientific evidence and its communication to the public.
7. Access to pandemic related products: Access to pandemic related products should focus on clinical trial capacity and sharing IP, not economic interests of private companies.
8. Data interoperability: Strengthening data interoperability should be a top priority in the Pandemic Instrument. This can be achieved through standardized data formats, interoperable data sharing protocols, harmonized terminologies, and robust health information exchange networks.
9. Balancing national sovereignty with international cooperation and solidarity: While countries have the right to make decisions that protect their citizens, it is essential to recognize that pandemics transcend borders and require global collaboration to effectively address them.

Concerns with the Zero Draft

1. Weak language around requirements and governance: Strengthening the language around requirements and governance is crucial to ensure that the proposed measures are binding and enforceable. Clear and specific language should be used to outline the responsibilities and obligations of countries and other stakeholders.
2. Inclusion of Indigenous and LMIC voices: It is important to ensure that the voices and perspectives of Indigenous communities and LMICs are adequately represented and considered in decision-making processes.
3. Decision-making, accountability, and transparency: To address concerns around decision-making, accountability, and transparency, it is essential to clearly define the processes and criteria for decision-making. This should include mechanisms for transparency in how and why decisions are made, as well as clear lines of accountability for the implementation and enforcement of the Instrument.
4. Buy-in: Ensuring buy-in from LMICs, other UN agencies, and global financing bodies is crucial for the Instrument's effectiveness. This can be achieved by actively involving these stakeholders in the drafting and negotiation process, addressing their concerns and priorities, and demonstrating the benefits of the Instrument in terms of global health security and equity.
5. Role of the private sector: The role of the private sector should be clearly defined within the Instrument. It should include provisions for responsible engagement of the private sector, such as ensuring transparency, preventing conflicts of interest, and promoting affordability and accessibility of vaccines and other essential medical products.
6. Implementation of IP waivers: Specifics on how IP waivers would be implemented should be provided in the Instrument. This could include mechanisms for compulsory licensing, technology transfer, or other approaches that facilitate the rapid and widespread production of vaccines and medical products during a pandemic, while ensuring fair compensation to innovators.
7. Role of the WHO in biosafety and biosecurity: Measures should be reevaluated to determine the appropriate role and authority of the WHO in managing international governance standards and oversight of biosafety and biosecurity, taking into account the expertise and capacity of relevant national bodies.

Meaningful engagement moving forward

The engagement process should focus more on equity. Indigenous, LGBTQ+, disability, vulnerable, marginalized, and other equity seeking groups need representation, particularly at the LMIC level. Engagement within Canada should not be Ottawa-centric. More hybrid and virtual methods should be employed to allow for more diverse contributions.

Engagement should be both top-down and bottom-up, employing human-centric design and deliberative dialogue. There should be an accountability and feedback process in which draft positions are shared and reviewed clause-by-clause.

There was also a recommendation to reach beyond stakeholders and consult more meaningfully with civil society, experts, academics and the legal community to draw on those with a greater depth of knowledge. Standing committees could be established with appropriate feedback loops.

Domestic civil society organizations

Priorities that should be addressed in the Pandemic Instrument

1. Equity and rights-based approach: Equity in access to services and addressing disparities between domestic and global responses should be a priority. Measures should be included to protect civil and human rights and reduce the impacts of ageism.
2. Accountability and compliance: The Instrument should incorporate accountability mechanisms based on measurable metrics. Incentives should be used to promote compliance with the Instrument.
3. Focus on prevention and recovery: Prevention and recovery should be addressed in separate sections of the document. Primordial prevention should receive greater emphasis, empowering authorities responsible for sustainable ecosystems, conservation, and sustainable agriculture. Clear timelines should be outlined for post-pandemic return-to-normal following a pandemic as well as for addressing long-term impacts, such as disruption of childhood development and education.
4. Embracing emerging technologies: The Instrument should acknowledge and utilize emerging technologies such as AI and automated tools for prevention, surveillance, and response efforts during a pandemic. Innovative approaches like intranasal vaccines and automated infection tracing should be considered.
5. Strengthening health systems and supply chains: Primary health systems should be strengthened globally, ensuring health human resources, training, and continuity of standard care. Supply chains should be robust to ensure the availability of vaccines and essential medicines. Support for informal caregivers and the explicit recognition of the right to health are crucial.
6. Travel restrictions and repatriation: The Instrument should address travel restrictions during pandemics and measures should be included to ensure the safe repatriation of individuals stranded in foreign countries. Guidelines for travel restrictions should be science-based, transparent, and proportionate to minimize the impact on individuals and global connectivity.
7. Addressing profiteering and conflicts of interest: The Instrument should ensure fair and equitable access to medical countermeasures, vaccines, and other essential supplies and measures should be put in place to prevent undue financial gains and promote the equitable distribution of resources.
8. Standing of civil society organizations: The Instrument should recognize and involve civil society organizations as key stakeholders in the negotiations and implementation processes.
9. Gap assessment and synergies with existing agreements: A comprehensive gap assessment should be conducted to identify synergies and areas where the Pandemic Instrument can complement existing agreements, such as the IHR.

Concerns with the Zero Draft

1. Handling of One Health: The document should address the conflation of One Health and AMR, recognizing that AMR is just one aspect of the broader One Health approach. The Instrument should focus on protecting and strengthening both human and animal health systems, emphasizing access to preventive measures and recovery resources. Investment in primordial prevention, biodiversity conservation, and sustainable agriculture should also be included to address the underlying causes of pandemics.
2. Measurable accountability: The Instrument should incorporate a framework for assessment, implementation, and tracking of progress. It should establish clear and measurable accountability mechanisms that translate high-level goals into actionable items at national and local levels.
3. Clarity: Greater clarity of language and definitions is needed throughout the document. Language should be explicit regarding equality, equity and the strengthening of public health systems.
4. Missing content: A full chapter should be dedicated to pandemic prevention, and palliative care articles should be returned to the Zero Draft.
5. Global North-centric perspective: The text should avoid assuming that the Global North is the central focus of the document. The Instrument should acknowledge the global nature of pandemics and provide equal importance and consideration to all regions and countries, taking into account the unique challenges and contexts they face.

Meaningful engagement moving forward

Participants appreciated that the Forum brought together multiple sectors. More similar meetings should be held, ensuring that more diverse groups are represented, including faith-based and other community organizations. Better promotion of engagement opportunities would allow for the participation of a greater diversity of groups. Providing funding would allow not-for-profit organizations and community stakeholders to participate actively.

Ongoing two-way exchanges were recommended, with opportunities for clause-by-clause analysis of subsequent drafts. A case-based approach with specific policy lenses would allow for the thinking through of issues such as social vulnerability, ageism, and unhoused populations. Further conversations about knowledge mobilization and transparency would also be desirable.

International civil society organizations

Priorities that should be addressed in the Pandemic Instrument

1. Prioritizing equity and human rights: The Pandemic Instrument should prioritize timely access to medical countermeasures, with a focus on health equity and gender equality. Measures should be included to address the shortage of healthcare workers and to expand on feminist international assistance policies. Human rights considerations must be central to the Instrument's framework.
2. Adopting an all-hazards approach: Pandemics should be categorized as emergencies alongside other disasters, emphasizing the need for an all-hazards approach to public safety. Lessons learned from previous endemic health issues and experiences with conflicts, such as Ebola and polio, should inform action in pandemic preparedness and response.
3. Addressing zoonotic spillover and multisectoral issues: The prevention of zoonotic spillover should be prioritized, implementing recommendations from the One Health High-Level Expert Panel. A comprehensive "one government" approach is necessary to address multisectoral issues such as deforestation, wildlife trade, biosecurity measures, integrated surveillance, and primary health care.
4. Clarity on funding: The Pandemic Instrument should provide clear information on how Canada's official development assistance funds will be allocated and utilized. It should specify if the Pandemic Fund will serve as the funding instrument for implementing the provisions of the Instrument, ensuring transparency and accountability in resource allocation.

Concerns with the Zero Draft

1. Gender equality: The Zero Draft should include explicit provisions that promote gender equality and ensure women's participation and leadership in health promotion, access to services, and decision-making processes. This can be achieved by incorporating language that highlights the importance of gender-transformative measures, enforcing gender equality, and addressing the specific needs of women and children during pandemics.
2. Human rights considerations: The Zero Draft should explicitly address the protection of human rights during pandemics. It should emphasize the importance of upholding human rights principles, such as non-discrimination, right to health, and access to information.
3. Equity: The charity model should be replaced with an equity-focused approach that aims to address the underlying social determinants of health and reduce power imbalances. The Instrument should emphasize the importance of addressing structural inequalities, promoting social justice, and empowering marginalized communities. It should prioritize measures that address the root causes of health disparities and ensure equitable access to essential services.
4. Protection of social determinants of health: The Instrument should explicitly address the protection of social determinants of health during pandemics. It should emphasize the importance of maintaining access to essential services, such as water, sanitation, hygiene, nutrition, education, and sexual and reproductive health and rights. Strategies should be outlined to mitigate disruptions to these services during emergencies and ensure their continuity.
5. Engagement of civil society and community leadership: The Zero Draft should provide clear guidelines on how civil society and community leaders will be engaged in the decision-making and implementation processes and should specify the mechanisms for their involvement.
6. One Health: The Instrument should expand the focus of the One Health article to include prevention and zoonotic surveillance in addition to AMR. It should also incorporate inputs and perspectives from a wider range of stakeholders, including representatives from other Quadripartite members, to ensure a comprehensive and collaborative approach.
7. Patents and IP flexibility: The Zero Draft should acknowledge the role of patents in innovation but also highlight the need to strike a balance that limits excessive profits. Time-bound patents or other mechanisms to ensure affordable access to technology by LMICs during pandemics should be explored. Canada, along with other countries, should demonstrate leadership by advocating for IP flexibility in times of emergencies and implementing the waiver signed onto in the WTO Qatar round, particularly during public health emergencies.
8. Incentives and disincentives: The Zero Draft should incorporate measures to reduce the stigmatization and negative impacts faced by countries reporting outbreaks. It should emphasize the importance of creating incentives for transparent and timely reporting, rather than punitive measures. This can help foster a culture of openness and cooperation in addressing pandemics.

Meaningful engagement moving forward

Meaningful engagement entails involving civil society, community leadership, and affected populations throughout the development of the Pandemic Instrument. Engagement should occur at the highest levels of leadership and continue through various drafts and issue-specific discussions. Canada should include civil society organizations in its negotiation delegation.

Private sector

Priorities that should be addressed in the Pandemic Instrument

1. Assess and address global barriers: Regulatory and export barriers should be addressed by focusing on streamlining regulatory processes, including maintaining expedited timelines for regulatory reviews without compromising quality, and promoting international cooperation and leadership. Shared regulatory frameworks can enhance efficiency and facilitate timely availability of pandemic products, while the WHO can coordinate efforts to address issues related to the movement of essential components and supplies across borders.
2. Preparedness: Simulation exercises, such as mock recalls and system testing, should be conducted in collaboration with Industry and other stakeholders to assess the readiness of countries and identify potential gaps in pandemic response.
3. Build capacity in LMICs: It is also necessary to prioritize the development of infrastructure in LMICs for receiving pandemic products, including transportation planning. This will help ensure equitable access to vaccines and other essential supplies in future pandemics.

Concerns with the Zero Draft

1. Scope of the Instrument: The Instrument should not burden the WHO with responsibilities beyond its expertise. Supply chains and logistics should be left to the private sector, however the Instrument can encourage partnerships and collaborations to ensure effective distribution and supply. Public-private partnerships have proven successful during the COVID-19 pandemic. This approach can harness the strengths and expertise of both sectors to enhance preparedness and response to future pandemics.
2. Intellectual property: Language around infringing on IP and expanding the TRIPS waiver is problematic. Strong IP protections are crucial for private sector innovation and rapid response to pandemics. The World Trade Organization should handle IP considerations.
3. Confidential information: Disclosing confidential information, such as price and contractual terms should be avoided to protect reputations and encourage future investments.
4. Centralized planning and conditionalities: The Instrument's proposal to centralize planning and funding for pandemic R&D, manufacturing and procurement worldwide and imposing rigid conditionalities will not solve the access challenge and is unlikely to be a workable solution. Focus should be on enabling the public–private partnerships that succeeded so well in the COVID-19 pandemic.
5. Long-term impacts: Pandemic planning also needs to focus on de-escalation. Consider potential future problems and whether the solutions found today may have negative implications down the road, such as the willingness of companies to invest in Canada in the future.
6. Clarify language and avoid subjectivity: The text of the Instrument should be clarified to minimize misunderstandings and provide clear guidance on actionable items. This will help ensure a more effective and consistent implementation of the Instrument's provisions.

Meaningful engagement moving forward

Industry should have a seat at the table in pandemic planning discussions as their perspectives and expertise are essential for effective decision-making and implementation. More in-depth discussions are needed across industry sectors, involving appropriate experts. For example, transportation, which plays a vital role in pandemic response, should be included in discussions to ensure comprehensive planning. To enhance pandemic preparedness private sector stakeholders recommended establishing a permanent table or agency that can facilitate ongoing engagement and collaboration between various stakeholders, including industry and government.

Youth

Priorities that should be addressed in the Pandemic Instrument

1. Empowering vulnerable populations: The Pandemic Instrument should acknowledge that vulnerable people are at greatest risk. Representatives from these vulnerable populations, including youth who experience intersectional inequities, must be included at all decision-making tables. These roles must be about more than representation and should empower vulnerable populations to make decisions for their own communities.
2. Addressing inequities: Addressing inequities wherever they occur should be a priority. The upstream determinants of health and the long-term impacts of chronic disease must be addressed. A framework that acknowledges equity and lays out concrete steps to ensure it at every level could be included in the Instrument.
3. Equitable allocation of and access to resources: Resources are finite and their allocation must balance political agendas and the global health agenda. The benefits derived from genomic sequencing, data, and medical countermeasures must be accessible in both the Global North and South, but the North is focused on protecting IP. Canada can play bridging role to help countries come to a consensus without sacrificing the principles of equity.
4. One Health approach: The Instrument should help breakdown down structural silos, such as programmatic barriers between human health and veterinary and environmental health. More training is needed for diverse people, including young people, in areas such as veterinary medicine, agriculture and research. Mechanisms are needed to support multi-disciplinary research.

Concerns with the Zero Draft

1. Language is important to ensure accountability: Youth participants raised concerns regarding the language used in the Zero Draft, underscoring the need for concrete steps, tangible actions, and firm language to hold Member States accountable. The Zero Draft uses words such as "encourage" and "we should" and frames issues as negative obligations ("you should not do this"). These are easier to enforce, but the treaty should also strive to advance aspirational principles, which are more difficult to enforce and define.
2. Youth needs should be better reflected throughout the Instrument: Youth are not mentioned in the Health Workforce. Notions of education, workforce strengthening, and youth training should be included.

Meaningful engagement moving forward

Youth engagement in the development of the Pandemic Instrument is important for creating an inclusive and effective response to pandemic prevention, preparedness, response, and recovery that addresses inequities and the needs of vulnerable populations. Youth are aware that their generation and generations to come will face the true burdens of global challenges, such as threats of AMR and an increasingly inequitable world. Growing up with this weight on their shoulders has led to a generation of highly-informed, passionate, and capable young people.

Meaningful engagement to youth means early and inclusive involvement in the planning process, enabling them to shape the Instrument from the beginning. Their lived experiences and expertise should be acknowledged and valued, going beyond age as the sole determinant of their contributions. Youth noted that there were significant gaps in the representation of youth from various communities, including Indigenous, LGBTQ+, and displaced/refugee communities emphasized the importance of making diversity a priority for youth engagement moving forward. Similarly, engagement should extend beyond formal consultations to grassroots initiatives in schools and communities, allowing for diverse representation. To facilitate inclusive engagement, youth are requesting financial support, including travel and accommodation compensation, to facilitate the participation of youth from various backgrounds. Ongoing feedback cycles and transparency are necessary to ensure that input from youth is incorporated into future drafts of the Instrument.

Key takeaways

The following are key takeaways coming out of the Pandemic Instrument Engagement Forum.

Embed equity in the process

Equity was part of nearly every discussion. Participants felt strongly that equity must be a primary consideration underpinning all aspects of the Pandemic Instrument and be central to its development process. Access to pandemic response products and services must be equitable and based on need, while equity must also guide how pandemic preparedness and response measures impact marginalized groups and communities.

Ensure meaningful engagement from diverse voices

Meaningful, ongoing engagement throughout the development and implementation of the Pandemic Instrument will be necessary to ensure equity. All stakeholders must be represented, but particularly marginalized groups and those most greatly impacted by pandemics and pandemic responses. The voices of LMICs and Indigenous groups must be given prominence; they have practical experience with similar healthcare crises and with practicing One Health principles. Frontline healthcare workers are another key group with valuable first-hand experience that must inform the development of the Instrument.

Be aware of colonial approaches

The Global North must work with LMICs, the Global South and Indigenous communities rather than do for them. Biased notions and practices must be avoided in areas such as health care recruitment, biosecurity, data extraction, IP protection and the application of One Health principles.

Promote cooperation and collaboration

Jurisdictional boundaries are barriers to effective PPPR. The Instrument must promote the sharing of information, data, best practices, expertise and resources. Within Canada, provincial/territorial, federal agency and sectoral silos must be minimized to facilitate cooperation and cross-disciplinary research and collaboration.

Emphasize transparency, accountability and communication

Transparent processes and decision-making are key to building trust and ensuring equity. Developers of the Instrument must be accountable for ensuring that stakeholder input is represented in the document and acted on in its implementation. The Instrument must include common, measurable progress metrics so countries can be held accountable for their commitments. Progress and status should be reported openly on an ongoing basis, and public education should be prioritized to improve the acceptance of public health measures and minimize the effects of disinformation.

Recognize the importance of data

Data and evidence must be central to future pandemic responses. Data must be collected on an ongoing basis for pathogen surveillance and monitoring. Standards must be implemented to ensure data quality and global interoperability. Data must be shared with the international community without fear of negative repercussions and be used to inform policy making. Privacy must be protected and data sovereignty ensured, particularly for LMICs and Indigenous communities.

Adopt a One Health approach

One Health requires collaboration and interdisciplinary cooperation among various sectors to tackle emerging and re-emerging zoonotic diseases. Prioritizing prevention, implementing recommendations, and addressing multisectoral issues are crucial for comprehensive surveillance and effective public health interventions. Tools, mechanisms, and resources are needed to help build capacity to implement a One Health approach.

Recommendations for further engagement

Many participants indicated their appreciation for the opportunity to attend the Forum, to share their thoughts, and to hear those of other attendees. Others stressed the importance of continuing the consultation process to represent a greater diversity of voices; to address complex issues, such as One Health, in greater detail; and to ensure that feedback is incorporated in future drafts of the Pandemic Instrument. Some said a clause-by-clause review of the document is needed. Particular emphasis was placed on the need for transparency in the process and to rebuild the public trust that eroded in various ways throughout the COVID-19 pandemic. Accountability in operationalizing the principles laid out in the document will help to achieve this.

Conclusion

The Pandemic Instrument Partner and Stakeholder Engagement Forum served as a platform for Canadian partners and stakeholders to provide input on key thematic issues related to pandemic prevention, preparedness, and response. The discussions highlighted the importance of embedding equity in the process, ensuring meaningful engagement from diverse voices, emphasizing transparency, accountability, and communication, promoting cooperation and collaboration, recognizing the importance of data, avoiding colonial approaches, and adopting a One Health approach. Moving forward, Canada will continue to engage partners and stakeholders throughout the development of the Pandemic Instrument through a variety of mechanisms, with an aim to include representations from a greater diversity of voices. Future engagements will address complex issues in greater detail.

Annex: Discussion questions

Leadership and governance

1. What approach(es) and mechanism(s) should be used to encourage and support countries to maintain and strengthen their commitments on pandemic prevention, preparedness and response (PPPR) over the long-term?
2. How can we better facilitate whole-of-government and whole-of-society approaches to pandemic prevention, preparedness and response?
3. How can we ensure low- and middle-income countries (LMICs) are represented in leadership and governance spaces with their expertise and experiences informing decision-making processes?

Capacities to detect, understand, act on public health emergencies

1. How can we better integrate public health intelligence (including surveillance and risk assessment) to better assess events and respond in a more timely and appropriate manner?
2. How can we better integrate a One Health into public health surveillance and risk assessment?
3. What steps should be taken to improve data and information sharing for effective public health responses while safeguarding biosecurity and personal or confidential information?

Health systems strengthening

1. Given the diversity of health systems globally, are there any particular health system building blocks that should be prioritized for collective action within the Pandemic Instrument? Which ones and why?
2. How should success in strengthening health systems for pandemic prevention, preparedness and response be measured? What indicators should be considered to help monitor public health system performance with regards to pandemic prevention, preparedness, and response?
3. What supports are critical for LMICs to build response capacities for health crises while also addressing systemic issues to increase health system resilience?

One Health

1. In what ways can Canada strengthen cross-sectoral cooperation to support the operationalization of a One Health approach to pandemic prevention, preparedness, and response?
2. What are the barriers to cross-sectoral cooperation at this point in time and how can they be better managed?
3. What role can Canada play in strengthening One Health capacities internationally, including in low- and middle-income countries?

Equitable access to pandemic response products

1. What does it mean for access to pandemic response products to be "equitable" and how can the Pandemic Instrument be leveraged to facilitate equitable access? What steps or measures should be prioritized?
2. Where are domestic and global interests aligned, and how can countries continue prioritizing their citizens while also advancing equitable access globally?
3. What opportunities and barriers have you/your organization experienced in promoting access to COVID-19 pandemic response products? Are there lessons learned or best practices from these experiences that should be taken into consideration when discussing a potential international instrument to address future pandemics?

Health equity and gender equality

1. In what ways should systemic inequities be addressed within the Pandemic Instrument to reduce health inequities and advance health equity?
2. What measures should be prioritized within the Pandemic Instrument to prevent women, girls, and gender diverse people from experiencing inequities in future pandemics?
3. What would "meaningful" representation, engagement, and participation in decision making processes look like to you?

Partner and stakeholder roundtable discussions

1. What issues would you like to see prioritized in the Pandemic Instrument? What kinds of measures should be included to advance these issues?
2. Are there elements within the existing zero-draft text that raise concern for you? How can your concerns be addressed or mitigated?
3. What does meaningful engagement look like to you? How should Canada engage with your sector in the development of the Pandemic Instrument moving forward?