Public health emergencies of international concern under Article 12 of the International Health Regulations: Implications for public health

A Public Health Emergency of International Concern (PHEIC) is a declaration made by the World Health Organization (WHO) when an event poses a significant public health threat across borders and may require an integrated global coordinated response. Such a declaration is issued in situations that are serious, unexpected, rapidly evolving, or unusual and that could demand immediate international action.^[1] Article 12 of the International Health Regulations (IHR) (2005) explains the procedure for declaring a PHEIC. It authorizes the WHO Director General to determine whether an event constitutes a PHEIC based on the information of affected countries, scientific evidence, and the advice of the emergency committee.^[2,3] It also emphasizes that such a declaration is made when an event poses a serious public health risk through the international spread of disease, requiring a coordinated international response. Annex 2 decision instrument of IHR (2005) guides the state parties in deciding whether an event requires notification to WHO within 24 hours under Article 6 of the IHR (2005). The four main questions in the decision instrument are assessed, and if the answer is YES to any two questions, the event must be reported to WHO.^[1,3] The high-priority events are subjected to rapid risk assessment (RRA) with detailed evaluation, which are classified as low, medium, high, and very high risk based on impact on human health, international spread, and insufficient control with limited resources.^[4] The 2024 amendment of IHR (2005) was adopted by consensus at the 77th World Health Assembly in June 2024, which entered into force on 19th September 2025 for 182 of the 196 States Parties under the amended entry into force rules of Article 59.^[1] The most structurally significant change was the introduction of a new alert tier under Article 12. Previously, the WHO would declare only PHEIC, but now the Director General determines that the event is a PHEIC or has become a pandemic emergency. A pandemic emergency is not a separate legal regime but a higher subset of PHEIC. Pandemic emergency, where appropriate, is a legal functional term that keeps the PHEIC as the primary legal trigger in recognizing the escalation layer for a pandemic.^[1,5,6] The amended Article 12 effectively codifies what counts as pandemic level and does not replace the PHEIC designation or create a separate system. This highlights that PHEIC already exists in Article 12 as a Director General decision point with amendments as a second threshold designation within the same decision framework. This main conceptual shift is subtle but is an important taxonomical refinement without the transfer of sovereign authority. Thus, the amendment does not give the WHO new coercive powers but strengthens the structural coordination architecture.^[7] This coordination is an obligation and expectation but is not an enforceable WHO command. So, Article 12 is the legal switch that activates Article 15, which generates a response action. Further, Article 13 allows the state to operationalize response capacity in real time. The pandemic-emergency determination is integrated into the existing PHEIC framework rather than constituting a separate legal regime. It is important to state that it does not add new legal force but certainly makes the system more synchronized with the emergency management framework rather than a poorly coordinated national response. COVID-19 did not change IHR by adding enforcement powers, but instead it led to system redesign aimed at late escalation, weak preparedness, and fragmented response. It is also argued that the system was upgraded, not redesigned, even though many argued that a redesign was needed in view of previous challenges.^[8] This further depends on political will, diplomatic pressure, and reputational incentive. It is reported that these reforms were politically visible but practically limited, as without funding and enforcement changes, they produced minimal or no real-world impact.^[9] WHO’s response to PHEIC is structured into levels of coordination, which are tiered and hierarchical as shown in Table 1. The research gaps in PHEIC are insufficient integration with One Health data, lack of clarity on probabilistic risks, limited surge capacity strategies, infodemic management, and challenged treatment during an emergency.^[2,3,10] The effectiveness of the PHEIC framework can be strengthened by addressing these gaps for early detection of emerging threats, supporting transparent decisions for a resilient health system and robust international health security based on public trust.

Article 12 has become increasingly important after the COVID-19 pandemic as countries are pushing for stronger global coordination, quicker reporting systems with improved preparedness for future pandemics and transnational health threats. Before 2024, the WHO recognized PHEIC regardless of scale difference, but after 2024, it was explicitly recognized that some PHEIC are qualitatively different. Understanding this relevance enhances preparedness, emergency response, and health security in public health.