Abstract Focusing on intellectual property rights (IPRs) and their role in global access to vaccines during the COVID-19 pandemic, this article argues that key aspects of the current institutional system align towards delivering individualistic state/regional/rightsholders priorities in the use of IPRs over pandemic health technologies. This played a key role in the vaccine nationalism and global vaccine inequity that emerged during the pandemic. It critically analyzes the IPR provisions within the World Health Organisation’s Pandemic Agreement and negotiation process. It argues that nationalistic/individualistic approaches toward the use of IPRs over health technologies also permeate such contexts. The final text of the Agreement leaves considerable discretion to states around IPRs, and much will depend on how it is implemented in practice. For effective future pandemic preparedness around how IPRs are used over health technologies, this article argues that a deeper bottom-up institutional change is needed — one which offers nuanced strategies to balance the potential incentivization role of IPRs with the implications certain uses of IPRs can have on access to downstream health technologies. A key element of this change is embedding a greater recognition of the range of resources provided by entities (e.g. funders, biobanks, and universities) necessary in the successful development of health technologies, including in pandemic contexts. Such entities should leverage these resources, including by attaching contractual conditions to access these, which mandate avenues for downstream access to pandemic health technologies. In the longer term such approaches could be part of a broader institutional change, which prioritises global collective health needs in pandemics.