On January 30, 2020, the World Health Organization (WHO) determined that the outbreak of the 2019 novel coronavirus (2019-nCoV) that originated in China was a Public Health Emergency of International Concern. Although researchers quickly identified and sequenced the virus, our weak global pandemic preparedness system has led to rising numbers of people infected with 2019-nCoV worldwide. The virus is highly transmissible, and is likely to become a pandemic. WHO has requested $675 million for a coronavirus preparedness and response plan.
Director, Center for Policy Impact in Global Health and Professor of Global Health - Duke Global Health Institute, Duke University
Managing Director - Open Consultants
When a pandemic occurs, global health donors rush to provide a burst of pandemic funding. Then, just as we saw in the wake of past outbreaks like the 2014-2016 Ebola outbreak or the 2003 severe acute respiratory syndrome (SARS) epidemic, once the pandemic is under control, funders move on to other concerns. As a result, we never actually get around to building a truly effective pandemic preparedness system. Peter Sands, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, calls this pattern “cycles of panic and neglect.” On Monday, February 3, WHO’s Director-General Tedros Adhanom Ghebreyesus urged the agency’s 196 member countries to “invest in preparedness,” and to not “panic.”
Global public health has long struggled with an “out of sight, out of mind” paradox. Once a disease seems to be under control, it becomes invisible to policymakers or funders, even if there is a threat of disease resurgence. We saw this with malaria, for example. From the 1930s to the 2000s, there were 75 episodes of malaria resurgence across 61 countries. In most cases, resurgence occurred because policymakers withdrew funding for malaria programs once the disease appeared to be under control.
All countries—both global health donors and low- and middle-income countries—need to invest in pandemic preparedness.
More recently, the Ebola outbreak in West Africa shone a spotlight on this paradox. When the outbreak hit, it soon became clear that many critical global public goods (GPGs) for health had been chronically underfunded, including regional and global surveillance systems and research and development (R&D) for pandemic vaccines and other technologies.
In the aftermath of Ebola in West Africa, there were promising signs that the international community might finally get its act together to create a pandemic preparedness system truly fit for purpose. Multiple independent panels and commissions conducted post-mortems on the weaknesses in the global response to Ebola and proposed ways to reform the pandemic preparedness system. The proposed reforms focused on strengthening national capabilities in outbreak preparedness; improving WHO’s handling of epidemics; mobilizing new pandemic funding; and accelerating the development of medical countermeasures (vaccines, diagnostics, and medicines) for outbreak control.
Some of these reforms have occurred. For example, in 2017 the Coalition for Epidemic Preparedness Innovations (CEPI) was launched at the World Economic Forum in Davos to fund the development of pandemic vaccines. New initiatives were launched to try to raise more money for pandemic control, such as WHO’s Contingency Fund for Emergencies and the World Bank’s Pandemic Emergency Financing Facility.
But have these reforms been enough—in other words, have they been commensurate with the large risk of future pandemics? Have they really mobilized the levels of funding that are needed to build a robust global preparedness system? We recently conducted a study to answer these questions. Unfortunately, the results are not reassuring.
In our study, we estimated trends in donor funding for what the Lancet Commission on Investing in Health calls “global functions”—global health activities that benefit multiple countries by tackling transnational threats. “Global functions” encompass three essential activities: providing GPGs for health (e.g., R&D to develop new medicines and vaccines for neglected diseases); managing cross-border threats (e.g., pandemic preparedness); and fostering global health leadership and stewardship (e.g., global health priority setting). These are the types of activities that had been historically underfunded when Ebola hit in 2014.
For the years 2013, 2015, and 2017, we estimated annual donor funding for health, the proportion of such funding that was invested in global functions, and the proportion that was invested in country-specific activities (i.e., investments that benefit individual countries only, with no transnational benefits). As shown in Figure 1, in 2013, just 23 percent of annual donor funding for health ($5.9 billion) was invested in global functions, rising to 29 percent ($7.3 billion) in 2015, but then falling to 24 percent ($7.0 billion) in 2017 (all figures are in 2017 US$). A substantial increase in donor funding for epidemic/pandemic preparedness and response, likely a reaction to Ebola, was the chief driver of the sharp rise in funding for global functions from 2013 to 2015. However, funders did not sustain their pandemic financing in 2017. Our paper provides more details of the methods, including the databases that we used.
Figure 1. Annual donor funding for health in 2013, 2015, and 2017, categorized by global versus country-specific funding.
Our findings, we conclude, are “in line with the notion that there was a ‘panic’ phase in response to the Ebola epidemic in which funding for preparedness efforts rose, followed by a decline in funding during the ‘neglect’ phase.” Dr. Tedros is right: All countries—both global health donors and low- and middle-income countries—need to invest in pandemic preparedness.
In a related analysis, one of us (Gavin) estimates that at least an additional $9.5 billion is needed each year to close the overall financing gap for global functions, which includes an additional $3.4 billion annually for pandemic preparedness. At first blush, this price tag may seem like a heavy lift. Yet it pales in comparison to the massive economic costs of inaction. For example, one study estimates the expected annual losses from pandemic risk to be around $500 billion (0.6 percent of global income per year).
Closing this financial gap is entirely feasible. Gavin’s analysis identifies three ways we can develop a sustainable financing architecture to close the financing gap. Most importantly, calling for a compulsory global taxation mechanism to mobilize revenue at the global level. Additionally, he calls for more pooled resources and coordination to enhance the provision of GPGs as well as an elevated role for strategic purchasing of GPGs, such as pooled procurement of vaccines.
Only if the global community makes a serious effort to implement these three approaches will we be able to establish a robust and proactive global pandemic preparedness system. In addition, low- and middle-income countries also need to invest in their own health systems to achieve stronger pandemic preparedness globally. Only then will we be able to break the vicious cycle of panic followed by neglect and prevent massive loss of life and economic shocks from outbreaks.