Measure Whether the Plan Works, Not Whether It Is Followed: Public Comment on WHO’s Draft Monitoring Framework for COVID

The World Health Organization (WHO) has asked for public comment on its draft framework for measuring progress in managing COVID through 2030 [1]. Our central comment is that the framework measures whether countries have adopted WHO’s guidance, not whether that guidance is effective in protecting people. It counts plans, programs, and vaccine availability. It does not count infections, Long COVID, infections acquired in healthcare settings, or the quality of indoor air. The result is accountability for process, not for outcomes: every measure can be met while infection and long-term harm persist.

The world will not judge WHO by these measures. It will judge WHO by how many people were infected, disabled, and killed. That is also WHO’s own stated standard: its constitution sets its objective as “the attainment by all peoples of the highest possible level of health” [2]. By that standard we believe the current guidance is insufficient regarding airborne transmission, clean air, respiratory protection, and Long COVID. We identified these issues when WHO’s strategic plan was in draft [3] and in an open letter signed by more than 2,300 people [4]. We have set out the evidence on the disease and the response to it [5], on respiratory protection [4,6,7], and on Long COVID and lasting organ and immune damage [8–13]. It is also laid out in the hundreds of thousands of scientific articles on COVID, its long-term harm, and how societies have responded.

Tens of millions of people have died in the COVID pandemic over the last 7 years. Countries reported about 7 million COVID deaths. WHO’s own estimate of excess deaths through 2023 exceeds 22 million [14]. WHO attributes the widening gap since 2022 largely to underreporting, as countries stopped testing [14]. More than 400 million people have had Long COVID, and the number grows with repeated infections [8]. Outcomes for countries have also differed tremendously, and those differences show which measures worked. This record is the most important scientific information that we have for managing COVID going forward, and the framework does not use it. It looks ahead to 2030 by counting plans and documents, and its measure of impact is reported deaths. That measure has grown less reliable each year. For 2023 alone, WHO’s estimates show about nine excess deaths for every reported COVID death [14].

The framework contains little science of its own. It measures whether countries adopt WHO’s guidance. For protective measures, it counts countries that have written them into their plans (indicator OP.2.2). The measures WHO now offers countries for COVID are in Annex II of its National actions document [15], a table developed for influenza (see Table 1 for selected rows). That table does not mention airborne transmission or respirators. It recommends mask wearing only under specific conditions, and it strongly recommends against air purification in community settings, even though the guideline panel judged that the health benefits probably favor it and based its recommendation on cost [16]. It also recommends against contact tracing, mass testing, and screening at borders. Its assessment of masks rests on trials in which they were worn only part of the time [4,7,17]. No one would judge an antibiotic by a trial in which it was taken for an incomplete course, or expect to stay dry using an umbrella only occasionally when it rains.

The framework commits WHO to publish recommendations on these measures for coronaviruses (milestone M.2.2). Those recommendations should start from how COVID spreads, through the air, and should not carry over the outdated influenza table. Ventilation, which WHO already strongly recommends, belongs at the center together with air cleaning and respirators, beginning in healthcare.

The same influenza template shapes the framework’s vaccination measure, which counts annual coverage (indicator OC.4.1). COVID circulates year-round and new variants continue to emerge. Protection against symptomatic illness falls by about half within three months of a dose [18–20]. One dose per year that wanes quickly is not sufficient for a non-seasonal disease that typically delivers two waves per year. The measure should count how many people are currently protected. For example, how many people have been vaccinated within the past three to six months.

Table 1: Selected rows from WHO’s list of public health and social measures for epidemic and pandemic influenza, which WHO offers countries for COVID [15, Annex II; 16]. The recommendations apply to community settings, not healthcare. “Certainty” is WHO’s rating of the evidence; “recommendation” is WHO’s advice, which also weighs cost and feasibility. “Strong” means WHO “recommends” or “recommends against”; “conditional” means it “suggests” or “suggests against.” Strength does not track WHO’s own certainty ratings: humidity and symptom screening at borders receive strong recommendations against on very low certainty, and air purification receives a strong recommendation against despite moderate certainty that it reduces transmission.

What the framework should measure

The framework’s own limitations section acknowledges that indicators of whether policies exist “provide limited information on their quality, reach, and use” [1]. It has outcome indicators only for vaccines and therapeutics; the other four intended outcomes have none. A framework for learning has to measure whether people are being protected. Healthcare is where to begin, because health authorities set its standards directly. Most infections happen outside it, and the same protections apply in schools, workplaces, and public buildings. We recommend adding the following indicators, detailed in Annex A:

1. Excess mortality, alongside reported deaths.
2. Infections acquired in healthcare, reported as rates using a common definition.
3. Infections among health and care workers.
4. Respiratory protection, recorded by category, up to respirators by default throughout healthcare as a national standard.
5. Engineered infection prevention, credited by verified performance rather than equipment installed.
6. National standards for healthcare facility design, ventilation, and cleaning and disinfection that include engineered requirements.
7. Indoor air quality in schools and other public buildings, measured against a national standard.
8. Whether respirators and tests are available and affordable to the public, and how widely they are used.
9. How many people have been vaccinated within the past three to six months.
10. How many people develop and live with Long COVID.
11. Infection levels from wastewater and seroprevalence surveys.

Existing science predicts how these measures are related: stronger protection should mean fewer infections, and fewer infections less illness, disability, and death. Evaluating the outcomes against each other should be part of the framework’s learning process.

The framework also sets a baseline but no targets, so any change can be described as progress. WHO already sets targets for this problem: its global action plan on infection prevention and control aims for every country to have a national target for reducing healthcare-associated infections by 2030, and tracks how many achieve them [22]. Its vision is that by 2030 everyone accessing or providing health care is safe from associated infections. Today, from a quarter to three-quarters of hospital COVID cases are acquired in hospital where this is measured (Annex A). That is far from WHO’s vision. Each indicator should have SMART global and national targets, with progress assessed as set out in Annex B.

We urge WHO to consider these recommendations in order to provide a more proactive and comprehensive approach to the management of COVID. 

WHO has asked how progress should be measured. Measure infections, disability, and death, and let the guidance follow the evidence.

Members of the public may leave public comments on the draft monitoring, evaluation, and learning framework [1] until November 13th, 2026 at 23:59 CET. Here is the link to the form.

Annex A: Recommended indicators

1. Excess mortality. Report WHO’s own modelled excess deaths alongside reported COVID deaths (IM.2.1). Reported deaths alone depend on testing and reporting and cannot show whether the plan is working [14].

2. Infections acquired in healthcare. Report the proportion of hospitalized COVID, influenza and RSV cases acquired in hospital and the rate per 10,000 patient-days, using a common onset definition. Some countries already report this weekly. Canada’s national surveillance program reports the share of COVID hospitalizations that are healthcare-associated, typically 25% to 40% [23]. In Wales, using a stricter definition (first positive test more than 7 days after admission), three-quarters of hospital inpatients with COVID in late September 2026 had acquired it in hospital [24]. Differences in definitions and in what is counted make these figures hard to compare, which is why a common WHO definition is needed. Hospitals are where WHO’s guidance applies most directly, and where its effect is easiest to measure. 

3. Health and care worker infections. Track infections among health and care workers as an occupational outcome.

4. Respiratory protection. Record each Member State’s highest national requirement for health care workers:

• (a) no national requirement;
• (b) medical masks or “masks” with the type not specified;
• (c) respirators (N95, FFP2 or better) for all care of suspected or confirmed cases;
• (d) as (c), with fit testing within an occupational respiratory protection program;
• (e) as (d), with respirators used throughout patient care areas during periods of elevated transmission;
• (f) a national standard requiring respirators by default throughout health care, with exemptions only for areas shown by risk assessment to be protected by engineering controls.

Canada’s draft national respirator standard takes approach (f) [25]. Few if any countries meet it today, which is a reason to measure it. Report the distribution across categories and how it changes between rounds. Medical masks are not respiratory protection and should not be counted as such.

5. Engineered infection prevention. Measure how far engineered controls, which work without relying on individual behavior, are in place, starting with emergency departments, intensive care, waiting rooms, and respiratory wards. For air, report the proportion of these areas with verified clean air delivery from ventilation, filtration, or upper-room germicidal UV, credited by measured performance rather than equipment installed. Under the framework’s pathogen-agnostic indicators, also report the use of automated room disinfection for terminal cleaning, and of sink and drain designs that prevent splash, biofilm spread, and pathogen-laden bioaerosols. These items could be added at low burden to WHO’s existing facility-level infection prevention assessments.

6. National standards for healthcare facilities. Record the highest level each Member State’s national standards for healthcare facility design, ventilation, and cleaning and disinfection reach:

• (a) no national standard;
• (b) design rates only, such as air changes per hour, with no verification;
• (c) performance requirements for airborne infection control, based on targeted, measured, objective, relevant metrics verified at commissioning;
• (d) as (c), with ongoing verification during operation;
• (e) as (d), with requirements for continuous, automated engineered disinfection of air, surfaces, water and drainage systems.

For cleaning and disinfection standards, record whether they cover automated systems and the air as well as surfaces, and whether cleaning effectiveness is monitored. WHO’s infection prevention action plan already aims for every country to have updated national standards for cleaning in healthcare facilities by 2030 [22]. Those standards should include engineered infection prevention requirements. Canada’s national standards for healthcare facility design (CSA Z8000), ventilation (CSA Z317.2), and cleaning and disinfection (CSA Z317.12) are examples [26].

7. Indoor air in schools and public buildings. Record the highest level each Member State’s national standards for indoor air in schools and other public buildings reach:

• (a) no national standard;
• (b) design rates only, such as air changes per hour, with no verification;
• (c) performance requirements for airborne infection control, verified by measurement;
• (d) as (c), with ongoing monitoring and public reporting of results.

Report also the share of schools measured and the share meeting the standard. A plan that mentions ventilation (OP.2.2) does not show that the air in any building is clean.

8. Respirators and tests for the public. Record whether respirators (N95, FFP2 or better) and rapid tests are available to the public free or at an affordable price, and measure how widely they are used through population surveys. Medical masks should not be counted as respirators.

9. Current vaccination. Report the share of people vaccinated within the past three to six months, by age and risk group, alongside annual coverage (OC.4.1). Protection against symptomatic illness falls by about half within three months of a dose [18–20], so annual coverage does not show how many people are protected at a given time.

10. Long COVID. Measure how many people develop and live with Long COVID through population surveys, not only whether care pathways exist (OP.3.3).

11. Infection levels. Use wastewater surveillance and blood-antibody (seroprevalence) surveys to estimate how much transmission is occurring, independent of how much testing is done.

Annex B: Targets and assessment of progress

For each outcome indicator, WHO should set a global target and ask Member States to set national targets. Progress can then be assessed in four steps:

1. Target set: does the country have a target?
2. Target SMART: does it have a defined indicator and case definition, a numeric baseline, a numeric target, a deadline, and public reporting?
3. On track: is the change from baseline at least proportional to the time elapsed?
4. Target met: was it achieved by the deadline?

For infections acquired in healthcare, targets should apply to the rate per 10,000 patient-days, not only to the proportion of hospital cases acquired in hospital. That proportion rises when community infection falls, even if hospitals are no safer. Each country should be assessed against its own baseline under a fixed definition. As a starting point, WHO could target a 50% reduction in the rate of hospital-acquired COVID from the 2026 baseline by 2030, with a 25% reduction by the 2028 mid-strategy evaluation. Changes in inpatient testing should be reported alongside the rate, so that less testing is not mistaken for fewer infections.

Targets can be set the same way for the category indicators in Annex A. For example the share of Member States at category (f) or higher for respiratory protection (item 4), or at category (e) for healthcare facility standards (item 6).

References

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