Deliberations to inform the Pandemic Treaty have seen calls from African scientists for attention to regional priorities in guidelines directing responses to outbreaks. They argue that Geneva-level protocols assume high-income settings and take insufficient account of contextual differences that determine what is possible in pandemic response. Such concerns have origins in experiences of Covid-19, where the effects of control measures in several African countries were more severe than the impacts of disease itself. Responses directed to a singular event did not take adequate account of intersecting crises and socio-economic realities. At the heart of this challenge lies the issue of where authority is located for decision-making and resource allocation in pandemics, pointing also to long-standing power dynamics that play out in global health policy. In practice, however, there are many challenges to navigating power hierarchies and adapting responses to different contexts. We illustrate these challenges with reference to research conducted in Lagos, Nigeria, during the multi-country mpox outbreak in 2022. Tensions emerged from a global emphasis on mpox as primarily affecting men who have sex with men (MSM). This framing did not match a heterogeneous epidemiological picture in Nigeria. It also generated difficulties in a legal environment where same sex relations are criminalised and undue attention to MSM can intensify discrimination. National health authorities pointed to a lack of attention to endemic disease prior to mpox detection in Europe. Some resented a diversion of resources from other priorities, in the context of multiple outbreaks and a stretched health system. We conclude by reflecting how a discourse of ‘competing priorities’ is rooted in longstanding structural and resource inequities. A pandemic treaty necessitates attention to financing that enables more equitable partnerships between regions. Such a transformation in established hierarchies requires more explicit attention to power and the political nature of pandemic response.