The Impact of Power Dynamics on Global Health Cooperation and Health Equity during the COVID-19 Crisis: Lessons for Future Policy and Pandemic Preparedness

The Impact of Power Dynamics on Global Health Cooperation and Health Equity during the COVID-19 Crisis: Lessons for Future Policy and Pandemic Preparedness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The Impact of Power Dynamics on Global Health Cooperation and Health Equity during the COVID-19 Crisis: Lessons for Future Policy and Pandemic Preparedness Oluwatosin Samson Jegede, Nicholas Aderinto, Timilehin Mercy Jegede, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6966773/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The COVID-19 pandemic is over, but its impact on global health equity remains a significant concern. The pandemic highlighted and, in some cases, exacerbated longstanding inequities in global health systems, especially in low-resource settings. Power dynamics played a critical role in shaping global health equity and cooperation, influencing the allocation of resources, decision-making processes, and access to life-saving interventions. While existing studies have examined the relationship between global health diplomacy and health equity, the specific impact of power dynamics on health equity and diplomacy during the pandemic remains underexplored. This review explores how power dynamics influenced global health cooperation and health equity during the COVID-19 pandemic. A narrative review, guided by Lukes' three-dimensional model of power, was conducted. The review spans publications from 2000 to 2025 and includes 89 eligible articles, encompassing research studies, policy documents, and global health reports. Data extraction focused on three key domains: Development Assistance for Health (DAH), equity in the pandemic response, and political power dynamics. The review revealed that donor countries increased Development Assistance for Health (DAH) support in response to COVID-19. However, vaccine nationalism, geopolitical tensions, sanctions, and intellectual property regimes perpetuated inequities between the Global North and South. Despite multilateral initiatives like COVAX, inequitable access to vaccines and diagnostics persisted, largely due to the concentration of decision-making power among high-income countries and powerful institutions. The review concludes that achieving sustainable global health equity requires confronting entrenched power asymmetries that hinder meaningful cooperation, promoting inclusive governance, and depoliticizing health diplomacy. Transparent, equity-focused policies, strengthened regional health systems, and expanded South-South collaboration are essential for building resilience to future global health crises. Further research is recommended to evaluate the post-pandemic impact of power dynamics on global health equity and cooperation. COVID-19 Diplomacy Health Equity International Cooperation Pandemics Policy Figures Figure 1 Figure 2 Figure 3 Introduction Power dynamics are crucial in shaping global health equity and international cooperation. In the context of intersecting public health and foreign affairs, power dynamics manifest through negotiations and collaborations among various stakeholders, including foreign governments, health ministries, multilateral organizations, and non-governmental entities [1]. These power dynamics influence decision-making processes, resource allocation, and the implementation of policies that impact health outcomes globally. Success in global health diplomacy requires navigating complex power structures while aligning agreements with both political feasibility and scientific evidence [2]. The primary goal of global health diplomacy is to achieve mutually beneficial agreements that align with political feasibility and scientific evidence [3,4]. The Graduate Institute Geneva outlines the global health framework, emphasizing the interconnectedness of instruments, diplomacy, and governance, which is essential in navigating global health challenges in the contemporary era [4]. International cooperation serves as a platform for addressing power differentials and fostering mutual understanding and collaboration among nations and organizations [4]. Through substantial financial contributions and Performance-based Financing (PBF) programs, donor countries and global institutions like the World Bank and the Global Fund support health systems in developing countries [5]. However, power dynamics can also shape the dynamics of international cooperation, influencing the distribution of resources, the prioritization of health issues, and the extent of involvement of different stakeholders[6,7]. Achieving global health equity and effective international cooperation thus requires a nuanced understanding of power dynamics and strategic approaches to navigate and mitigate potential disparities in influence and decision-making [8–10]. Equity is commonly defined as the pursuit of "fairness and justice" or the endeavor to achieve a balanced resolution of competing claims within a community without bias [7,11–13]. The Centers for Disease Control and Prevention (CDC) defines health equity as the state where everyone has an impartial opportunity to achieve their optimal level of health [14]. However, interpretations of fairness and justice can vary, leading to differing understandings of equity across individuals and contexts [11–13,15]. As a result, policymakers often prioritize the principle of equality of need, advocating for the allocation of healthcare resources based on individuals' needs [16]. Health is also frequently leveraged as a strategic tool by governments to advance national interests or resolve geopolitical conflicts [5]. As a result, the interplay between power dynamics and health diplomacy can complicate the relationship between health equity and international cooperation [8–10,13,15]. Although the COVID-19 pandemic has subsided, its lessons remain critical for addressing future global health challenges. The power dynamics observed during the pandemic are not unique to this crisis but reflect long-standing systemic inequities in global health governance. As new health emergencies emerge—whether due to infectious diseases, climate change, or other factors—understanding and addressing these imbalances will be essential for building resilient, equitable health systems. Theoretical perspectives on power offer useful lenses for analyzing these dynamics. Steven Lukes’ three-dimensional view of power demonstrates how power operates not only through overt decision-making but also through agenda-setting and the subtle shaping of beliefs and preferences, often reinforcing structural inequities [17]. Michel Foucault’s concept of biopolitics further illustrates how health is used as a tool of governance, with institutions exercising control over populations through surveillance, regulation, and the management of life itself [18]. In the global health context, these frameworks suggest that power is exercised not only through financial contributions, but also through the ability to shape norms, priorities, and institutional arrangements that define international health cooperation. To strengthen the discussion on the intersection of power dynamics and health equity, this paper draws on specific examples from the COVID-19 pandemic to offer contextualized analysis of global health challenges. One such example is vaccine nationalism , in which wealthier countries, particularly the United States, the European Union, and the United Kingdom, prioritized their own populations for vaccine access, securing large quantities ahead of lower-income nations [19-21]. While initiatives like the COVAX facility aimed to promote equitable vaccine distribution, many high-income countries engaged in resource hoarding, leading to delays in vaccine access for vulnerable populations in the Global South. Simultaneously, geopolitical strategies such as China’s Belt and Road vaccine diplomacy and Russia’s distribution of Sputnik V highlighted the use of vaccines as instruments of soft power [22, 23]. These developments illustrate how power dynamics can distort principles of equity and international cooperation in public health. The challenges faced by COVAX, including supply limitations, political resistance, and unequal bargaining power, further underscore the impact of power asymmetries in global pandemic responses [24]. Countries like China and Russia leveraged vaccine access to strengthen diplomatic ties with developing nations, positioning themselves as key players in the global pandemic response [25]. These examples demonstrate how the distribution of power, not just the distribution of vaccines, shaped global health outcomes. The lessons from COVID-19 extend beyond pandemic preparedness. They also inform broader issues in global health, including access to essential medicines, vaccine development, and resource allocation for non-communicable diseases. Moreover, ongoing efforts such as the Pandemic Preparedness Treaty and the push for regional vaccine manufacturing in low- and middle-income countries highlight the continuing importance of power analysis in shaping global health equity and cooperation [26, 27]. To develop actionable strategies for more equitable responses to future health crises, it is essential to first understand how power dynamics influenced the COVID-19 response and its impact on health equity. This narrative review therefore aims to explore the influence of power dynamics at the intersection of international cooperation and global health equity during the COVID-19 pandemic. Methods Our research methodology commenced with an exhaustive examination of existing literature on Power Dynamics, global health Cooperation, and Health Equity. This preliminary review revealed a pervasive limitation in the analytical rigor and theoretical scrutiny of power dynamics in global health equity, highlighting the potential to leverage theoretical frameworks on power to foster a more nuanced understanding. Subsequently, we conducted a narrative review to investigate the application of political power within global health, particularly concerning decision-making processes, resource allocation, and the implementation of policies that impact health outcomes during the COVID-19 pandemic and beyond. A narrative review was conducted to examine the intersection of power dynamics, global health cooperation, and health equity during the COVID-19 pandemic. This review draws on frameworks from Health Policy and Systems Research and social science theories of power to operationalize power dynamics, which is central to understanding how global health systems function and respond during crises. By incorporating these frameworks, this review aims to analyze power not only in terms of structural inequalities between countries but also in how global health actors (governments, multilateral organizations, and non-state actors) influence the distribution of health resources and decision-making processes. Given that power dynamics are often implicit and not always openly discussed in formal publications, this methodological approach enables the triangulation of information from multiple perspectives, including peer-reviewed research, institutional reports, and expert analyses. Theoretical Framework: Power is inherently relational, shaped by interactions among actors, structures, and institutions. To analyze how power—both visible and invisible—shaped global health equity and COVID-19 responses, this study applies Lukes' three-dimensional model of power as a conceptual lens [17]. Lukes’ framework provides a structured approach to understanding how power operates at multiple levels within global health systems: The First Dimension (Visible Power) – Power is exercised through direct decision-making, such as pandemic lockdowns, vaccination campaigns, and vaccine purchasing and distribution policies, where actors explicitly allocate resources and make public health decisions. The Second Dimension (Agenda-Setting Power) – Power is exerted by shaping which issues are prioritized and which are excluded from decision-making spaces. For example, the COVAX initiative reflects this dimension, as it was designed to promote equitable vaccine distribution but was constrained by the priorities and financial commitments of high-income countries. The Third Dimension (Ideological and Perceptual Power) – Power influences how problems are framed and understood, shaping public perceptions and policy narratives. The framing of vaccine nationalism as a strategy to protect national interests, despite its consequences for global health equity, illustrates this dimension. This framework allowed us to interrogate both overt policy decisions and the less visible forces that shape global health cooperation and equity outcomes. Operationalizing Power Dynamics: Power dynamics were operationalized as multifaceted and relational, spanning political, economic, institutional, and ideological dimensions. The analysis considered how these forces influenced global health governance structures, resource flows, and the relative agency of low- and middle-income countries (LMICs) in shaping pandemic response strategies. To account for temporal shifts, we also assessed the transformative impact of power dynamics over the past 25 years, with a particular focus on the period spanning 2020 to 2025, encompassing the height of the COVID-19 crisis and its ongoing aftermath. Search Strategy: The review encompassed articles and publications indexed in PubMed, Scopus, Google Scholar, and the Directory of Open Access Journals (DOAJ). Due to limited journal publications in the domain of "power dynamics," supplementary searches were performed on the websites of reputable sources such as the World Health Organization (WHO), CDC, and trusted online newspapers. The search strategy involved the use of various combinations of the following search terms: ‘Global Health’, ‘International cooperation’, ‘Health equity’ ‘Power dynamics’, and ‘COVID-19’. The search terms were ‘Power dynamics and COVID-19’, ‘Power dynamics and International cooperation’, Power dynamics and Health equity’, ‘COVID-19 and Global Health’, ‘COVID-19 and Health equity’, ‘COVID-19 and International cooperation’, and ‘Health equity and International cooperation’. Inclusion Criteria: Articles published between 2000 and 2025 were included to analyze the pre-existing landscape of development assistance for health and international cooperation before the emergence of COVID-19 and its impact post-pandemic. Original research articles, policy documents, and global health reports from multilateral organizations were considered. Geographical restrictions were not imposed due to the global nature of the topic. Exclusion Criteria: Studies were excluded if they were duplicates, systematic reviews, lacked full-text access, or were not sufficiently relevant to the research topic. Following the screening process, a total of 89 articles met the inclusion criteria and were incorporated into the review. A PRISMA flow diagram (Figure 1) illustrates the identification, screening, and selection process. The characteristics of the included studies—such as year of publication, study type, and country of origin—are summarized in Table 1. Data Extraction: Data extraction focused on key domains and the thematic relationships: Global Health Cooperation and Power Dynamics: This theme focused on how power was distributed among key global health actors such as the World Health Organization (WHO), national governments, and multinational institutions and how this distribution influenced the coordination and effectiveness of the global COVID-19 response. Power Dynamics and Health Equity: This component explored how power influenced the allocation of essential health resources, including vaccines, personal protective equipment (PPE), and funding. It also examined disparities in access between countries in the Global North and Global South. International Cooperation and Health Equity: This theme analyzed the extent to which multilateral initiatives such as COVAX and DAH were able to promote health equity amid existing power asymmetries. It also assessed how the imbalance of influence among international actors may have hindered the goals of equitable distribution and collaborative response. Synthesis Approach: A narrative synthesis approach was employed, which followed a systematic process of categorizing and synthesizing findings to capture a comprehensive understanding of the topic. The conceptual framework (Figure 2) provided a visual representation of the interconnected themes, helping to structure the synthesis and ensure clarity and consistency across the review. Findings Pre-existing landscape of DAH and global health cooperation Development Assistance for Health (DAH) has long served as a vital mechanism for promoting international cooperation and advancing global health equity, particularly between the Global North and South [28]. By supporting health systems in low- and middle-income countries, DAH contributes to improved health outcomes, capacity building, and collective progress toward achieving Sustainable Development Goal 3 (SDG 3): Good Health and Well-being. Understanding the distribution and political underpinnings of DAH provides essential context for evaluating global health governance and cooperation before and during the COVID-19 pandemic. The top four donor countries providing DAH are the U.S, the U.K., Germany, and Japan [17]. The U.S. saw a sharp increase in DAH during the pandemic, rising from $9.5 billion in 2019 to $12.1 billion in 2020, followed by $16.2 billion in 2021 and $17.5 billion in 2022. Of this, more than 70% was allocated through bilateral agreements. COVID-19-specific funding by the U.S. totaled $506.8 million in 2020, increasing to $921.7 million in 2021 and $3.1 billion in 2022 [18]. U.S. bilateral assistance in 2020 targeted areas such as Covid-19, HIV/AIDS, malaria, reproductive health, and pandemic response. The U.K.’s DAH also peaked in 2020 at $3.4 billion, a slight increase from $3.3 billion in 2019. However, it declined in subsequent years, falling to $2.6 billion in 2021 and $2.1 billion in 2022. The UK has traditionally prioritized multilateral mechanisms, with the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and the Vaccine Alliance (Gavi) receiving the largest shares of its multilateral contributions [19]. In terms of COVID-19 response, the UK contributed $456.5 million in 2020, $261.0 million in 2021, and $314.9 million in 2022. Germany multilateral DAH flows also increased significantly during the pandemic, rising from $1.6 billion in 2019 to $3.5 billion in 2020, then $4.8 billion in 2021 and $4.5 billion in 2022 [28]. COVID-19 response constituted the largest portion of this spending, totaling $1.5 billion in 2020, $2.4 billion in 2021, and $2.3 billion in 2022 [28]. Japan’s DAH has historically emphasized bilateral support, focusing on basic health care services, medical research, and the control of sexually transmitted diseases [20]. Most of Japan’s bilateral assistance targeted countries in Africa and Central Asia. Although one estimate suggested that $54.8 billion was allocated for global DAH in 2020—with $13.7 billion for COVID-19 response, $3.1 billion for country-level coordination, and $2.4 billion for supply chain and logistics [21]—other sources report more conservative figures for Japan’s DAH. According to alternative estimates, Japan spent $809 million in 2019, $1.5 billion in 2020, $1.7 billion in 2021, and $2.6 billion in 2022. Its COVID-19-specific DAH totaled $612.8 million in 2020, $591.3 million in 2021, and $835.1 million in 2022 [29]. In 2020, many donor countries increased their DAH contributions in response to the COVID-19 crisis, with the European Union (EU) institutions emerging as the largest funders of pandemic-related health activities [22]. However, funding patterns also reveal how political considerations shaped global health priorities. Major powers such as the United States and China leveraged vaccine distribution as a form of soft power, often tying aid to diplomatic or strategic interests [30]. This politicization of health assistance complicated efforts to ensure equitable access, as recipient countries were at times expected to align with donor preferences. This politicization of health assistance complicated efforts toward equitable resource distribution, as recipient countries were sometimes implicitly expected to align with the geopolitical interests of donor nations [31]. Power dynamics and global health cooperation during the COVID-19 crisis The involvement of the EU, U.S., China, India, and African countries not only affected health outcomes but also shaped the political and economic landscape of international cooperation in public health. European Union countries united in their response to the COVID-19 pandemic, pooling funds and coordinating vaccination campaigns across the Union. Since the pandemic began in early 2020, the EU, EU Member States, and European financial institutions (collectively known as Team Europe) have disbursed €47.7 billion to support partner countries in addressing the pandemic and its aftermath, fulfilling their commitments with tangible results [23]. By June 2022, 86% of adults in the EU were fully vaccinated against COVID-19 [23,24]. Similarly, the U.S. government committed significant resources to combating COVID-19 both domestically and globally through initiatives such as the American Rescue Plan and the distribution of vaccines [32, 33]. Notably, the U.S. pledged nearly 1.1 billion covid 19 doses to support COVAX, and over $380 million in political risk insurance to Gavi [34]. The U.S. played a crucial role in funding global health organizations such as the World Health Organization (WHO) during the pandemic, contributing US$ 1.284 billion during the 2022–2023 biennium [35]. However, its initial threat to withdraw funding introduced a complex dynamic in global health cooperation, raising uncertainties about the WHO’s leadership in vaccine distribution and global health policy coordination. China’s role in the global response to the COVID-19 pandemic was characterized by a combination of direct support through vaccine diplomacy and the provision of medical supplies and expertise [36]. China also played a prominent role in vaccine distribution, providing vaccines to dozens of countries in Africa, Asia, and Latin America. By December 2022, China had distributed a total of 1.65 billion vaccine doses globally [37]. While higher-income countries dominated global financial and vaccine distributions, several countries in the Global South also took significant steps to address the crisis. India, for example, became a global hub for vaccine production, especially through the Serum Institute of India, which produced millions of doses for both domestic use and export [38]. India’s capacity to produce vaccines for COVAX and other international partners played a crucial role in addressing the global vaccine shortage [39]. The African Union’s engagement with COVAX, as well as the establishment of initiatives like the Africa Medical Supplies Platform (AMSP) in June 2020, highlighted the importance of South-South cooperation in managing the crisis [40]. In the first quarter of 2021, the African Union allocated US$2 billion in advance procurement guarantees to secure 270 million COVID-19 vaccine doses for its Member States [41]. Nonetheless, the challenges confronting global health diplomacy became glaringly evident during the COVID-19 pandemic, which perhaps stands as the most significant pandemic in modern history [25]. The pandemic prompted governments worldwide to implement unprecedented and extraordinary measures to safeguard public health, including closing international borders and suspending air travel [26]. These measures were implemented knowing that diseases transcend national boundaries, requiring a more integrated and coordinated global response to tackle the unprecedented global challenge [5]. Nonetheless, the emergence of new variants like the omicron variant led to diplomatic incidents such as travel bans and reciprocal actions among nations [27, 42-44]. These actions reflected not only the challenges in aligning responses to a global health crisis but also the broader implications of power dynamics on diplomatic relations and cooperation strategies [45]. As the COVID-19 crisis unfolded, the WHO reported staggering statistics on global cases and deaths, prompting intensified scrutiny of multilateral organizations like the WHO [46]. The substantial loss of lives resulting from the COVID-19 outbreak has raised questions about the effectiveness of global cooperation and brought intense scrutiny upon the WHO and other multilateral organizations tasked with disease control. Some WHO Member States have expressed doubts about the timeliness of WHO's response to the pandemic, while countries severely impacted by the virus threatened to withdraw their financial support for WHO [47]. Consequently, the president of the United States, through an executive order, announced plans to withdraw the U.S. from the WHO, ceasing its funding to the global health organization [48]. Geopolitical tensions were amplified during the pandemic, particularly evident in the rhetoric surrounding the virus's origin and implications, notably between China and the United States [49, 50]. These tensions intersected with economic considerations, influencing international relations and cooperation strategies, as seen in political statements supporting pandemic-affected industries [51]. This intersection highlights the intricate relationship between power dynamics, global health, and international cooperation in crises. Global health diplomacy faces significant challenges at a critical juncture when its importance is more pronounced than ever before. Analysts of international politics widely acknowledge that multilateralism experienced a period of instability [25]. Emerging political and economic dynamics, particularly geopolitical power shifts, have raised questions about the viability of existing institutions and the foundational principles upon which they were established [5]. Power dynamics and health equity during the COVID-19 crisis The COVID-19 crisis underscored the critical intersection between power dynamics and health equity, particularly in the context of vaccine access and distribution. The pandemic revealed longstanding disparities in global health, magnifying existing inequities across different regions [52, 53]. One of the key challenges highlighted was equitable access to COVID-19 vaccines, especially for countries in the Global South, which became a focal point for affected governments and international organizations [54-56]. A glaring example of these disparities is seen in Latin America, where despite accounting for 34.3% of COVID-19 deaths among low- and middle-income countries, the region received only $714.4 million (7%) of COVID-19 DAH funding [21]. This discrepancy in funding allocation reflects broader power dynamics in global health governance, where wealthier nations with economic power and political influence can secure more resources, leaving low-income regions disproportionately underfunded [57]. Brazil’s COVID-19 vaccine strategy illustrates how both global and domestic power dynamics can shape health equity outcomes. As of June 2021, Brazil had reported over 16 million confirmed COVID-19 cases and more than 470,000 deaths—ranking it second globally in terms of total fatalities, according to the WHO COVID-19 Dashboard [58, 59]. Although Brazil participated in COVAX as a self-financing country, its upper-middle-income classification meant it received less subsidized support and had to pay higher premiums to maintain procurement autonomy [60]. Negotiations with Pfizer were prolonged due to political tensions and disputes over liability and contractual terms [61]. The eventual agreement was secured only after legal responsibility was devolved to subnational governments, illustrating the intersection of domestic governance fragmentation and international contractual complexities. Similarly, Peru had the world’s highest COVID-19 death rate per 100,000 population, according to Johns Hopkins University, as of July 2021 [62]. In January 2021, Peru signed a bilateral deal for 38 million Sinopharm doses, reflecting the urgency driven by global vaccine competition and limited multilateral access [63]. It was also among the first in the Americas to receive COVAX vaccines, with 117,000 Pfizer doses delivered in March as part of a 13 million-dose allocation. UN agencies, including UNICEF and PAHO, supported distribution through cold chain infrastructure, including ultra-low freezers and solar-powered units for remote areas [64, 65]. Despite early efforts, supply remained insufficient to meet national demand. To address these shortages, Peru pursued additional agreements, such as the September 2021 deal with Moderna for 20 million doses, with deliveries beginning in early 2022 [66]. Consequently, by December 2021, approximately 75.8% of the adult population had received full vaccination. Furthermore, despite evidence that herd immunity to COVID-19 can only be achieved through vaccination, especially from promising technologies such as nano vaccines [67, 68], significant disparities emerged in the licensing of vaccines for emergency use. For instance, pharmaceutical companies in India faced delays in international approval for their vaccines despite securing national regulatory authorization. These delays reflect the complex interplay between global regulatory frameworks and the political dimensions of health diplomacy [69]. These instances highlight the need for greater transparency, collaboration, and equity-focused policies in addressing health disparities and ensuring equitable access to life-saving medical interventions during crises like the COVID-19 pandemic [70, 72]. In Africa, advocacy for equity in the accessibility and distribution of COVID-19 testing kits and vaccines was done [73]. Additionally, the African Centers for Disease Control and Prevention (Africa CDC) has urged African leaders to strengthen their health systems. The former Director General of Africa CDC, John Nkengasong, emphasized the importance of regionalizing health systems to enhance responsiveness during crises, stating, “Equity starts by regionalizing health systems so that when a crisis hits, regions have the capacity and ability to respond” [73]. This statement underscores the vision and objectives of South-South Collaboration [74]. Discussion The discussion on the COVID-19 pandemic and global health diplomacy highlights several key points regarding international cooperation, power dynamics, and health equity. One crucial aspect is the recognition that diseases like COVID-19 do not differentiate between donor and recipient countries when it comes to major health crises such as pandemics. Before the COVID-19 era, donor funds have assisted developing countries in addressing their major health challenges and progress towards achieving the third Sustainable Development Goal. The surge in donations towards DAH during the COVID-19 pandemic highlights the significance of global health to donors. In 2020, while the European Union (EU) institutions made the largest contributions towards COVID-19 related activities, the U.S. government emerged as the largest donor to DAH overall [17]. Moreover, the U.S. government's contribution in 2020 surpassed that of the UK, Germany, and Japan combined. However, it's important to note that donor organizations influence the allocation of DAH and the selection of implementing organizations based on their relationships [9], potentially impacting health equity and universal coverage due to underlying power differentials. While it was crucial for countries to implement measures to control epidemics domestically and at international borders, some countries exploited COVID-19 travel restrictions for political gain. The application of territorial sovereignty to impose travel restrictions during the pandemic overshadowed the WHO’s 2025 International Health Regulations, which were designed to guide the international response to health emergencies [75, 76]. This disregard for the IHR reflected how political power often interfered with health decisions, complicating the global response to the pandemic. In an effort to depoliticize the global health response and avoid the political use of health measures, alternative strategies, such as targeted health surveillance and control measures, instead of blanket flight bans and reciprocity, could have been more effective in managing the pandemic's spread while preserving individual rights and fostering international cooperation. For instance, individuals testing positive before travel could be prevented from boarding until cleared, and those testing positive upon arrival could be isolated. Quarantine measures, as implemented during the Middle East respiratory syndrome coronavirus (MERS-CoV) and severe acute respiratory syndrome (SARS) outbreaks could also be applied based on COVID-19 guidelines at the destination for symptomatic individuals or those in contact with positive cases during travel [77, 78]. Amidst the global fight against COVID-19, the UN Secretary-General emphasized the imperative that "no one is safe until everyone is" [79]. This ethos, which mirrors the foundational principles of the WHO, must remain central to global health diplomacy, reinforced through ongoing relationship-building and negotiation processes. To prevent stigmatization and discrimination, WHO issued guidelines prohibiting naming infectious agents or diseases after geographic locations [80]. Policymakers are expected to reference this guidance in discussions regarding the nomenclature of infectious diseases in the future. Market-driven approaches to healthcare have exacerbated existing inequities and hindered equitable access to COVID-19 diagnostic kits and vaccines. Wealthier countries with economic power secured timely access to licensed COVID-19 vaccines, leaving lower-income countries struggling to access sufficient supplies [81]. Yet , Peru offers a notable example of national initiative amid these disparities. Despite early challenges and limited COVAX access, the government pursued bilateral agreements and expanded cold chain capacity. By December 2021, over 75.8% of adults were fully vaccinated—demonstrating how strategic national action and partnerships can overcome structural barriers to health equity [82-84]. The Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement further complicated equitable access by protecting intellectual property rights that limited the ability of low- and middle-income countries to produce vaccines locally. Also, stringent intellectual property rights may partially explain the delays in licensing of vaccines from developing countries. For instance, India’s Covaxin was delayed in its approval for international distribution due to regulatory challenges, exacerbating access issues and contributing to the delays in vaccine availability to countries relying on COVAX for supplies [85]. This disparity highlighted structural inequities in the global health system, with vaccines often being treated as commodities rather than essential public health resources. The TRIPS waiver advocated by global health organizations and developing countries aimed to mitigate these inequities by allowing for the temporary suspension of intellectual property protections on COVID-19 vaccines, enabling wider access to production and distribution [85-89]. Such measures would allow developing nations to produce generic versions of life-saving vaccines, thereby advancing global health equity. The withdrawal of the United States, the major financial contributor, from the WHO would significantly weaken the multilateral organization’s capacity to support health initiatives in resource-limited settings. While regionalizing health systems may strengthen healthcare delivery in individual countries within a region, the proposed step by the U.S. Government could have profound implications for global health equity. This would likely exacerbate existing health inequities, particularly in regions like Southeast Asia and South America, where regionalization may not be a practical or prioritized approach. Furthermore, the establishment of a new regional health organization risks fragmenting global health efforts, potentially leading to duplication of initiatives and inefficiencies in addressing transnational health challenges. Such actions could undermine the spirit of multilateral cooperation, which is crucial for coordinated and effective responses to global health crises. LESSONS LEARNED AND IMPLICATIONS FOR FUTURE HEALTH CRISES The emergence of COVID-19 has underscored the intricate intersection of global health diplomacy with politics and power asymmetry, significantly impacting international cooperation between high-income and low-income countries. COVID-19 has not only magnified the existing challenges of global health diplomacy but has also exposed systemic weaknesses that are likely to persist and evolve in future public health emergencies. Notably, the pandemic catalyzed both regressive and progressive shifts. On the one hand, power imbalances, sanctions, travel restrictions, and nationalistic agendas undermined equitable collaboration. On the other, increased DAH in response to the pandemic and collaborative efforts, such as regional manufacturing initiatives and the advocacy for intellectual property waivers, signal emerging pathways toward more equitable global health governance. The shared goal of controlling the pandemic has facilitated collective progress towards achieving sustainable development goal 3. A key lesson from COVID-19 is the growing momentum among developing nations to assert greater visible and agenda-setting power in shaping health policy and preparedness through South-South cooperation and regional alliances. These developments offer a critical opportunity to reconfigure power structures and decision-making mechanisms before the next crisis emerges. However, enduring challenges remain. Persistent disparities in healthcare infrastructure, underinvestment in public health, and limited ideological power continue to undermine resilience in low- and middle-income countries. Without structural reform in global health financing, governance, and knowledge-sharing systems, future health crises could replicate, or even deepen, the inequities observed during COVID-19. Finally, multilateralism and global solidarity will remain essential to addressing future health emergencies. The pandemic demonstrated that health is a global public good and that coordinated international action is critical. Moving forward, it is imperative to build on initiatives such as COVAX and to strengthen multilateral partnerships among governments, international organizations, the private sector, and civil society to improve global health resilience and equity. Global health efforts must also carefully navigate the tension between political considerations and equity-driven action. Political pressures, whether rooted in intellectual property rights or national self-interest, must not eclipse the fundamental human right to health. In this light, the pandemic offers not only a reflection of past and present shortcomings but also a blueprint for reimagining a more inclusive and equitable global health order—one that prioritizes long-term solidarity, regional capacity-building, and fair participation in global decision-making processes. LIMITATIONS AND STRENGTH Global health cooperation and health equity involve complex interactions between multiple stakeholders. We recognize that our review may not capture all the intricacies and nuances of these interactions. Also, our study focuses primarily on power dynamics using the COVID-19 pandemic as a case study, which may limit the application of findings to other global health crises or contexts. Lastly, we did not include the Web of Science database during our search potentially excluding other articles and publications relevant to this topic. Despite these limitations, our study includes citations from various countries and continents, encompassing perspectives from both the global north and south. This broad representation enhances the potential generalizability of our findings and enriches the diversity of insights into power dynamics, international cooperation, and global health equity. Conclusion and Recommendations This review has explored the complex role of power dynamics in shaping global health equity and cooperation during the COVID-19 pandemic. As the world confronted unprecedented challenges, it became clear that global health diplomacy is deeply entwined with political interests and systemic power imbalances between high-income and low-income countries. Evidence from initiatives such as COVAX illustrates how power disparities—reflected in funding priorities and decision-making control—shaped access to vaccines and diagnostics, often to the detriment of the Global South. These inequities affected the fairness and effectiveness of international collaboration. While global health diplomacy is unquestionably influenced by political forces, the COVID-19 crisis highlighted the urgent need for ongoing global dialogue to depoliticize health policies and promote more equitable cooperation. Proposals to diminish the use of health as a political tool, along with the development of a comprehensive global strategic framework for health diplomacy, are crucial to improving preparedness for future challenges pandemics. The pandemic presents a critical opportunity for reflection and transformative action. Policymakers and global health leaders must prioritize equitable health outcomes by promoting transparent, inclusive governance in the short and long term. Strengthening regional health systems and expanding South-South collaboration are vital to creating a more resilient global health architecture. These strategies should be grounded in policies that address visible, agenda-setting, and ideological dimensions of power, as outlined in Lukes’ three-dimensional model, to address structural inequalities at their root. Further research is essential to assess the post-pandemic impact of power dynamics on global health equity and cooperation. Systematic reviews and meta-analyses, supported by robust statistical methods, can offer crucial insights into the most effective interventions for reducing inequities and building inclusive global health systems. Ultimately, the lessons of COVID-19 must inform a more just and cooperative future for global health. Abbreviations Africa CDC African Centers for Disease Control and Prevention CDC Centers for Disease Control and prevention DAH Development Assistance for Health DOAJ Directory of Open Access Journals EU European Union HIV/AIDS Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome IHR International Health Regulations MERS-CoV Middle East Respiratory Syndrome Coronavirus PBF Performance-Based Financing STD Sexually transmitted diseases SARS Severe Acute Respiratory Syndrome SDG Sustainable Development Goals TRIPS Trade-Related Aspects of Intellectual Property Rights UN United Nations USA United States of America U.S. United States WHO World Health Organization Declarations Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: Not applicable Competing interests: The authors declare that they have no competing interests Funding: No funding was received for this study Authors' contributions: OSJ conceptualised the study; All authors were involved in the literature review; OSJ and NA extracted the data from the reviewed studies; All authors wrote the final and first drafts. 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Characteristics of articles included in this review Study Characteristics n=89 n Year of Publication 2025 1 2024 6 2023 9 2022 13 2021 30 2020 15 2019 1 2017 1 2016 1 2015 3 2013 1 2012 1 2010 2 2006 1 2005 2 2000 2 Type of Publication Research Article 25 Book and Book Chapters 4 Review 12 Organizational/ Commission Report 10 Document 13 Policy Review/Brief 5 Press Release and News Report 17 Letter to Editor 2 University’s blog 1 Country of Publication/ Source of Article United States of America 24 United Kingdom 9 Canada 1 Germany 4 Other EU countries 6 United Nations/WHO/GAVI 12 Japan 1 India 5 Nepal 1 Nigeria 3 East and Southern Africa 6 Egypt 1 Mixed countries 3 Cameroon 1 Liberia 1 China 2 Taiwan 1 Korea 1 Brazil 2 Peru 3 Australia 1 EU – European Union Additional Declarations No competing interests reported. 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14:23:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6966773/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6966773/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85925419,"identity":"16ada792-5597-4718-bbe3-ef1ecf73b9e6","added_by":"auto","created_at":"2025-07-03 08:37:35","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49925,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Diagram Illustrating Identification, Screening, and Inclusion of Articles.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6966773/v1/a872b296c5b8f0d0427b378f.jpg"},{"id":85926842,"identity":"16e06554-56da-4ac0-ba19-5bce64b660de","added_by":"auto","created_at":"2025-07-03 08:45:35","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":51100,"visible":true,"origin":"","legend":"\u003cp\u003eA conceptual framework of the impact of power dynamics on global health cooperation and health equity during the COVID-19 Crisis\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6966773/v1/c613b87fae590498cf966e73.jpg"},{"id":85925420,"identity":"505ce3f9-4f1d-4966-87f3-d3f3d787f73a","added_by":"auto","created_at":"2025-07-03 08:37:35","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51537,"visible":true,"origin":"","legend":"\u003cp\u003eCombined DAH and Pandemic-Specific Aid from the Top Four Donor Countries (2019–2022)\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6966773/v1/60e4322221d5673280309507.jpg"},{"id":85927573,"identity":"98a00169-0a80-4a97-a363-e81c9037cdcf","added_by":"auto","created_at":"2025-07-03 08:53:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":994949,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6966773/v1/8d328f01-2051-4218-9343-70775fc784e0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of Power Dynamics on Global Health Cooperation and Health Equity during the COVID-19 Crisis: Lessons for Future Policy and Pandemic Preparedness","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePower dynamics are crucial in shaping global health equity and international cooperation. In the context of intersecting public health and foreign affairs, power dynamics manifest through negotiations and collaborations among various stakeholders, including foreign governments, health ministries, multilateral organizations, and non-governmental entities [1]. These power dynamics influence decision-making processes, resource allocation, and the implementation of policies that impact health outcomes globally. Success in global health diplomacy requires navigating complex power structures while aligning agreements with both political feasibility and scientific evidence [2]. The primary goal of global health diplomacy is to achieve mutually beneficial agreements that align with political feasibility and scientific evidence [3,4]. The Graduate Institute Geneva outlines the global health framework, emphasizing the interconnectedness of instruments, diplomacy, and governance, which is essential in navigating global health challenges in the contemporary era [4].\u003c/p\u003e\n\u003cp\u003eInternational cooperation serves as a platform for addressing power differentials and fostering mutual understanding and collaboration among nations and organizations [4]. Through substantial financial contributions and Performance-based Financing (PBF) programs, donor countries and global institutions like the World Bank and the Global Fund support health systems in developing countries [5]. However, power dynamics can also shape the dynamics of international cooperation, influencing the distribution of resources, the prioritization of health issues, and the extent of involvement of different stakeholders[6,7]. Achieving global health equity and effective international cooperation thus requires a nuanced understanding of power dynamics and strategic approaches to navigate and mitigate potential disparities in influence and decision-making [8\u0026ndash;10].\u003c/p\u003e\n\u003cp\u003eEquity is commonly defined as the pursuit of \u0026quot;fairness and justice\u0026quot; or the endeavor to achieve a balanced resolution of competing claims within a community without bias [7,11\u0026ndash;13]. The Centers for Disease Control and Prevention (CDC) defines health equity as the state where everyone has an impartial opportunity to achieve their optimal level of health [14]. However, interpretations of fairness and justice can vary, leading to differing understandings of equity across individuals and contexts [11\u0026ndash;13,15]. As a result, policymakers often prioritize the principle of equality of need, advocating for the allocation of healthcare resources based on individuals\u0026apos; needs [16].\u003c/p\u003e\n\u003cp\u003eHealth is also frequently leveraged as a strategic tool by governments to advance national interests or resolve geopolitical conflicts [5]. As a result, the interplay between power dynamics and health diplomacy can complicate the relationship between health equity and international cooperation [8\u0026ndash;10,13,15].\u003c/p\u003e\n\u003cp\u003eAlthough the COVID-19 pandemic has subsided, its lessons remain critical for addressing future global health challenges. The power dynamics observed during the pandemic are not unique to this crisis but reflect long-standing systemic inequities in global health governance. As new health emergencies emerge\u0026mdash;whether due to infectious diseases, climate change, or other factors\u0026mdash;understanding and addressing these imbalances will be essential for building resilient, equitable health systems.\u003c/p\u003e\n\u003cp\u003eTheoretical perspectives on power offer useful lenses for analyzing these dynamics. Steven Lukes\u0026rsquo; three-dimensional view of power demonstrates how power operates not only through overt decision-making but also through agenda-setting and the subtle shaping of beliefs and preferences, often reinforcing structural inequities [17]. Michel Foucault\u0026rsquo;s concept of biopolitics further illustrates how health is used as a tool of governance, with institutions exercising control over populations through surveillance, regulation, and the management of life itself [18]. In the global health context, these frameworks suggest that power is exercised not only through financial contributions, but also through the ability to shape norms, priorities, and institutional arrangements that define international health cooperation.\u003c/p\u003e\n\u003cp\u003eTo strengthen the discussion on the intersection of power dynamics and health equity, this paper draws on specific examples from the COVID-19 pandemic to offer contextualized analysis of global health challenges. One such example is vaccine nationalism\u003cstrong\u003e,\u003c/strong\u003e in which wealthier countries, particularly the United States, the European Union, and the United Kingdom, prioritized their own populations for vaccine access, securing large quantities ahead of lower-income nations [19-21].\u003c/p\u003e\n\u003cp\u003eWhile initiatives like the COVAX facility aimed to promote equitable vaccine distribution, many high-income countries engaged in resource hoarding, leading to delays in vaccine access for vulnerable populations in the Global South. Simultaneously, geopolitical strategies such as China\u0026rsquo;s Belt and Road vaccine diplomacy\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eRussia\u0026rsquo;s distribution of Sputnik V\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ehighlighted the use of vaccines as instruments of soft power [22, 23]. These developments illustrate how power dynamics can distort principles of equity and international cooperation in public health.\u003c/p\u003e\n\u003cp\u003eThe challenges faced by COVAX, including supply limitations, political resistance, and unequal bargaining power, further underscore the impact of power asymmetries in global pandemic responses [24]. Countries like China and Russia leveraged vaccine access to strengthen diplomatic ties with developing nations, positioning themselves as key players in the global pandemic response [25]. These examples demonstrate how the distribution of power, not just the distribution of vaccines, shaped global health outcomes.\u003c/p\u003e\n\u003cp\u003eThe lessons from COVID-19 extend beyond pandemic preparedness. They also inform broader issues in global health, including access to essential medicines, vaccine development, and resource allocation for non-communicable diseases. Moreover, ongoing efforts such as the Pandemic Preparedness Treaty\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand the push for\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eregional vaccine manufacturing in low- and\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003emiddle-income countries highlight the continuing importance of power analysis in shaping global health equity and cooperation [26, 27].\u003c/p\u003e\n\u003cp\u003eTo develop actionable strategies for more equitable responses to future health crises, it is essential to first understand how power dynamics influenced the COVID-19 response and its impact on health equity. This narrative review therefore aims to explore the influence of power dynamics at the intersection of international cooperation and global health equity during the COVID-19 pandemic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eOur research methodology commenced with an exhaustive examination of existing literature on Power Dynamics, global health Cooperation, and Health Equity. This preliminary review revealed a pervasive limitation in the analytical rigor and theoretical scrutiny of power dynamics in global health equity, highlighting the potential to leverage theoretical frameworks on power to foster a more nuanced understanding. Subsequently, we conducted a narrative review to investigate the application of political power within global health, particularly concerning decision-making processes, resource allocation, and the implementation of policies that impact health outcomes during the COVID-19 pandemic and beyond.\u003c/p\u003e\n\u003cp\u003eA narrative review was conducted to examine the intersection of power dynamics, global health cooperation, and health equity during the COVID-19 pandemic. This review draws on frameworks from Health Policy and Systems Research and social science theories of power to operationalize power dynamics, which is central to understanding how global health systems function and respond during crises. By incorporating these frameworks, this review aims to analyze power not only in terms of structural inequalities between countries but also in how global health actors (governments, multilateral organizations, and non-state actors) influence the distribution of health resources and decision-making processes.\u003c/p\u003e\n\u003cp\u003eGiven that power dynamics are often implicit and not always openly discussed in formal publications, this methodological approach enables the triangulation of information from multiple perspectives, including peer-reviewed research, institutional reports, and expert analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Framework:\u0026nbsp;\u003c/strong\u003ePower is inherently relational, shaped by interactions among actors, structures, and institutions. To analyze how power\u0026mdash;both visible and invisible\u0026mdash;shaped global health equity and COVID-19 responses, this study applies Lukes\u0026apos; three-dimensional model of power as a conceptual lens [17].\u003c/p\u003e\n\u003cp\u003eLukes\u0026rsquo; framework provides a structured approach to understanding how power operates at multiple levels within global health systems:\u003c/p\u003e\n\u003cp\u003eThe First Dimension (Visible Power) \u0026ndash; Power is exercised through direct decision-making, such as pandemic lockdowns, vaccination campaigns, and vaccine purchasing and distribution policies, where actors explicitly allocate resources and make public health decisions. The Second Dimension (Agenda-Setting Power) \u0026ndash; Power is exerted by shaping which issues are prioritized and which are excluded from decision-making spaces. For example, the COVAX initiative reflects this dimension, as it was designed to promote equitable vaccine distribution but was constrained by the priorities and financial commitments of high-income countries. The Third Dimension (Ideological and Perceptual Power) \u0026ndash; Power influences how problems are framed and understood, shaping public perceptions and policy narratives. The framing of vaccine nationalism as a strategy to protect national interests, despite its consequences for global health equity, illustrates this dimension.\u003c/p\u003e\n\u003cp\u003eThis framework allowed us to interrogate both overt policy decisions and the less visible forces that shape global health cooperation and equity outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperationalizing Power Dynamics:\u0026nbsp;\u003c/strong\u003ePower dynamics were operationalized as multifaceted and relational, spanning political, economic, institutional, and ideological dimensions. The analysis considered how these forces influenced global health governance structures, resource flows, and the relative agency of low- and middle-income countries (LMICs) in shaping pandemic response strategies.\u003c/p\u003e\n\u003cp\u003eTo account for temporal shifts, we also assessed the transformative impact of power dynamics over the past 25 years, with a particular focus on the period spanning 2020 to 2025, encompassing the height of the COVID-19 crisis and its ongoing aftermath.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSearch Strategy:\u003c/strong\u003e The review encompassed articles and publications indexed in PubMed, Scopus, Google Scholar, and the Directory of Open Access Journals (DOAJ). Due to limited journal publications in the domain of \u0026quot;power dynamics,\u0026quot; supplementary searches were performed on the websites of reputable sources such as the World Health Organization (WHO), CDC, and trusted online newspapers.\u003c/p\u003e\n\u003cp\u003eThe search strategy involved the use of various combinations of the following search terms: \u0026lsquo;Global Health\u0026rsquo;, \u0026lsquo;International cooperation\u0026rsquo;, \u0026lsquo;Health equity\u0026rsquo; \u0026lsquo;Power dynamics\u0026rsquo;, and \u0026lsquo;COVID-19\u0026rsquo;. The search terms were \u0026lsquo;Power dynamics and COVID-19\u0026rsquo;, \u0026lsquo;Power dynamics and International cooperation\u0026rsquo;, Power dynamics and Health equity\u0026rsquo;, \u0026lsquo;COVID-19 and Global Health\u0026rsquo;, \u0026lsquo;COVID-19 and Health equity\u0026rsquo;, \u0026lsquo;COVID-19 and International cooperation\u0026rsquo;, and \u0026lsquo;Health equity and International cooperation\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria:\u003c/strong\u003e Articles published between 2000 and 2025 were included to analyze the pre-existing landscape of development assistance for health and international cooperation before the emergence of COVID-19 and its impact post-pandemic. Original research articles, policy documents, and global health reports from multilateral organizations were considered. Geographical restrictions were not imposed due to the global nature of the topic.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria:\u003c/strong\u003e Studies were excluded if they were duplicates, systematic reviews, lacked full-text access, or were not sufficiently relevant to the research topic. Following the screening process, a total of 89 articles met the inclusion criteria and were incorporated into the review.\u003c/p\u003e\n\u003cp\u003eA PRISMA flow diagram (Figure 1) illustrates the identification, screening, and selection process. The characteristics of the included studies\u0026mdash;such as year of publication, study type, and country of origin\u0026mdash;are summarized in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Extraction:\u003c/strong\u003e Data extraction focused on key domains and the thematic relationships:\u003c/p\u003e\n\u003cp\u003eGlobal Health Cooperation and Power Dynamics: This theme focused on how power was distributed among key global health actors such as the World Health Organization (WHO), national governments, and multinational institutions and how this distribution influenced the coordination and effectiveness of the global COVID-19 response.\u003c/p\u003e\n\u003cp\u003ePower Dynamics and Health Equity: This component explored how power influenced the allocation of essential health resources, including vaccines, personal protective equipment (PPE), and funding. It also examined disparities in access between countries in the Global North and Global South.\u003c/p\u003e\n\u003cp\u003eInternational Cooperation and Health Equity: This theme analyzed the extent to which multilateral initiatives such as COVAX and DAH were able to promote health equity amid existing power asymmetries. It also assessed how the imbalance of influence among international actors may have hindered the goals of equitable distribution and collaborative response.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSynthesis Approach:\u0026nbsp;\u003c/strong\u003eA narrative synthesis approach was employed, which followed a systematic process of categorizing and synthesizing findings to capture a comprehensive understanding of the topic. The conceptual framework (Figure 2) provided a visual representation of the interconnected themes, helping to structure the synthesis and ensure clarity and consistency across the review.\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003e\u003cstrong\u003ePre-existing landscape of DAH and global health cooperation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDevelopment Assistance for Health (DAH) has long served as a vital mechanism for promoting international cooperation and advancing global health equity, particularly between the Global North and South [28]. By supporting health systems in low- and middle-income countries, DAH contributes to improved health outcomes, capacity building, and collective progress toward achieving Sustainable Development Goal 3 (SDG 3): Good Health and Well-being. Understanding the distribution and political underpinnings of DAH provides essential context for evaluating global health governance and cooperation before and during the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003eThe top four donor countries providing DAH are the U.S, the U.K., Germany, and Japan [17]. The U.S. saw a sharp increase in DAH during the pandemic, rising from $9.5 billion in 2019 to $12.1 billion in 2020, followed by $16.2 billion in 2021 and $17.5 billion in 2022. Of this, more than 70% was allocated through bilateral agreements. COVID-19-specific funding by the U.S. totaled $506.8 million in 2020, increasing to $921.7 million in 2021 and $3.1 billion in 2022 [18]. U.S. bilateral assistance in 2020 targeted areas such as Covid-19, HIV/AIDS, malaria, reproductive health, and pandemic response.\u003c/p\u003e\n\u003cp\u003eThe U.K.\u0026rsquo;s DAH also peaked in 2020 at $3.4 billion, a slight increase from $3.3 billion in 2019. However, it declined in subsequent years, falling to $2.6 billion in 2021 and $2.1 billion in 2022. The UK has traditionally prioritized multilateral mechanisms, with the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and the Vaccine Alliance (Gavi) receiving the largest shares of its multilateral contributions [19]. In terms of COVID-19 response, the UK contributed $456.5 million in 2020, $261.0 million in 2021, and $314.9 million in 2022.\u003c/p\u003e\n\u003cp\u003eGermany multilateral DAH flows also increased significantly during the pandemic, rising from $1.6 billion in 2019 to $3.5 billion in 2020, then $4.8 billion in 2021 and $4.5 billion in 2022 [28]. COVID-19 response constituted the largest portion of this spending, totaling $1.5 billion in 2020, $2.4 billion in 2021, and $2.3 billion in 2022 [28].\u003c/p\u003e\n\u003cp\u003eJapan\u0026rsquo;s DAH has historically emphasized bilateral support, focusing on basic health care services, medical research, and the control of sexually transmitted diseases [20]. Most of Japan\u0026rsquo;s bilateral assistance targeted countries in Africa and Central Asia. Although one estimate suggested that $54.8 billion was allocated for global DAH in 2020\u0026mdash;with $13.7 billion for COVID-19 response, $3.1 billion for country-level coordination, and $2.4 billion for supply chain and logistics [21]\u0026mdash;other sources report more conservative figures for Japan\u0026rsquo;s DAH. According to alternative estimates, Japan spent $809 million in 2019, $1.5 billion in 2020, $1.7 billion in 2021, and $2.6 billion in 2022. Its COVID-19-specific DAH totaled $612.8 million in 2020, $591.3 million in 2021, and $835.1 million in 2022 [29].\u003c/p\u003e\n\u003cp\u003eIn 2020, many donor countries increased their DAH contributions in response to the COVID-19 crisis, with the European Union (EU) institutions emerging as the largest funders of pandemic-related health activities [22]. However, funding patterns also reveal how political considerations shaped global health priorities. Major powers such as the United States and China leveraged vaccine distribution as a form of soft power, often tying aid to diplomatic or strategic interests [30]. This politicization of health assistance complicated efforts to ensure equitable access, as recipient countries were at times expected to align with donor preferences. This politicization of health assistance complicated efforts toward equitable resource distribution, as recipient countries were sometimes implicitly expected to align with the geopolitical interests of donor nations [31].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePower dynamics and global health cooperation during the COVID-19 crisis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe involvement of the EU, U.S., China, India, and African countries not only affected health outcomes but also shaped the political and economic landscape of international cooperation in public health.\u003c/p\u003e\n\u003cp\u003eEuropean Union countries united in their response to the COVID-19 pandemic, pooling funds and coordinating vaccination campaigns across the Union. Since the pandemic began in early 2020, the EU, EU Member States, and European financial institutions (collectively known as Team Europe) have disbursed \u0026euro;47.7 billion to support partner countries in addressing the pandemic and its aftermath, fulfilling their commitments with tangible results [23]. By June 2022, 86% of adults in the EU were fully vaccinated against COVID-19 [23,24].\u003c/p\u003e\n\u003cp\u003eSimilarly, the U.S. government committed significant resources to combating COVID-19 both domestically and globally through initiatives such as the American Rescue Plan and the distribution of vaccines [32, 33]. Notably, the U.S. pledged nearly 1.1 billion covid 19 doses to support COVAX, and over $380 million in political risk insurance to Gavi [34]. The U.S. played a crucial role in funding global health organizations such as the World Health Organization (WHO) during the pandemic, contributing US$\u0026nbsp;1.284\u0026nbsp;billion during the 2022\u0026ndash;2023 biennium [35]. However, its initial threat to withdraw funding introduced a complex dynamic in global health cooperation, raising uncertainties about the WHO\u0026rsquo;s leadership in vaccine distribution and global health policy coordination.\u003c/p\u003e\n\u003cp\u003eChina\u0026rsquo;s role in the global response to the COVID-19 pandemic was characterized by a combination of direct support through vaccine diplomacy and the provision of medical supplies and expertise [36]. \u0026nbsp;China also played a prominent role in vaccine distribution, providing vaccines to dozens of countries in Africa, Asia, and Latin America. By December 2022, China had distributed a total of 1.65 billion vaccine doses globally [37].\u003c/p\u003e\n\u003cp\u003eWhile higher-income countries dominated global financial and vaccine distributions, several countries in the Global South also took significant steps to address the crisis. India, for example, became a global hub for vaccine production, especially through the Serum Institute of India, which produced millions of doses for both domestic use and export [38]. India\u0026rsquo;s capacity to produce vaccines for COVAX and other international partners played a crucial role in addressing the global vaccine shortage [39].\u003c/p\u003e\n\u003cp\u003eThe African Union\u0026rsquo;s engagement with COVAX, as well as the establishment of initiatives like the Africa Medical Supplies Platform (AMSP) in June 2020, highlighted the importance of South-South cooperation in managing the crisis [40]. In the first quarter of 2021, the African Union allocated US$2 billion in advance procurement guarantees to secure 270 million COVID-19 vaccine doses for its Member States [41].\u003c/p\u003e\n\u003cp\u003eNonetheless, the challenges confronting global health diplomacy became glaringly evident during the COVID-19 pandemic, which perhaps stands as the most significant pandemic in modern history [25]. The pandemic prompted governments worldwide to implement unprecedented and extraordinary measures to safeguard public health, including closing international borders and suspending air travel [26]. These measures were implemented knowing that diseases transcend national boundaries, requiring a more integrated and coordinated global response to tackle the unprecedented global challenge [5]. Nonetheless, the emergence of new variants like the omicron variant led to diplomatic incidents such as travel bans and reciprocal actions among nations [27, 42-44]. These actions reflected not only the challenges in aligning responses to a global health crisis but also the broader implications of power dynamics on diplomatic relations and cooperation strategies [45].\u003c/p\u003e\n\u003cp\u003eAs the COVID-19 crisis unfolded, the WHO reported staggering statistics on global cases and deaths, prompting intensified scrutiny of multilateral organizations like the WHO [46]. The substantial loss of lives resulting from the COVID-19 outbreak has raised questions about the effectiveness of global cooperation and brought intense scrutiny upon the WHO and other multilateral organizations tasked with disease control. Some WHO Member States have expressed doubts about the timeliness of WHO\u0026apos;s response to the pandemic, while countries severely impacted by the virus threatened to withdraw their financial support for WHO [47]. Consequently, the president of the United States, through an executive order, announced plans to withdraw the U.S. from the WHO, ceasing its funding to the global health organization [48].\u003c/p\u003e\n\u003cp\u003eGeopolitical tensions were amplified during the pandemic, particularly evident in the rhetoric surrounding the virus\u0026apos;s origin and implications, notably between China and the United States [49, 50]. These tensions intersected with economic considerations, influencing international relations and cooperation strategies, as seen in political statements supporting pandemic-affected industries [51]. This intersection highlights the intricate relationship between power dynamics, global health, and international cooperation in crises.\u003c/p\u003e\n\u003cp\u003eGlobal health diplomacy faces significant challenges at a critical juncture when its importance is more pronounced than ever before. Analysts of international politics widely acknowledge that multilateralism experienced a period of instability [25]. Emerging political and economic dynamics, particularly geopolitical power shifts, have raised questions about the viability of existing institutions and the foundational principles upon which they were established [5].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePower dynamics and health equity during the COVID-19 crisis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe COVID-19 crisis underscored the critical intersection between power dynamics and health equity, particularly in the context of vaccine access and distribution. The pandemic revealed longstanding disparities in global health, magnifying existing inequities across different regions [52, 53]. One of the key challenges highlighted was equitable access to COVID-19 vaccines, especially for countries in the Global South, which became a focal point for affected governments and international organizations [54-56].\u003c/p\u003e\n\u003cp\u003eA glaring example of these disparities is seen in Latin America, where despite accounting for 34.3% of COVID-19 deaths among low- and middle-income countries, the region received only $714.4 million (7%) of COVID-19 DAH funding [21]. This discrepancy in funding allocation reflects broader power dynamics in global health governance, where wealthier nations with economic power and political influence can secure more resources, leaving low-income regions disproportionately underfunded [57].\u003c/p\u003e\n\u003cp\u003eBrazil\u0026rsquo;s COVID-19 vaccine strategy illustrates how both global and domestic power dynamics can shape health equity outcomes. As of June 2021, Brazil had reported over 16 million confirmed COVID-19 cases and more than 470,000 deaths\u0026mdash;ranking it second globally in terms of total fatalities, according to the WHO COVID-19 Dashboard [58, 59]. Although Brazil participated in COVAX as a self-financing country, its upper-middle-income classification meant it received less subsidized support and had to pay higher premiums to maintain procurement autonomy [60]. Negotiations with Pfizer were prolonged due to political tensions and disputes over liability and contractual terms [61]. The eventual agreement was secured only after legal responsibility was devolved to subnational governments, illustrating the intersection of domestic governance fragmentation and international contractual complexities.\u003c/p\u003e\n\u003cp\u003eSimilarly, Peru had the world\u0026rsquo;s highest COVID-19 death rate per 100,000 population, according to Johns Hopkins University, as of July 2021 [62]. In January 2021, Peru signed a bilateral deal for 38 million Sinopharm doses, reflecting the urgency driven by global vaccine competition and limited multilateral access [63]. It was also among the first in the Americas to receive COVAX vaccines, with 117,000 Pfizer doses delivered in March as part of a 13 million-dose allocation. UN agencies, including UNICEF and PAHO, supported distribution through cold chain infrastructure, including ultra-low freezers and solar-powered units for remote areas [64, 65]. Despite early efforts, supply remained insufficient to meet national demand. To address these shortages, Peru pursued additional agreements, such as the September 2021 deal with Moderna for 20 million doses, with deliveries beginning in early 2022 [66]. Consequently, by December 2021, approximately 75.8% of the adult population had received full vaccination.\u003c/p\u003e\n\u003cp\u003eFurthermore, despite evidence that herd immunity to COVID-19 can only be achieved through vaccination, especially from promising technologies such as nano vaccines [67, 68], significant disparities emerged in the licensing of vaccines for emergency use. For instance, pharmaceutical companies in India faced delays in international approval for their vaccines despite securing national regulatory authorization. These delays reflect the complex interplay between global regulatory frameworks and the political dimensions of health diplomacy [69]. These instances highlight the need for greater transparency, collaboration, and equity-focused policies in addressing health disparities and ensuring equitable access to life-saving medical interventions during crises like the COVID-19 pandemic [70, 72].\u003c/p\u003e\n\u003cp\u003eIn Africa, advocacy for equity in the accessibility and distribution of COVID-19 testing kits and vaccines was done [73]. Additionally, the African Centers for Disease Control and Prevention (Africa CDC) has urged African leaders to strengthen their health systems. The former Director General of Africa CDC, John Nkengasong, emphasized the importance of regionalizing health systems to enhance responsiveness during crises, stating, \u0026ldquo;Equity starts by regionalizing health systems so that when a crisis hits, regions have the capacity and ability to respond\u0026rdquo; [73]. This statement underscores the vision and objectives of South-South Collaboration [74].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe discussion on the COVID-19 pandemic and global health diplomacy highlights several key points regarding international cooperation, power dynamics, and health equity. One crucial aspect is the recognition that diseases like COVID-19 do not differentiate between donor and recipient countries when it comes to major health crises such as pandemics. Before the COVID-19 era, donor funds have assisted developing countries in addressing their major health challenges and progress towards achieving the third Sustainable Development Goal.\u003c/p\u003e\n\u003cp\u003eThe surge in donations towards DAH during the COVID-19 pandemic highlights the significance of global health to donors. In 2020, while the European Union (EU) institutions made the largest contributions towards COVID-19 related activities, the U.S. government emerged as the largest donor to DAH overall [17]. Moreover, the U.S. government\u0026apos;s contribution in 2020 surpassed that of the UK, Germany, and Japan combined. However, it\u0026apos;s important to note that donor organizations influence the allocation of DAH and the selection of implementing organizations based on their relationships [9], potentially impacting health equity and universal coverage due to underlying power differentials.\u003c/p\u003e\n\u003cp\u003eWhile it was crucial for countries to implement measures to control epidemics domestically and at international borders, some countries exploited COVID-19 travel restrictions for political gain. The application of territorial sovereignty to impose travel restrictions during the pandemic overshadowed the WHO\u0026rsquo;s 2025 International Health Regulations, which were designed to guide the international response to health emergencies [75, 76]. This disregard for the IHR reflected how political power often interfered with health decisions, complicating the global response to the pandemic.\u003c/p\u003e\n\u003cp\u003eIn an effort to depoliticize the global health response and avoid the political use of health measures, alternative strategies, such as targeted health surveillance and control measures, instead of blanket flight bans and reciprocity, could have been more effective in managing the pandemic\u0026apos;s spread while preserving individual rights and fostering international cooperation. For instance, individuals testing positive before travel could be prevented from boarding until cleared, and those testing positive upon arrival could be isolated. Quarantine measures, as implemented during the Middle East respiratory syndrome coronavirus (MERS-CoV) and severe acute respiratory syndrome (SARS) outbreaks could also be applied based on COVID-19 guidelines at the destination for symptomatic individuals or those in contact with positive cases during travel [77, 78].\u003c/p\u003e\n\u003cp\u003eAmidst the global fight against COVID-19, the UN Secretary-General emphasized the imperative that \u0026quot;no one is safe until everyone is\u0026quot; [79]. This ethos, which mirrors the foundational principles of the WHO, must remain central to global health diplomacy, reinforced through ongoing relationship-building and negotiation processes.\u003c/p\u003e\n\u003cp\u003eTo prevent stigmatization and discrimination, WHO issued guidelines prohibiting naming infectious agents or diseases after geographic locations [80]. Policymakers are expected to reference this guidance in discussions regarding the nomenclature of infectious diseases in the future.\u003c/p\u003e\n\u003cp\u003eMarket-driven approaches to healthcare have exacerbated existing inequities and hindered equitable access to COVID-19 diagnostic kits and vaccines. Wealthier countries with economic power secured timely access to licensed COVID-19 vaccines, leaving lower-income countries struggling to access sufficient supplies [81]. Yet\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003ePeru offers a notable example of national initiative amid these disparities. Despite early challenges and limited COVAX access, the government pursued bilateral agreements and expanded cold chain capacity. By December 2021, over 75.8% of adults were fully vaccinated\u0026mdash;demonstrating how strategic national action and partnerships can overcome structural barriers to health equity [82-84].\u003c/p\u003e\n\u003cp\u003eThe Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement further complicated equitable access by protecting intellectual property rights that limited the ability of low- and middle-income countries to produce vaccines locally. Also, stringent intellectual property rights may partially explain the delays in licensing of vaccines from developing countries. For instance, India\u0026rsquo;s Covaxin was delayed in its approval for international distribution due to regulatory challenges, exacerbating access issues and contributing to the delays in vaccine availability to countries relying on COVAX for supplies [85]. This disparity highlighted structural inequities in the global health system, with vaccines often being treated as commodities rather than essential public health resources.\u003c/p\u003e\n\u003cp\u003eThe TRIPS waiver advocated by global health organizations and developing countries aimed to mitigate these inequities by allowing for the temporary suspension of intellectual property protections on COVID-19 vaccines, enabling wider access to production and distribution [85-89]. Such measures would allow developing nations to produce generic versions of life-saving vaccines, thereby advancing global health equity.\u003c/p\u003e\n\u003cp\u003eThe withdrawal of the United States, the major financial contributor, from the WHO would significantly weaken the multilateral organization\u0026rsquo;s capacity to support health initiatives in resource-limited settings. While regionalizing health systems may strengthen healthcare delivery in individual countries within a region, the proposed step by the U.S. Government could have profound implications for global health equity. This would likely exacerbate existing health inequities, particularly in regions like Southeast Asia and South America, where regionalization may not be a practical or prioritized approach. Furthermore, the establishment of a new regional health organization risks fragmenting global health efforts, potentially leading to duplication of initiatives and inefficiencies in addressing transnational health challenges. Such actions could undermine the spirit of multilateral cooperation, which is crucial for coordinated and effective responses to global health crises.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLESSONS LEARNED AND IMPLICATIONS FOR FUTURE HEALTH CRISES\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe emergence of COVID-19 has underscored the intricate intersection of global health diplomacy with politics and power asymmetry, significantly impacting international cooperation between high-income and low-income countries. COVID-19 has not only magnified the existing challenges of global health diplomacy but has also exposed systemic weaknesses that are likely to persist and evolve in future public health emergencies.\u003c/p\u003e\n\u003cp\u003eNotably, the pandemic catalyzed both regressive and progressive shifts. On the one hand, power imbalances, sanctions, travel restrictions, and nationalistic agendas undermined equitable collaboration. On the other, increased DAH in response to the pandemic and collaborative efforts, such as regional manufacturing initiatives and the advocacy for intellectual property waivers, signal emerging pathways toward more equitable global health governance. The shared goal of controlling the pandemic has facilitated collective progress towards achieving sustainable development goal 3.\u003c/p\u003e\n\u003cp\u003eA key lesson from COVID-19 is the growing momentum among developing nations to assert greater visible and agenda-setting power in shaping health policy and preparedness through South-South cooperation and regional alliances. These developments offer a critical opportunity to reconfigure power structures and decision-making mechanisms before the next crisis emerges.\u003c/p\u003e\n\u003cp\u003eHowever, enduring challenges remain. Persistent disparities in healthcare infrastructure, underinvestment in public health, and limited ideological power continue to undermine resilience in low- and middle-income countries. Without structural reform in global health financing, governance, and knowledge-sharing systems, future health crises could replicate, or even deepen, the inequities observed during COVID-19.\u003c/p\u003e\n\u003cp\u003eFinally, multilateralism and global solidarity will remain essential to addressing future health emergencies. The pandemic demonstrated that health is a global public good and that coordinated international action is critical. Moving forward, it is imperative to build on initiatives such as COVAX and to strengthen multilateral partnerships among governments, international organizations, the private sector, and civil society to improve global health resilience and equity. Global health efforts must also carefully navigate the tension between political considerations and equity-driven action. Political pressures, whether rooted in intellectual property rights or national self-interest, must not eclipse the fundamental human right to health.\u003c/p\u003e\n\u003cp\u003eIn this light, the pandemic offers not only a reflection of past and present shortcomings but also a blueprint for reimagining a more inclusive and equitable global health order\u0026mdash;one that prioritizes long-term solidarity, regional capacity-building, and fair participation in global decision-making processes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIMITATIONS AND STRENGTH\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGlobal health cooperation and health equity involve complex interactions between multiple stakeholders. We recognize that our review may not capture all the intricacies and nuances of these interactions. Also, our study focuses primarily on power dynamics using the COVID-19 pandemic as a case study, which may limit the application of findings to other global health crises or contexts. Lastly, we did not include the Web of Science database during our search potentially excluding other articles and publications relevant to this topic. Despite these limitations, our study includes citations from various countries and continents, encompassing perspectives from both the global north and south. This broad representation enhances the potential generalizability of our findings and enriches the diversity of insights into power dynamics, international cooperation, and global health equity.\u003c/p\u003e"},{"header":"Conclusion and Recommendations","content":"\u003cp\u003eThis review has explored the complex role of power dynamics in shaping global health equity and cooperation during the COVID-19 pandemic. As the world confronted unprecedented challenges, it became clear that global health diplomacy is deeply entwined with political interests and systemic power imbalances between high-income and low-income countries.\u003c/p\u003e\n\u003cp\u003eEvidence from initiatives such as COVAX illustrates how power disparities\u0026mdash;reflected in funding priorities and decision-making control\u0026mdash;shaped access to vaccines and diagnostics, often to the detriment of the Global South. These inequities affected the fairness and effectiveness of international collaboration.\u003c/p\u003e\n\u003cp\u003eWhile global health diplomacy is unquestionably influenced by political forces, the COVID-19 crisis highlighted the urgent need for ongoing global dialogue to depoliticize health policies and promote more equitable cooperation. Proposals to diminish the use of health as a political tool, along with the development of a comprehensive global strategic framework for health diplomacy, are crucial to improving preparedness for future challenges pandemics.\u003c/p\u003e\n\u003cp\u003eThe pandemic presents a critical opportunity for reflection and transformative action. Policymakers and global health leaders must prioritize equitable health outcomes by promoting transparent, inclusive governance in the short and long term. Strengthening regional health systems and expanding South-South collaboration are vital to creating a more resilient global health architecture. These strategies should be grounded in policies that address visible, agenda-setting, and ideological dimensions of power, as outlined in Lukes\u0026rsquo; three-dimensional model, to address structural inequalities at their root.\u003c/p\u003e\n\u003cp\u003eFurther research is essential to assess the post-pandemic impact of power dynamics on global health equity and cooperation. Systematic reviews and meta-analyses, supported by robust statistical methods, can offer crucial insights into the most effective interventions for reducing inequities and building inclusive global health systems. Ultimately, the lessons of COVID-19 must inform a more just and cooperative future for global health.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAfrica CDC\u0026nbsp; \u0026nbsp;\u0026nbsp;African Centers for Disease Control and Prevention\u003c/p\u003e\n\u003cp\u003eCDC \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Centers for Disease Control and prevention\u003c/p\u003e\n\u003cp\u003eDAH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Development Assistance for Health\u003c/p\u003e\n\u003cp\u003eDOAJ \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Directory of Open Access Journals\u003c/p\u003e\n\u003cp\u003eEU \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;European Union\u003c/p\u003e\n\u003cp\u003eHIV/AIDS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Human Immunodeficiency Virus/\u0026nbsp;Acquired Immunodeficiency Syndrome\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIHR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;International Health Regulations\u003c/p\u003e\n\u003cp\u003eMERS-CoV\u0026nbsp; \u0026nbsp;\u0026nbsp;Middle East Respiratory Syndrome Coronavirus\u003c/p\u003e\n\u003cp\u003ePBF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Performance-Based Financing\u003c/p\u003e\n\u003cp\u003eSTD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Sexually transmitted diseases\u003c/p\u003e\n\u003cp\u003eSARS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Severe Acute Respiratory Syndrome\u003c/p\u003e\n\u003cp\u003eSDG \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sustainable Development Goals\u003c/p\u003e\n\u003cp\u003eTRIPS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Trade-Related Aspects of Intellectual Property Rights\u003c/p\u003e\n\u003cp\u003eUN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;United Nations\u003c/p\u003e\n\u003cp\u003eUSA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;United States of America\u003c/p\u003e\n\u003cp\u003eU.S.\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;United States\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was received for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e OSJ conceptualised the study; All authors were involved in the literature review; OSJ and NA extracted the data from the reviewed studies; All authors wrote the final and first drafts. \u0026nbsp; All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eU.S. Department of Health \u0026amp; Human Services. 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SERUM INSTITUTE OF INDIA TO PRODUCE UP TO AN ADDITIONAL 100 MILLION COVID-19 VACCINE DOSES FOR INDIA AND LOW-AND MIDDLE-INCOME COUNTRIES IN 2021. 2020 [cited 2025 Mar 31]; Available from: https://www.seruminstitute.com/news/press_sii_gavi_bmgf.pdf\u003c/li\u003e\n\u003cli\u003eAnjana Pasricha. India\u0026rsquo;s Serum Institute Resumes Vaccine Exports to COVAX Vaccine Sharing Program [Internet]. Voice of America website. 2021 [cited 2025 Mar 31]. Available from: https://www.voanews.com/a/india-s-serum-institute-resumes-vaccine-exports-to-covax-vaccine-sharing-program/6330056.html\u003c/li\u003e\n\u003cli\u003eUnited Nations Economic Commission for Africa. Showcasing the African Medical Supplies Platform (AMSP): Engaging the Common Market for Eastern and Southern Africa (COMESA) [Internet]. UNECA website. 2020 [cited 2025 Mar 31]. Available from: https://www.uneca.org/events/regional-integration-and-trade-african-trade-policy-centre/showcasing-african-medical\u003c/li\u003e\n\u003cli\u003eAfrica Centres for Disease Control. AMSP opens COVID-19 vaccines pre-orders for 55 African Union Member States [Internet]. Africa CDC Press Release. 2021 [cited 2025 Mar 31]. Available from: https://africacdc.org/news-item/amsp-opens-covid-19-vaccines-pre-orders-for-55-african-union-member-states/\u003c/li\u003e\n\u003cli\u003eInstitute for Health Metrics and Evaluation. Development assistance for health. In: Financing global health 2013: transition in an age of austerity [Internet]. Seattle (WA): IHME; 2014. p. 73-106. [cited 2025 Apr 21]. Available from: https://www.healthdata.org/sites/default/files/files/policy_report/2014/FGH2013/IHME_FGH2013_Chapter4.pdf\u003c/li\u003e\n\u003cli\u003evan Dijk, R.J.L., Lo, C.Yp. The effect of Chinese vaccine diplomacy during COVID-19 in the Philippines and Vietnam: a multiple case study from a soft power perspective. Humanit Soc Sci Commun 10, 687 (2023). https://doi.org/10.1057/s41599-023-02073-3\u003c/li\u003e\n\u003cli\u003eBlair, R. A., Marty, R., \u0026amp; Roessler, P. (2021). Foreign Aid and Soft Power: Great Power Competition in Africa in the Early Twenty-first Century. British Journal of Political Science, 1\u0026ndash;22. doi:10.1017/s0007123421000193\u003c/li\u003e\n\u003cli\u003eDonor Tracker. Global health [Internet]. Online. 2022 [cited 2022 Dec 14]. Available from: https://donortracker.org/sector/global-health.\u003c/li\u003e\n\u003cli\u003eDonor Tracker. United States - Global health [Internet]. Online. 2022 [cited 2022 Dec 14]. Available from: https://donortracker.org/united-states/globalhealth.\u003c/li\u003e\n\u003cli\u003eDonor Tracker. United Kingdom - Global health [Internet]. Online. 2022 [cited 2022 Dec 14]. 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Available from: https://www.consilium.europa.eu/en/policies/coronavirus-pandemic/.\u003c/li\u003e\n\u003cli\u003eWhat\u0026rsquo;s in the American Rescue Plan for COVID-19 Vaccine and Other Public Health Efforts? https://www.kff.org/policy-watch/whats-in-the-american-rescue-plan-for-covid-19-vaccine-and-other-public-health-efforts\u003c/li\u003e\n\u003cli\u003eFACT SHEET: The Biden Administration\u0026rsquo;s Commitment to Global Health. https://bidenwhitehouse.archives.gov/briefing-room/statements-releases/2022/02/02/fact-sheet-the-biden-administrations-commitment-to-global-health\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Global leaders commit further support for global equitable access to COVID-19 vaccines and COVAX [Internet]. WHO Joint News Release. 2021 [cited 2025 Mar 31]. Available from: https://www.who.int/news/item/23-09-2021-global-leaders-commit-further-support-for-global-equitable-access-to-covid-19-vaccines-and-covax\u003c/li\u003e\n\u003cli\u003eLiu, L., Huang, Y., \u0026amp; Jin, J. (2022). China\u0026rsquo;s Vaccine Diplomacy and Its Implications for Global Health Governance. Healthcare, 10(7), 1276. https://doi.org/10.3390/healthcare10071276\u003c/li\u003e\n\u003cli\u003eKampmark B, Kurečić P. Vaccine nationalism: Competition, EU parochialism, and COVID-19. Journal of Global Faultlines. 2022;9(1):9\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eSoares Dos Santos Junior AC. Brazil and the COVID-19 Pandemic. Kidney Int Rep. 2021 Aug;6(8):2017-2018. doi: 10.1016/j.ekir.2021.06.021. Epub 2021 Jul 6. PMID: 34250316\u003c/li\u003e\n\u003cli\u003eWHO Coronavirus (COVID-19) Dashboard. https://covid19.who.int.\u003c/li\u003e\n\u003cli\u003eFonseca EMD, Shadlen KC, Bastos FI. The politics of COVID-19 vaccination in middle-income countries: Lessons from Brazil. Soc Sci Med. 2021 Jul;281:114093. doi: 10.1016/j.socscimed.2021.114093. Epub 2021 Jun 2.\u003c/li\u003e\n\u003cli\u003eInvestigation: Drugmaker \u0026lsquo;bullied\u0026rsquo; Latin American nations https://www.aljazeera.com/news/2021/3/11/investigation-pfizer-bullied-latin-american-nations\u003c/li\u003e\n\u003cli\u003eJohns Hopkins University School of Medicine . Baltimore, MD: Coronavirus Resource Center. Johns Hopkins University School of Medicine; Baltimore, MD, USA: 2021. [(accessed on 21 July 2021)]. Mortality Analyses: Cases and Mortality by Country. Available online: https://coronavirus.jhu.edu/data/mortality\u003c/li\u003e\n\u003cli\u003ePeru Buys First Batch of COVID-19 Vaccines https://www.voanews.com/a/covid-19-pandemic_peru-buys-first-batch-covid-19-vaccines/6200430.html\u003c/li\u003e\n\u003cli\u003ePeru is among the first countries in the Americas to receive COVAX vaccines. https://www.paho.org/en/news/11-3-2021-peru-among-first-countries-americas-receive-covax-vaccines\u003c/li\u003e\n\u003cli\u003eHern\u0026aacute;ndez-V\u0026aacute;squez, A., Vargas-Fern\u0026aacute;ndez, R., \u0026amp; Rojas-Roque, C. (2023). Geographic and Socioeconomic Determinants of Full Coverage COVID-19 Vaccination in Peru: Findings from a National Population-Based Study. Vaccines, 11(7), 1195. https://doi.org/10.3390/vaccines11071195\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. United States of America: A global force for health [Internet]. About WHO funding webpage. 2024 [cited 2025 Mar 31]. Available from: https://www.who.int/about/funding/contributors/usa?\u003c/li\u003e\n\u003cli\u003eLiu, L., Huang, Y., \u0026amp; Jin, J. (2022). China\u0026rsquo;s Vaccine Diplomacy and Its Implications for Global Health Governance. Healthcare, 10(7), 1276. https://doi.org/10.3390/healthcare10071276\u003c/li\u003e\n\u003cli\u003evan Dijk, R.J.L., Lo, C.Yp. The effect of Chinese vaccine diplomacy during COVID-19 in the Philippines and Vietnam: a multiple case study from a soft power perspective. Humanit Soc Sci Commun 10, 687 (2023). https://doi.org/10.1057/s41599-023-02073-3\u003c/li\u003e\n\u003cli\u003eModerna Announces Supply Agreement with Peru for 20 Million Doses of Its COVID-19 Vaccine. https://investors.modernatx.com/news/news-details/2021/Moderna-Announces-Supply-Agreement-with-Peru-for-20-Million-Doses-of-Its-COVID-19-Vaccine/default.aspx\u003c/li\u003e\n\u003cli\u003eRubin R. More Transparency Needed for COVID-19 Emergency Authorizations. JAMA. 2020;324(24):2475. doi:10.1001/jama.2020.24201\u003c/li\u003e\n\u003cli\u003eJohnson, C., Wolff, C., Xu, J. et al. Health Equity and Access to COVID-19 Treatments Available through Emergency Use Authorizations. J. Racial and Ethnic Health Disparities (2024). https://doi.org/10.1007/s40615-024-02094-x\u003c/li\u003e\n\u003cli\u003eSerum Institute. SERUM INSTITUTE OF INDIA TO PRODUCE UP TO AN ADDITIONAL 100 MILLION COVID-19 VACCINE DOSES FOR INDIA AND LOW-AND MIDDLE-INCOME COUNTRIES IN 2021. 2020 [cited 2025 Mar 31]; Available from: https://www.seruminstitute.com/news/press_sii_gavi_bmgf.pdf\u003c/li\u003e\n\u003cli\u003eAnjana Pasricha. India\u0026rsquo;s Serum Institute Resumes Vaccine Exports to COVAX Vaccine Sharing Program [Internet]. Voice of America website. 2021 [cited 2025 Mar 31]. Available\u003c/li\u003e\n\u003cli\u003eUnited Nations Economic Commission for Africa. Showcasing the African Medical Supplies Platform (AMSP): Engaging the Common Market for Eastern and Southern Africa (COMESA) [Internet]. UNECA website. 2020 [cited 2025 Mar 31]. Available from: https://www.uneca.org/events/regional-integration-and-trade-african-trade-policy-centre/showcasing-african-medical\u003c/li\u003e\n\u003cli\u003eAfrica Centres for Disease Control. AMSP opens COVID-19 vaccines pre-orders for 55 African Union Member States [Internet]. Africa CDC Press Release. 2021 [cited 2025 Mar 31]. Available from: https://africacdc.org/news-item/amsp-opens-covid-19-vaccines-pre-orders-for-55-african-union-member-states/\u003c/li\u003e\n\u003cli\u003eGeneva Graduate Institute. Multilateralism Is in Crisis \u0026ndash; Or Is It? | Global Challenges [Internet]. Global Challenges Website. 2020 [cited 2022 Dec 15]. Available from: https://globalchallenges.ch/issue/7/multilaterism-is-in-crisis-or-is-it/.\u003c/li\u003e\n\u003cli\u003eJegede OS, Olarewaju S. The Impact of COVID-19 Lockdown on Global Warming: A Call for Policy Review. Int J Travel Med Glob Health. 2021;9:4\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGOV.UK Department of Health and Social Care UHSA and D for T. 6 African countries added to red list to protect public health as UK designates new variant under investigation [Internet]. 2021 [cited 2023 Feb 2]. Available from: https://www.gov.uk\u003c/li\u003e\n\u003cli\u003eTimothy Obiezu. Nigeria Criticizes British Travel Ban Imposed Due to Omicron [Internet]. Voice of America. 2021 [cited 2022 Nov 24]. Available from: https://www.voanews.com/a/nigeria-criticizes-british-travel-ban-imposed-due-to-omicron-/6342353.html.\u003c/li\u003e\n\u003cli\u003eWorld Health Organisation. Updated WHO recommendations for international traffic in relation to COVID-19 outbreak [Internet]. WHO website. 2020 [cited 2023 Feb 9]. Available from: https://www.who.int/news-room/articles-detail/updated-who-recommendations-for-international-traffic-in-relation-to-covid-19-outbreak.\u003c/li\u003e\n\u003cli\u003eLabont\u0026eacute; R, Gagnon ML. Framing health and foreign policy: Lessons for global health diplomacy. Global Health [Internet]. 2010 [cited 2024 May 24];6:1\u0026ndash;19. Available from: https://globalizationandhealth.biomedcentral.com/articles/10.1186/1744-8603-6-14.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO Coronavirus (COVID-19) Dashboard With Vaccination Data [Internet]. Online. 2022 [cited 2022 Dec 14]. Available from: https://covid19.who.int/.\u003c/li\u003e\n\u003cli\u003eBBC News. Coronavirus: US to halt funding to WHO, says Trump - BBC News [Internet]. Online. 2020 [cited 2022 Nov 24]. Available from: https://www.bbc.com/news/world-us-canada-52289056.\u003c/li\u003e\n\u003cli\u003eThe White House. Withdrawing The United States From The World Health Organization [Internet]. The White House website. 2025 [cited 2025 Mar 31]. Available from: https://www.whitehouse.gov/presidential-actions/2025/01/withdrawing-the-united-states-from-the-worldhealth-organization/\u003c/li\u003e\n\u003cli\u003ePeru Buys First Batch of COVID-19 Vaccines https://www.voanews.com/a/covid-19-pandemic_peru-buys-first-batch-covid-19-vaccines/6200430.html\u003c/li\u003e\n\u003cli\u003eModerna Announces Supply Agreement with Peru for 20 Million Doses of Its COVID-19 Vaccine. https://investors.modernatx.com/news/news-details/2021/Moderna-Announces-Supply-Agreement-with-Peru-for-20-Million-Doses-of-Its-COVID-19-Vaccine/default.aspx\u003c/li\u003e\n\u003cli\u003eHern\u0026aacute;ndez-V\u0026aacute;squez, A., Vargas-Fern\u0026aacute;ndez, R., \u0026amp; Rojas-Roque, C. (2023). Geographic and Socioeconomic Determinants of Full Coverage COVID-19 Vaccination in Peru: Findings from a National Population-Based Study. Vaccines, 11(7), 1195. https://doi.org/10.3390/vaccines11071195\u003c/li\u003e\n\u003cli\u003eErfani P, Binagwaho A, Jalloh MJ, et al. Intellectual property waiver for covid-19 vaccines will advance global health equity. The BMJ. 2021;374.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Characteristics of articles included in this review\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"616\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en=89\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear of Publication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003e2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Publication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n 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\u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eDocument\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003ePolicy Review/Brief\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003ePress Release and News Report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n 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33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eNigeria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eEast and Southern Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eEgypt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eMixed countries\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eCameroon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eLiberia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n 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\u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003ePeru\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.9837%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 45.8537%;\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20.1626%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eEU \u0026ndash; European Union\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, Diplomacy, Health Equity, International Cooperation, Pandemics, Policy","lastPublishedDoi":"10.21203/rs.3.rs-6966773/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6966773/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"The COVID-19 pandemic is over, but its impact on global health equity remains a significant concern. The pandemic highlighted and, in some cases, exacerbated longstanding inequities in global health systems, especially in low-resource settings. Power dynamics played a critical role in shaping global health equity and cooperation, influencing the allocation of resources, decision-making processes, and access to life-saving interventions. While existing studies have examined the relationship between global health diplomacy and health equity, the specific impact of power dynamics on health equity and diplomacy during the pandemic remains underexplored. This review explores how power dynamics influenced global health cooperation and health equity during the COVID-19 pandemic. A narrative review, guided by Lukes' three-dimensional model of power, was conducted. The review spans publications from 2000 to 2025 and includes 89 eligible articles, encompassing research studies, policy documents, and global health reports. Data extraction focused on three key domains: Development Assistance for Health (DAH), equity in the pandemic response, and political power dynamics. The review revealed that donor countries increased Development Assistance for Health (DAH) support in response to COVID-19. However, vaccine nationalism, geopolitical tensions, sanctions, and intellectual property regimes perpetuated inequities between the Global North and South. Despite multilateral initiatives like COVAX, inequitable access to vaccines and diagnostics persisted, largely due to the concentration of decision-making power among high-income countries and powerful institutions. The review concludes that achieving sustainable global health equity requires confronting entrenched power asymmetries that hinder meaningful cooperation, promoting inclusive governance, and depoliticizing health diplomacy. Transparent, equity-focused policies, strengthened regional health systems, and expanded South-South collaboration are essential for building resilience to future global health crises. Further research is recommended to evaluate the post-pandemic impact of power dynamics on global health equity and cooperation.","manuscriptTitle":"The Impact of Power Dynamics on Global Health Cooperation and Health Equity during the COVID-19 Crisis: Lessons for Future Policy and Pandemic Preparedness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-03 08:37:31","doi":"10.21203/rs.3.rs-6966773/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"adc54790-6c6e-4a9b-aff7-8077e1bd70cb","owner":[],"postedDate":"July 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-03T08:37:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-03 08:37:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6966773","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6966773","identity":"rs-6966773","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}