Geneva, Switzerland · 19 September 2025 — The amended International Health Regulations (IHR) entered into force on 19 September 2025, marking a milestone in global health governance and reflecting a renewed commitment to international cooperation in the face of public health emergencies. The amendments, adopted by consensus at the Seventy-seventh World Health Assembly in June 2024, represent the most significant revision to the IHR since the last major overhaul in 2005 following the SARS outbreak.
The IHR are global regulations that guide 196 States Parties — including all 194 WHO Member States — on their rights and obligations concerning public health risks that cross borders. They recognise that infectious diseases and other health threats do not respect national boundaries and that coordinated global action is critical to protecting populations worldwide.
A New Alert Level: "Pandemic Emergency"
One of the most consequential changes introduced by the amendments is the creation of a new tier in the global alert system — a "pandemic emergency" — designed to trigger stronger international collaboration when a health risk escalates beyond a Public Health Emergency of International Concern (PHEIC) and poses the risk of becoming, or has already become, a pandemic with widespread impact on health systems and disruption to societies.
The new alert level addresses a gap identified during the COVID-19 pandemic, when the existing binary system — either a PHEIC was declared or it was not — was criticised for lacking intermediate escalation steps. The "pandemic emergency" category provides a mechanism for heightened coordination before a situation reaches full pandemic proportions, while preserving the PHEIC designation for earlier-stage emergencies.
| IHR Alert Level | Description |
|---|---|
| Public Health Emergency of International Concern (PHEIC) | Extraordinary event constituting public health risk to other States; requires coordinated international response |
| Pandemic Emergency (new) | Escalation beyond PHEIC; risk of becoming or having become a pandemic with widespread health system impact and societal disruption |
Key Provisions of the Amendments
The amended IHR introduce several structural changes beyond the new alert level:
- National IHR Authorities: Governments are now required to establish National IHR Authorities to coordinate implementation of the regulations within their jurisdictions, ensuring a clear focal point for communication and action.
- Equity and solidarity provisions: The amendments include provisions to strengthen access to medical products and financing based on principles of equity and solidarity, addressing one of the most contentious failures of the COVID-19 response — the stark inequity in vaccine and therapeutic access between high-income and low- and middle-income countries.
- Enhanced cooperation mechanisms: The amendments strengthen the framework for international collaboration during health emergencies, building on lessons learned from the COVID-19 pandemic about the importance of timely information sharing and coordinated response.
Historical Context
The origins of the IHR can be traced to the 19th century, when the expansion of travel and trade accelerated the spread of disease from port to port, prompting the introduction of quarantine measures. Initially governed by bilateral and regional treaties, these efforts were made global under the International Sanitary Regulations in 1951 following the founding of WHO. The regulations were later renamed the International Health Regulations and have evolved to meet the changing landscape of global health.
The last major revision, adopted in 2005, was driven by lessons from the 2003 SARS outbreak and significantly expanded the scope of the IHR from a narrow focus on a few specific diseases to encompass any "public health event of international concern." The 2024 amendments build on that foundation, incorporating the hard-won lessons of the COVID-19 pandemic — the largest global health emergency since the IHR were last revised.
Complementing the Pandemic Agreement
The entry into force of the amended IHR complements another landmark achievement of 2025: the adoption of the WHO Pandemic Agreement at the Seventy-eighth World Health Assembly in May 2025. Together, the two instruments form a reinforced framework for pandemic prevention, preparedness, and response.
While the IHR govern the operational response to public health emergencies — surveillance, reporting, and coordinated action — the Pandemic Agreement addresses the broader systemic issues of research and development, technology transfer, and benefit-sharing. Member States are actively negotiating an annex to the agreement on Pathogen Access and Benefit Sharing, which is set for consideration at the Seventy-ninth World Health Assembly in May 2026.
WHO Director-General Dr Tedros Adhanom Ghebreyesus described the strengthening of the IHR as "a historic commitment to protect future generations from the devastating impact of epidemics and pandemics." He added: "We know that no one is safe until everyone is safe. The IHR amendments reaffirm our shared responsibility and solidarity in the face of global health risks."
Limitations and Sovereignty
The IHR operate within the framework of national sovereignty. Under the regulations, WHO serves as the Secretariat, without authority to compel action by countries. States retain the sovereign right to implement legislation related to health policies. The IHR provide a framework for cooperation and coordination, but their effectiveness ultimately depends on the political will of Member States to comply with their obligations.
The eleven rejections of the 2024 amendments illustrate this tension. While 185 States Parties accepted the amendments, the eleven that rejected them will continue to operate under previous versions of the IHR. WHO has committed to supporting all IHR States Parties, as requested, in integrating the amendments into national legal frameworks and strengthening institutional capacities.
Looking Ahead
The entry into force of the amended IHR on 19 September 2025 represents the culmination of a negotiation process that began during the height of the COVID-19 pandemic, when the limitations of the existing global health architecture were laid bare. The amendments, alongside the Pandemic Agreement, signal a renewed commitment to multilateral cooperation in health — at a time when global solidarity faces significant headwinds from geopolitical tensions, funding cuts, and rising scepticism about international institutions.
The true test of these reforms will come not in the quiet of peacetime, but when the next pandemic threat emerges. Whether the new "pandemic emergency" alert level, the National IHR Authorities, and the equity provisions will translate into faster, fairer, and more effective response will depend on the commitment of countries to implement them in practice — and on the willingness of the international community to hold each other accountable.
Sources:
- World Health Organization, "Amended International Health Regulations enter into force," 19 September 2025,
- World Health Organization, "World Health Assembly agreement reached on wide-ranging, decisive package of amendments to improve the International Health Regulations," 1 June 2024,
- World Health Organization, "Questions and answers on the IHR amendments,"
- World Health Organization, "Stronger together: milestones that mattered in 2025," 23 December 2025,
- International Health Regulations (2005) as amended in 2014, 2022 and 2024,
FIRAT Editorial Board
Institutional Research Desk · Foresight Institute of Research and Translation
The collective editorial and research translation board of FIRAT, synthesising peer-reviewed evidence, policy briefs, and division milestones across our seven foundational research pillars.
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