COVID-19:
Make it theLast Pandemic

Disclaimer:
The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the Independent Panel for Pandemic
Preparedness and Response concerning the legal status of any country, territory, city of area orof its authorities, or concerning the delimitation of its frontiers or boundaries.
Report Design: Michelle Hopgood, Toronto, Canada
Icon Illustrator: Janet McLeod Wortel
Maps: Taylor Blake
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Contents

Preface4Abbreviations6
1. Introduction

8

2. The devastating reality of the COVID-19 pandemic

10

3. The Panel’s call for immediate actions to stop the COVID-19 pandemic

12

4. What happened, what we’ve learned and what needs to change

15

4.1

Before the pandemic — the failure to take preparation seriously

15

4.2

A virus moving faster than the surveillance and alert system

21

4.2.1 The first reported cases
4.2.2 The declaration of a public health emergency of international concern
4.2.3 Two worlds at different speeds

22
24
26

4.3

28

Early responses lacked urgency and effectiveness

4.3.1 Successful countries were proactive, unsuccessful ones denied and delayed
4.3.2 The crisis in supplies
4.3.3 Lessons to be learnt from the early response 

31
33
36

4.4

38

The failure to sustain the response in the face of the crisis

4.4.1 National health systems under enormous stress
4.4.2 Jobs at risk
4.4.3 Vaccine nationalism

38
38
41

5. The Independent Panel’s recommendations45

6. A roadmap forward

62

Terms of reference for the Global Health Threats Council

71

7. About the Panel and its work

75

Acknowledgements80
References83Preface
The COVID-19 pandemic is a sign of how vulnerable
and fragile our world is. The virus has upended societies,
put the world’s population in grave danger and exposed
deep inequalities. Division and inequality between andwithin countries have been exacerbated, and the impact
has been severe on people who are already marginalized
and disadvantaged. In less than a year and a half,
COVID-19 has infected at least 150 million people
and killed more than three million. It is the worst
combined health and socioeconomic crisis in living
memory, and a catastrophe at every level.
The new millennium has seen the havoc which global health threats likesevere acute respiratory syndrome (SARS), Ebola and Zika can cause.
Experts have been warning of the threat of new pandemic diseases
and urged major changes in the way we protect against them — but thechange needed has not come about. As soon as a health threat or deadly
outbreak fades from memory, complacency takes over in what has been
dubbed a cycle of panic and neglect. This cycle must end.
COVID-19 is the 21st century’s Chernobyl moment — not because a disease
outbreak is like a nuclear accident, but because it has shown so clearly thegravity of the threat to our health and well-being. It has caused a crisis so
deep and wide that presidents, prime ministers and heads of internationaland regional bodies must now urgently accept their responsibility totransform the way in which the world prepares for and responds to global
health threats. If not now, then when?

Our message for change is clear: no more pandemics.
If we fail to take this goal seriously, we will condemn
the world to successive catastrophes.
At the same time, our careful scrutiny of the evidence has revealed failuresand gaps in international and national responses that must be corrected.
Current institutions, public and private, failed to protect people from adevastating pandemic. Without change, they will not prevent a future one.
That is why the Panel is recommending a fundamental transformation
designed to ensure commitment at the highest level to a new systemthat is coordinated, connected, fast-moving, accountable, just, andequitable — in other words, a complete pandemic preparedness andresponse system on which citizens can rely to keep them safe and healthy.

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Given the devastation of this pandemic and its impact on people
everywhere, our findings are necessarily tough, and our recommendations
actionable.
Since September 2020, the Independent Panel has learned from many
stakeholders — front-line health workers, women, youth, mayors, ministers,scientists, chief executive officers, international officials and diplomats. We
have also heard loud and clear that citizens are demanding an end to thispandemic, and that is what they deserve. It is the responsibility of leadersof all countries, as duty bearers, to respond to these demands.
The pandemic is not yet over — it is still killing more than 10 000 people
every day. Our recommendations are therefore directed first to theimmediate measures needed to curb transmission and to begin work
now to strengthen future protections. People in many countries continue
to suffer successive waves of infection - hospitals have again filled with
COVID-19 patients, and families are losing loved ones. The vaccines
available are a scientific triumph, but they must now be delivered acrossthe globe. At the time of writing, fewer than one in 100 people in lowincome countries had received a first dose — a graphic demonstration of
global inequality. As the virus spreads, it is also mutating and creating
new challenges.
We must work together to end this pandemic, and we must act urgently
to avert the next. Let history show that the leaders of today had thecourage to act.

Rt Hon. Helen Clark

H.E. Ellen Johnson Sirleaf

Mauricio CárdenasDavid Miliband

Aya Chebbi

Thoraya Obaid

Mark Dybul

Preeti Sudan

Michel Kazatchkine

Ernesto Zedillo

Joanne Liu

Zhong Nanshan

Co-Chair

Co-ChairPrecious Matsoso

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Abbreviations
ACT-A
Africa CDC
CEPI
COVAX Facility
COVID-19
Global FundIHR (2005)
IMF
MERS
MS
ODA
PHEIC
PPE
ProMEDR&D
SARS
SARS-CoV-2
WHA
WTO

Access to COVID-19 Tools Accelerator
Africa Centres for Disease Control and Prevention
Coalition for Epidemic Preparedness Innovations
COVID-19 Vaccines Global Access Facility
coronavirus disease
Global Fund to Fight AIDS, Tuberculosis and Malaria
International Health Regulations (2005)
International Monetary Fund
Middle East respiratory syndrome
Member States
official development assistancepublic health emergency of international concern
personal protective equipment
Program for Monitoring Emerging Diseases
research and development
severe acute respiratory syndrome
severe acute respiratory syndrome coronavirus 2
World Health AssemblyWorld Trade Organization

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Credit: Rosem
WatsamonMorton
Tri-Yasakda

1. Introduction
The world is still in the midst of a pandemic that has
spread wider and faster than any in human history.
The social and economic crisis precipitated by COVID-19
is affecting families, communities and nations acrossthe globe.
Seized by the gravity of the crisis, in May 2020 the World Health
Assembly requested the Director-General of WHO to initiate an impartial,
independent, and comprehensive review of the international healthresponse to COVID-19 and of experiences gained and lessons learned
from that, and to make recommendations to improve capacities for the
future. The Director-General asked H.E. Ellen Johnson Sirleaf and theRt Hon. Helen Clark to convene an independent panel for this purpose
and to report to the World Health Assembly in May 2021.
The Panel has taken a systematic, rigorous and comprehensive approach
to its work. It has sought to listen to and learn from a wide range ofinterlocutors. Since mid-September 2020, the Panel has reviewed
extensive literature, conducted original research, heard from experts
in 15 round-table discussions and in interviews, received the testimonyof people working on the front lines of the pandemic in town-hall-stylemeetings, and welcomed many submissions from its open invitation
to contribute.
The Panel has examined the state of pandemic preparedness prior
to COVID-19, the circumstances of the identification of severe acuterespiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease
it causes, coronavirus disease (COVID-19), and responses globally,
regionally and nationally, particularly in the pandemic’s early months.
It has also analysed the wide-ranging impact of the pandemic andthe ongoing social and economic crisis that it has precipitated.
This report presents the Panel’s findings on what happened, the lessons
to be learned from that, and our recommendations for strategic action
now to end this pandemic and to ensure that any future infectious disease
outbreak does not become a catastrophic pandemic.
Complementing this report, the Panel presents a companion report
describing thirteen defining moments which have been pivotal in shaping
the course of the pandemic. In addition, the Panel is publishing a seriesof background papers representing in-depth research including achronology of the early response.

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The recommendations are ambitious and crucial. The Panel believes thatthe international system requires fundamental transformation to preventa future pandemic. The Panel calls on political decision-makers at every
level to champion major change and to make available the resources tomake it effective. The ask is large and challenging, but the prize is evenlarger and more rewarding. With so many lives at stake, now is the time
for resolve.

The ask is large and challenging, but the prize is evenlarger and more rewarding. With so many lives at stake,now is the time for resolve.

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2. The devastating realityof the COVID-19 pandemic
COVID-19 has shown how an infectious disease can sweep
the globe in weeks and, in the space of a few months, setback sustainable development by years.
By all measures, the impact of the pandemic is massive:• 148 million people were confirmed infected and more than
3 million have died in 223 countries, territories and areas(as at 28 April 2021) (1);• at least 17 000 health workers died from COVID-19 during
the pandemic’s first year (2);• US$ 10 trillion of output is expected to be lost by the end of 2021,
and US$ 22 trillion in the period 2020–2025 — the deepest shock to
the global economy since the Second World War and the largest
simultaneous contraction of national economies since the Great
Depression of 1930–32 (3);• At its highest point in 2020, 90% of schoolchildren were unable
to attend school (4);• 10 million more girls are at risk of early marriage becauseof the pandemic (5);• gender-based violence support services have seen fivefold
increases in demand (6);• 115–125 million people have been pushed into extreme poverty (7).
The language of health statistics and economics cannot convey thedepth of disruption as COVID-19 has overturned people’s lives. People
are grieving the loss of their loved ones, and those with long-term healthimpacts from the disease continue to suffer. There are instances where
people with cancer have been unable to attend chemotherapy sessions,and people with suspected tuberculosis have not been diagnosed ortreated. Market sellers have been unable to work and put food on thetable. Women have found their double workload tripled or quadrupled,as they try to maintain the family income, care for the elderly and sick,become teachers for their home-schooled children, and maintain thewell-being of their families.
Most dispiriting is that those who had least before the pandemic haveeven less now. The experience of previous epidemics shows that income
inequality increased in affected countries over the five years following
each event. Those working in the informal sector have had little or no
support. Migrants, refugees, and displaced people have often been
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shut out of testing services and health facilities. Perhaps 11 million of thepoorest girls in the world may never go back to the classroom (8). People
living in the poorest countries are at the tail-end of the vaccine queue.
It does not have to be this way.
A groundswell of opinion is determined to address inequality so that
we can come out of the pandemic looking forward to a better world,
sustaining and expanding responses where they have shown a better
path. Governments have offered income support to millions of people inplaces where, before the pandemic, that had been considered a politicalimpossibility. Campaign-based health services, like immunization, havebounced back rapidly. Service delivery in health is being changed for the
better through people-centred initiatives, such as those in telemedicine orwith the multi-month dispensing of medications. The links between green
and sustainable futures and a pandemic-free world are being drawn
more clearly than ever before.
Ending this pandemic as quickly as possible goes hand in hand withpreparing to avert another one. Paying attention to what went wrong, as
well as to what went right, will be invaluable pointers to ways in which theworld can get back on track to realise the 2030 Agenda for Sustainable
Development.
This pandemic has shaken some of the standard assumptions that acountry’s wealth will secure its health. Leadership and competence
have counted more than cash in pandemic responses. Many of the best
examples of decisive leadership have come from governments andcommunities in more resource-constrained settings. There is a clear
opportunity to build a future beyond the pandemic that draws on thewellsprings of wisdom from every part of the world.

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3. The Panel’s call for immediate actions
to stop the COVID-19 pandemic
The Panel is deeply concerned and alarmed about thecurrent persistent high levels of transmission of SARSCoV-2, which are driving illness and deaths, and about
the development of virus variants all of which continue toimpose an intolerable burden on societies and economies.
Countries have varied significantly in their application of public healthmeasures to keep the spread of the virus in check. Some have sought tocontain the epidemic aggressively and drive towards elimination; somehave aimed at virus suppression; and some have aimed just to mitigate
the worst impacts. Countries with the ambition to aggressively containand stop the spread whenever and wherever it occurs have shown that
this is possible. Given what is known already, all countries should apply
public health measures consistently and at the scale the epidemiologicalsituation requires. Vaccination alone will not end this pandemic. It must
be combined with testing, contact-tracing, isolation, quarantine, masking,physical distancing, hand hygiene, and effective communication withthe public.
Alongside these non-pharmaceutical measures, vaccine rollout needs
to be scaled up urgently and equitably across the world. A number ofeffective vaccines are now approved. Current production capacity,
however, is stretched close to its limits, and vaccination coverage is far
from being at the scale needed to reduce the burden of illness and curbtransmission globally.
The uneven access to vaccination is one of today’s pre-eminent
global challenges. High-income countries have over 200% population
coverage of vaccine doses, obtained mainly through bilateral deals with
manufacturers to secure existing and future stocks. In many cases lowand middle-income countries have been shut out of these arrangements.
In the poorest countries, at the time of finalising this report, fewer than
1% of people have had a single dose of vaccine. The COVID-19 Vaccines
Global Access Facility (COVAX Facility), rapidly established with theintention of ensuring global, equitable access, is making good progress
but has been hampered in that goal by a lack of sufficient funds and by
vaccine nationalism, and now, vaccine diplomacy.

There are 5.7 billion people in the world aged 16 and over.
All need access to safe and effective COVID-19 vaccines.
This is not some aspiration for tomorrow — it is urgent, now.
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To prepare ourselves for new phases of the COVID-19 pandemic and torespond effectively, a global strategy with clear goals, milestones andpriority actions is needed. The significant inequity in vaccine access must
be addressed immediately, as it is not only unjust, but also threatens theeffectiveness of global efforts to control the pandemic. Variants may still
emerge that our vaccines cannot manage. The more quickly we vaccinate
now, the less likelihood there is of ever more variants emerging. One
action which can be taken now is an equitable redistribution of available
vaccine doses. Scaling up the development and supply of therapeutics
and of diagnostic tests is also very urgent to save lives.
Moreover, to prepare for likelihood of of COVID-19 becoming endemic
and to address inequity in vaccine access in a more sustained way,
manufacturing capacity of mRNA and other vaccines must urgently
be built in Africa, Latin America and other low- and middle-income
regions. Vaccine manufacturing is highly specialized and difficult.
Boosting production takes time so enabling it must begin now. It requires
agreements on voluntary licensing and technology transfer.
There are 5.7 billion people in the world aged 16 and over. All needaccess to safe and effective COVID-19 vaccines. This is not some
aspiration for tomorrow — it is urgent, now. COVAX has secured 1.1 billion
vaccine doses and has optioned 2.5 billion more (9). Before the end of
April, one billion vaccine doses were administered, overwhelmingly inhigh-income or upper-middle-income countries. The Panel joins with
political and faith leaders across the world and calls for an all-out
effort to reach the world’s population with vaccines within a year andset in place the infrastructure needed for at least 5 billion booster
doses annually.
Immediate action to end COVID-19 must be guided by explicit strategies
with measurable milestones. The Panel recognizes the WHO COVID-19
Strategic Preparedness and Response Plan for 2021 (10) provides usefultechnical guidance but the Panel’s view is that there is a need for ahigher level roadmap for ending the pandemic with clear targets,
milestones and dates.

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The Independent Panel makes
the following urgent calls
I.

Apply non-pharmaceutical public health measures systematicallyand rigorously in every country at the scale the epidemiologicalsituation requires. All countries to have an explicit evidence-based
strategy agreed at the highest level of government to curb
COVID-19 transmission.

II.

High income countries with a vaccine pipeline for adequate
coverage should, alongside their scale up, commit to provide to
the 92 low and middle income countries of the Gavi COVAX AdvanceMarket Commitment, at least one billion vaccine doses no later than
1 September 2021 and more than two billion doses by mid-2022, to bemade available through COVAX and other coordinated mechanisms.

III. G7 countries to commit to providing 60% of the US$ 19 billion
required for ACT-A in 2021 for vaccines, diagnostics, therapeutics
and strengthening health systems with the remainder being
mobilised from others in the G20 and other higher income countries.
A formula based on ability to pay should be adopted for predictable,
sustainable, and equitable financing of such global public goods
on an ongoing basis.
IV.

The World Trade Organization and WHO to convene major
vaccine-producing countries and manufacturers to get agreementon voluntary licensing and technology transfer arrangements for
COVID-19 vaccines (including through the Medicines Patent Pool).
If actions do not occur within three months, a waiver of intellectual
property rights under the Agreement on Trade-Related Aspects ofIntellectual Property Rights should come into force immediately.

V.

Production of and access to COVID-19 tests and therapeutics,
including oxygen, should be scaled up urgently in low- and middleincome countries with full funding of US$1.7 billion for needs in 2021
and the full utilization of the US$3.7 billion in the Global Fund’s
COVID-19 Response Mechanism Phase 2 for procuring tests,
strengthening laboratories and running surveillance and tests.

VI. WHO to develop immediately a roadmap for the short-term,
and within three months scenarios for the medium- and long-term
response to COVID-19, with clear goals, targets and milestones
to guide and monitor the implementation of country and global
efforts towards ending the COVID-19 pandemic.

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4. What happened, what we’ve learned
and what needs to change
The Panel has carefully reviewed each phase of thepresent crisis in order to establish facts and draw lessons
for the future.

4.1 Before the pandemic — the failure to takepreparation seriously
In under three months from when SARS-CoV-2 was first identified as
the cause of clusters of unusual pneumonia cases in Wuhan, China,
COVID-19 had become a global pandemic threatening every country in theworld (11). Although public health officials, infectious disease experts, andprevious international commissions and reviews had warned of potential
pandemics and urged robust preparations since the first outbreak of
SARS, COVID-19 still took large parts of the world by surprise. It should
not have done. The number of infectious disease outbreaks has been
accelerating, many of which have pandemic potential.
It is clear to the Panel that the world was not prepared and had ignored
warnings which resulted in a massive failure: an outbreak of SARS-COV-2
became a devastating pandemic.
The fast-moving SARS epidemic had shaken the world in 2003. Whilethe epidemic only lasted some six months and was responsible for 8096
cases and 774 deaths (12), it was judged by the WHO Regional Director
for the Western Pacific to have “caused more fear and social disruption
than any other outbreak of our time” (13). SARS was a novel coronavirus
causing respiratory disease. It travelled rapidly to 29 countries, territories
and areas, and debilitated health systems, with many health workers
being infected. Even so, expert observers knew that, with SARS, the world
had dodged a bullet — screening and isolation could readily contain its
spread, because people with SARS did not transmit the virus until several
days after showing symptoms and were most infectious when symptoms
were most severe. It was understood that if a new fast-moving pathogen
were transmissible in the absence of symptoms, it would pose a muchdeadlier challenge.
The SARS epidemic was followed by the 2009 H1N1 influenza pandemic,
the 2014–2016 Ebola outbreak in west Africa, Zika and other disease
outbreaks, including another new coronavirus, Middle East respiratory
syndrome (MERS). These outbreaks were the impetus for a series of
initiatives to strengthen health security, animated by the conviction thatdisease outbreaks and other health threats constituted a major global risk
and required a web of actions across all countries.

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SARS propelled the decade-long negotiations to revise and broaden theInternational Health Regulations (IHR) to a rapid conclusion. The current
regulations were adopted in 2005, setting out legally binding duties forboth States and WHO in notification and information-sharing, prohibitions
on unnecessary interference with international travel and trade, andcooperation for the containment of disease spread. The new IHR (2005)
came into force in 2007 and imposed new requirements that must be met
before the WHO Director-General could act on emergencies, rather thanenabling WHO to act immediately and independently.
Groups of States also took initiatives to boost health security. The Global
Health Security Initiative was established in 2001 by eight States and theEuropean Commission, with WHO as an observer. The Global Health
Security Action Group was its implementation and information-sharing
body. The Global Health Security Agenda was launched by the UnitedStates in partnership with two dozen other countries in 2014 and has
now grown to include seventy countries and a number of internationalorganizations. It has sought to complement efforts to strengthen IHR(2005) implementation, including through support for voluntary Joint
External Evaluations. The fact, however, that not all States participate in the
Agenda and its related processes has limited its effectiveness and reach.

Despite the consistent messages that significant change wasneeded to ensure global protection against pandemic threats,
the majority of recommendations were never implemented.
Since the 2009 H1N1 influenza pandemic, at least 11 high-level panels
and commissions have made specific recommendations in 16 reports toimprove global pandemic preparedness. Many concluded that the World
Health Organization needed to strengthen its role as the leading andcoordinating organization in the field of health, focus on its normative
work, and receive more secure funding. Reviews also suggested
improvements in the implementation of the IHR (2005). Some of
the reviews resulted in specific action, including the establishmentof the new WHO Health Emergencies Programme in 2016.
Yet, despite the consistent messages that significant change was needed
to ensure global protection against pandemic threats, the majority ofrecommendations were never implemented. At best, there has been
piecemeal implementation. A coalition of interests with sufficient power
and momentum to achieve a package of essential reforms has never beenassembled. As a result, pandemic and other health threats have not been
elevated to the same level of concern as threats of war, terrorism, nuclear
disaster or global economic instability. When steps have been explicitly
recommended, they have been met with indifference by Member States,
resulting in weakened implementation that has severely blunted theoriginal intentions. It is clear to the Panel that pandemics pose potential
existential threats to humanity and must be elevated to the highest level.
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The United Nations High-level Panel on the Global Response to
Health Crises, chaired by President Kikwete of the United Republicof Tanzania, was established in response to the 2014–2016 epidemicof Ebola. It recommended that the United Nations General Assembly
should immediately create a high-level council on global public healthcrises. On receiving its report, the United Nations Secretary-General
Ban Ki-moon established a task force to oversee implementation of its
recommendations. The task force’s report in June 2017 recommended that
the Secretary-General implement a time-limited independent mechanism
for reporting on the world’s preparedness, rather than the high-level
independent council which had been recommended by the Kikwete-led
panel. The outcome was the establishment of the Global Preparedness
Monitoring Board in May 2018, with its members appointed by the headsof WHO and the World Bank.
National pandemic preparedness has been vastly underfunded, despite
the clear evidence that its cost is a fraction of the cost of responses
and losses incurred when an epidemic occurs. The total cost of theeconomic losses due to SARS was estimated at US$ 60 billion (14). The
2015 MERS outbreak in just one country, the Republic of Korea, with 185
cases and 38 deaths, cost US$ 2.6 billion in lost tourism revenue and US$
1 billion in response costs (15). The 2016 Commission on a Global Health
Risk Framework for the Future argued that its proposed preparedness
spending boost of US$ 4.5 billion annually was a small investmentcompared with a scenario of the potential global cost of pandemics
over the whole of the 21st century, which they assessed as being“in excess of $6 trillion” (16).

“…the Panel notes that the high risk of major health crises iswidely underestimated, and that the world’s preparedness andcapacity to respond is woefully insufficient. Future epidemics
could far exceed the scale and devastation of the West Africa
Ebola outbreak.”From: Protecting humanity from future health crises Report of the High-level
Panel on the Global Response to Health Crises, February 2016.

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While there have been concerted efforts in recent years to boost
pandemic preparedness, they have fallen far short of what is required.
Too many national governments lacked solid preparedness plans, corepublic health capacities and organized multisectoral coordination withclear commitment from the highest national leadership (17). The selfreported assessment of core capacities for preparedness that countries
are required to submit to the WHO under IHR (2005) gave a global
average score of 64 out of 100 (18). Only two-thirds of countries reported
having full enabling legislation and financing to support needed healthemergency prevention, detection, and response capabilities (19). Country
preparedness was also assessed under the voluntary Joint External
Evaluation process, undertaken to date by 98 countries. An independent
academic exercise, the Global Health Security Index, also sought to scorecountry pandemic preparedness.

Figure 1: Death rates in this figure shows the cumulative, reported, age-standardized to COVID-19 deaths per
hundred thousand people in the 50 days following the date of the first death in that country
Source and adapted from: Sawyer Crosby et al, IHME, Think Global Health

Death Rate

Joint External Evaluation Scores vs. COVID-19 Death Rates
32.2

BEL

16.1

STP

8

KWT
DJI

4
2
1
0.5

GAB
COG

TGO

CIV

0.1

GHA

LTU
ZAF
MAR
LVA

TUN

SDN
GEO

BEN

ZWE LBY

KGZ

IDN

30

SGP

NZL

JOR

AUS

BGD
PHL

BDI

ARM

BHR

BGD

0
0

IRQ KEN

GMB
MWI

ALB
LBN

FIN

OMN

SRB
MUS

SEN

SVN

SAU

QAT
PAK

COD

0.1

MDA

LBR

AFG

0.3

CAN

SLE

CMR

TCD

ARE

MKD

MDV
GNB

CHE

USA

THA

LKA

JPN

ETH

40

50

60

70

80

90

Joint External Evaluation Score
Central/Eastern Europe & Central Asia

North Africa & Middle East

Southeast/East Asia & Oceania

Latin America & Caribbean

South Asia

Sub-Saharan Africa

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What all these measures have in common was that their rankingof countries did not predict the relative performance of countries
in the COVID-19 response (20, 21, 22). The measures failed to accountsufficiently for the impact on responses of political leadership, trust in
government institutions and country ability to mount fast and adaptable
responses (23). For example, while the US ranked highest in its aggregate
score on the Global Health Security Index, it scored less well on universal
health care access, and in relation to public confidence in government
received a score of zero indicating a confidence level of less than 25% (24).
The failure of these metrics to be predictive demonstrates the needfor a fundamental reassessment which better aligns preparedness
measurement with operational capacities in real-world stress situations,
including the points at which coordination structures and decision-making
may fail. The current pandemic will generate a wealth of data to guidethat reassessment.
Underscoring the consequences of a failure to invest sufficiently in
preparedness capacity is the increasing background level of risk.
Population growth and accompanying environmental stresses are driving
an increase in emerging novel pathogens. Air travel, which has increased
fourfold since 1990, enables a virus to reach any place in the world in amatter of hours (25). A new pathogen could emerge and spread at any time.
Most of the new pathogens are zoonotic in origin. Driving their increasing
emergence are land use and food production practices and populationpressure. Global surveillance systems need to monitor burgeoning
infrastructure, environmental loss and the status of animal health.
One Health interagency and multisectoral collaboration need to be an
integral part of pandemic preparedness planning. Accelerating tropicalFigure 2: Air travel has increased four-fold since 1990. This figure shows concurrent flights in the air
as of 02 May 2021, 9pm CET
Source: FlightAware, accessed online 2 May 2021.

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Pandemic preparedness planning is a core function of
governments and of the international system and must be
overseen at the highest level. It is not a responsibility of thehealth sector alone.
deforestation and incursion destroys wildlife health and habitat andspeeds interchange between humans, wildlife and domestic animals.
The threats to human, animal and environmental health are inextricably
linked, and instruments to address them need to include climate change
agreements and “30x30” global biodiversity targets (26, 27).
SARS-CoV-2 is just such a virus of zoonotic origin whose emergence
was highly likely. Current evidence suggests that a species of bat is
the most likely reservoir host. The intermediate host is still unknown,
as is the exact transmission cycle. WHO convened a technical mission
to better understand the origins of the virus (28). While the mission has
now reported, investigations of the origins of the virus will continue. The
experience of other pandemics, such as HIV, suggest that it will be sometime, possibly years, before there is an accepted consensus about how
and when the virus first infected humans and when and where the firsthuman-to-human transmission clusters occurred. There is some evidence,
based both on reconstructions looking backwards in time at the likely
epidemiology and through the analysis of samples collected and stored,that the virus may already have been in circulation outside China in
the last months of 2019. This evidence, however, still requires further
examination, and confounding explanations, such as the contaminationof samples, are still to be ruled out.
COVID-19 exposed a yawning gap between limited, disjointed efforts
at pandemic preparedness and the needs and performance of asystem when actually confronted by a fast-moving and exponentiallygrowing pandemic.
The Panel’s conclusion is that closing the preparedness gap not only
requires sustained investment, it requires a new approach to measuring
and testing preparedness. Drills and simulation exercises resulting in
immediate rectification of identified weaknesses must become routine,and preparedness assessment must place more focus on the way thesystem functions in actual conditions of pandemic stress.
Zoonotic outbreaks are becoming more frequent, increasing the urgency
for better detection and more robust preparedness. Given the increasing
stakes, monitoring pandemic threat needs to be on the agenda ofdecision-makers at the highest levels of governmental, intergovernmental,
corporate and community organizations.
Pandemic preparedness planning is a core function of governments andof the international system and must be overseen at the highest level.
It is not a responsibility of the health sector alone.
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4.2 A virus moving faster than the surveillance
and alert system
The earliest possible recognition of a novel pathogen is critical tocontaining it. The emergence of COVID-19 was characterized by a mixof some early and rapid action, but also by delay, hesitation, and denial,with the net result that an outbreak became an epidemic and an epidemic
spread to pandemic proportions.
The Independent Panel has consulted widely in order to develop a
meticulous and verified chronology of events as they took place fromthe end of 2019 when cases were first detected in China through tothe end of March 2020, by when the outbreak had spread extensively
worldwide and had been characterized as a pandemic. Inputs to thischronology have included a systematic review of all the relevant publishedstudies — both those that were available at the time and retrospective
studies; submissions from WHO Member States, interviews with key actors
in China and other countries, with WHO and other organizations; anda review of internal documents and correspondence from WHO.
The intention of the Panel in examining in detail the steps taken to
respond to COVID-19 is not to assign blame, but rather to understandwhat took place and what, if anything, could be done differently if
similar circumstances arise again, as they almost certainly will. We areconscious that our judgements benefit from the wisdom of hindsight andacknowledge that the decisions made at the time were made in conditionsof great uncertainty.

Figure 3: A short segment of the authoritative chronology of the Independent Panel
Source: The Independent Panel for Pandemic Preparedness and Response

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4.2.1 The first reported cases
In December 2019, a number of patients with pneumonia of
unknown origin were admitted to hospitals in Wuhan, China.
Later tests on a cohort of patients admitted between 16 Decemberand 2 January found 41 with COVID-19. On 24 December, doctors
concerned about a pneumonia patient not responding to theusual treatments sent a sample to a private laboratory for testing.
Clinicians noticed that a number of patients — although not all —had attended the Huanan Seafood Market in Wuhan. For example,
in a family group, a woman who was treated on 26 December
had attended the seafood market, while her husband and son,whose chest scans were conducted shortly thereafter and showedsimilar patterns, had not. While the market was the initial focus
of investigation, two later studies (29, 30) of the early laboratoryconfirmed cases linked only 55–66% of cases to exposures there,suggesting that the market may have been a site of amplification of
the virus rather than its origin. The evidence of human-to-humantransmission of a new pathogen was not definitive in December 2019
but by the end of the month there were signs of it being likely.

One of the urgent
notices issued on
30 December 2019 by
the Wuhan Municipal
Health Commission.

On 30 December 2019, the Wuhan Municipal Health Commission
issued two urgent notices to hospital networks in the city aboutcases of pneumonia of unknown origin linked to the Huanan
Seafood Market. The market was closed and cleaned between
31 December and 1 January. On the morning of 31 December,
Chinese business publication Finance Sina reported on one of
the notices issued by the Wuhan Municipal Health Commission.
This report was replicated and picked up by several disease
surveillance systems, including the Centers for Disease Control,
Taiwan, China, which in turn contacted WHO via email throughthe IHR (2005) reporting system, requesting further information.
A machine translation of the Finance Sina report was publishedon the website of the Program for Monitoring Emerging Diseases(ProMED). This report was picked up by the Epidemic Intelligencefrom Open Sources (EIOS) system and alerted WHO Headquarters
to the outbreak. Later in the afternoon of 31 December, the Wuhan
Municipal Health Commission issued a public bulletin describing 27
cases of pneumonia of unknown origin. The WHO Country Officein China took note of the bulletin shortly after it was posted and
immediately informed the IHR focal point in the WHO Western
Pacific Regional Office (WPRO).
The Wuhan Institute of Virology sequenced almost the entire
genome of the virus on 2 January 2020. On 5 January 2020, thecomplete genetic sequence was submitted to the open-accesswebsite GenBANK from a sample sequenced by the Shanghai
Public Health Centre and this was made public on 11 January (31),and further sequences were uploaded by the China CDC. The
China CDC successfully isolated the virus by 7 January 2020.
Chinese scientists developed a PCR testing reagent for the virusby 10 January 2020 (29).

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These events, as they unfolded in Wuhan in the last two weeks ofDecember 2019 and into January 2020, demonstrate the diligenceof clinicians who noticed clusters of unusual pneumonia, sent samples
for screening where commercially available next-generation
sequencing detected signs indicative of a new SARS-like
coronavirus, and escalated their concerns about this cluster of
unexplained disease to local health authorities. The local healthauthorities closed and cleaned the market that was suspected
as a potential source of the virus.
Within a day of the local alert being issued to hospitals, it wasnoted in the media. The signal was picked up by other healthauthorities and by the global epidemic surveillance networks that
constantly scour open sources around the world. There were thus
three routes through which WHO became aware of the outbreakon 31 December 2019 — the Centers for Disease Control, Taiwan,
China contacting WHO through the IHR (2005) reporting systemafter noting media references to the outbreak; the alert publishedon the ProMED website and picked up by the epidemic surveillancesystem; and the WHO Country Office in China noting the public
bulletin from the Wuhan Municipal Health Commission.

These events, as they unfolded in Wuhan in the last
two weeks of December 2019 and into January 2020,
demonstrate the diligence of clinicians who noticed
clusters of unusual pneumonia
On 1 January 2020, WPRO formally requested further information;and on 3 January it requested verification under the IHR (2005)
Article 10 procedures. The Chinese National Health Commission and
the Country Office met for a technical briefing on 3 January andprovided initial information about the first set of 44 reported cases
during the briefing and by email. The WHO subsequently publisheda Twitter thread about the cases on 4 January, and on 5 January
officially alerted all country governments through the IHR Event
Information System, as well as issuing its first Disease OutbreakNews notice on the cluster.
The Chinese authorities and WHO held a subsequent briefing on
11 January. The Country Office reached an agreement with Chinese
authorities on 15 January to visit Wuhan. On 16 January, a further
briefing was held, and a more complete list of case information
was shared. The first WHO mission to Wuhan took place on
20–21 January.
In an announcement on national television on 20 January 2020
Chinese health experts confirmed publicly that human to humantransmission was occurring and that health workers were among
those who had become infected. Wuhan instituted a drastic

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population lockdown on 23 January to try to contain the virus,
as 830 cases and 25 deaths were reported (32). According to the reportof the second joint WHO-China mission, which took place from 16
to 24 February, the lockdown and public health measures taken in
China were considered successful in rapidly reducing transmission.
Some places began screening incoming visitors almost immediately,as news of the Wuhan outbreak became public. Meanwhile in
Thailand, a case was confirmed on 13 January of a woman who
had travelled there from Wuhan on 8 January, the first case to be
confirmed outside China. Japan reported an infected person on
16 January.

4.2.2 The declaration of a public health emergency
of international concern
A Public Health Emergency of International Concern (PHEIC) is theloudest alarm that can be sounded by the WHO Director-General.
The IHR (2005) mandate that in determining whether an event
constitutes a PHEIC, the WHO Director-General consider the adviceof an Emergency Committee convened for the purpose and drawn
from a roster of experts maintained by WHO. The affected State is
invited to present its views to the Emergency Committee. If a PHEIC
is recommended, the WHO Director-General has the final authority
to make a declaration, taking all information into account. The
meeting of the WHO IHR Emergency Committee called to discuss
the outbreak on 22–23 January was split on whether to recommendthat the outbreak be declared a PHEIC. The Committee met again
the following week when the Director-General returned from a
mission to China. Following the Committee’s recommendation, theWHO Director-General declared that the outbreak constituted a
PHEIC on 30 January. At that time there were 98 cases in 18 countries
outside China (33, 34). In the statement from the Emergency Committee
reported by the Director-General, it was specified that no travel
restrictions were recommended, based on the information available.
Reference to the PHEIC outbreak was included in the 3 February2020 report by the WHO Director-General to the WHO Executive
Board (35). On 4 February in an oral briefing to Member States
he reported that there had been 20 471 confirmed cases and425 deaths reported in China, and a total of 176 cases in 24
other countries.
The IHR (2005) do not use or define the term “pandemic”. The mostextensive use of the term by WHO is in relation to the detailed
framework and guidelines for pandemic influenza, although even
there the distinction between seasonal and pandemic influenza is
not clear-cut (36). As COVID-19 spread during February 2020, andthere was an apparent lack of understanding that declaring a PHEIC
was to sound the loudest possible alarm, there was an increasing
clamour for WHO to describe the situation as a pandemic.
Eventually, stating that it was alarmed by the extent of both the
spread of the disease and the level of inaction in response, WHO

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went on to characterize COVID-19 as a global pandemic
on 11 March 2020, when there were a reported 118 000 casesin 114 countries (37).
The Panel has considered this sequence of events between
December 2019 and the declaration of a PHEIC on 30 January 2020
in detail in order to assess what could potentially have been done
differently and whether changes are needed in the international
system of alert.

There is a case for applying the precautionary principle
in any outbreak caused by a new pathogen resulting
in respiratory infections, and thereby for assuming thathuman-to-human transmission will occur unless theevidence specifically indicates otherwise
The IHR (2005) are designed to ensure that countries have thecapacity to detect and notify health events. They require that, when
disease or deaths above expected levels are detected, essential
information is reported immediately to subnational or national
levels. If urgent events, defined as having “serious public healthimpact and/or unusual or unexpected nature with high potential
for spread” are detected, they must be reported immediately tothe national level and assessed within 48 hours. Events assessed to
warrant a potential PHEIC must be reported to WHO within 24 hours
of assessment, via the IHR national focal point. Events with PHEIC
potential must meet at least two of four conditions, namely:(1) have serious public health impact; (2) be an unusual or
unexpected event; (3) have significant risk of international spread;and (4) carry significant risk of travel or trade restrictions. (a) The
Panel’s view is that the outbreak in Wuhan is likely to have met thecriteria to be declared a PHEIC by the time of the first meeting of
the Emergency Committee on 22 January 2020.
While WHO was rapid and assiduous in its early dissemination of
the outbreak alert to countries around the world, its approach inpresenting the nature and level of risk was based on its establishedprinciples guided by the International Health Regulations of issuing
advice on the balance of existing evidence. While WHO advisedof the possibility of human-to-human transmission in the period
until it was confirmed, and recommended measures that healthworkers should take to prevent infection, the Panel’s view is that it
could also have told countries that they should take the precautionof assuming that human-to-human transmission was occurring.
Given what is known about respiratory infections, there is a casea In addition, SARS, poliomyelitis, smallpox and a new subtype of influenza are automaticallydefined as events that may constitute a PHEIC. See International Health Regulations (2005),
3rd edition. Geneva: World Health Organization; 2016 (https://www.who.int/publications/i/
item/9789241580496, accessed 26 April 2021).
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Credit: Watsamon Tri-yasakda

for applying the precautionary principle and assuming that in any
outbreak caused by a new pathogen of this type, sustained humanto-human transmission will occur unless the evidence specificallyindicates otherwise.
The Panel’s conclusion is that the alert system does not operatewith sufficient speed when faced with a fast-moving respiratory
pathogen, that the legally binding IHR (2005) are a conservative
instrument as currently constructed and serve to constrain rather
than facilitate rapid action and that the precautionary principle was
not applied to the early alert evidence when it should have been.
The Panel’s view is that the definition of a new suspected outbreakwith pandemic potential needs to be refined, as different classes ofpathogen have very different implications for the speed with which
they are likely to spread and their implications for the type of
response needed.

4.2.3 Two worlds at different speeds
The chronology of the early events in raising the alarm about
COVID-19 show two worlds operating at very different speeds.
One is the world of fast-paced information and data-sharing.
Open digital platforms for epidemic surveillance, in which WHO
plays a leading role, constantly update and share outbreakinformation. Digital tools are now core elements in disease
surveillance and alert, sifting through vast quantities of instantly
available information. Epidemic surveillance operates symbioticallywith information exchange — the constant pace of news, gossip
and rumour that characterize social media and can be minedfor epidemic-relevant signals. Open data on the information and

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collaboration platforms central to scientific exchange also, by theirnature, enable near-instant global availability of information.
The other world is that of the slow and deliberate pace with which
information is treated under the IHR (2005), with their step-by-step
confidentiality and verification requirements and threshold criteria
for the declaration of a PHEIC, with greater emphasis on action thatshould not be taken, rather than on action that should.
The critical issue for this two-speed world is that viruses, especiallyhighly transmissible respiratory pathogens, operate at the faster
pace, not the slower one.
The Panel’s conclusion is that surveillance and alert systems at
national, regional and global levels must be redesigned, bringing
together their detection functions — picking up signals of potential
outbreaks — and their relay functions — ensuring that signals areverified and acted upon. Both must be able to function at nearinstantaneous speed.
This will require the consistent application of digital tools, including
the incorporation of machine learning, together with fast-paced
verification and audit functions. It will also require a commitment toopen data principles as the foundation of a system that can adapt
and correct itself.

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4.3 Early responses lacked urgency and effectivenessThe declaration of a PHEIC by the WHO Director-General on 30
January 2020 was not followed by forceful and immediate emergency
responses in most countries, despite the mounting evidence that ahighly contagious new pathogen was spreading around the world. Fora strikingly large number of countries, it was not until March 2020, after
COVID-19 was characterized as a “pandemic”, and when they had alreadyseen widespread cases locally and/or reports of growing transmission
elsewhere in the world, and/or their hospitals were beginning to fillwith desperately ill patients, that concerted government action was
finally taken.
In recommending the declaration of a PHEIC on 30 January, the WHO
COVID-19 IHR Emergency Committee stated its view that it was “still
possible to interrupt virus spread, provided that countries put in placestrong measures to detect disease early, isolate and treat cases, tracecontacts and promote social distancing measures commensurate withthe risk” (38). Most countries did not seem to get that message, despite thefact that, at the time, cases had been reported in 19 countries and humanto-human transmission was reported in at least four countries in addition
to China. The majority of reported cases outside China had a history oftravel in China, but that was partly because testing was initially directed
only at those who both had symptoms and had recently travelledfrom Wuhan.

Figure 4: Cumulative COVID-19 cases by country as of 30 January 2020
Source: World Health Organization Coronavirus (COVID-19) Dashboard. Data as of 21 April 2021.

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Figure 5: Cumulative COVID-19 cases by country as of 11 March 2020
Source: World Health Organization Coronavirus (COVID-19) Dashboard. Data as of 21 April 2021.

On 30 January 2020, it should have been clear to all countries from thedeclaration of the PHEIC that COVID-19 represented a serious threat.
China had reported upwards of 20 000 confirmed or suspected cases and
170 deaths. The number of countries to which the virus had spread andwhere local transmission was occurring was growing by the day. Even so,
only a minority of countries set in motion comprehensive and coordinated
COVID-19 protection and response measures — a handful even before
seeing a confirmed case, and the remainder once cases had arrived.
The question we must ask ourselves is why the PHEIC declaration did notspur more action, when the impending threat should have been clearly
evident? After a stuttering start to the global response in January 2020
by the end of that month it was clear that a full-scale response would beneeded. It is glaringly obvious to the Panel that February 2020 was alost month, when steps could and should have been taken to curtail theepidemic and forestall the pandemic.
The Panel’s analysis suggests that the failure of most countries to respondduring February was a combination of two things. One was that they did
not sufficiently appreciate the threat and know how to respond. The second
was that, in the absence of certainty about how serious the consequencesof this new pathogen would be, “wait and see” seemed a less costly andless consequential choice than concerted public health action.

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Credit: Rosem
Mindy Tan
Morton4.3.1 Successful countries were proactive,
unsuccessful ones denied and delayed
The Panel’s review of a range of country responses up until March
2021 (b) demonstrates that countries that recognized the threat of
SARS-CoV-2 early, and were able to react comprehensively, faredmuch better than those that waited to see how the pandemic would
develop. The early-responding countries acted in a precautionary
way to buy time, while getting information from other countries,
particularly from Wuhan in China where the impact of the lockdown
showed that stringent measures could effectively stop the outbreak.
Response models developed in relation to earlier outbreaks,
including SARS and MERS, were rapidly adapted to the specificcharacteristics of this novel virus and its pathways of transmission.
The 2003 SARS epidemic had left a permanent mark, especiallyin the most affected east Asian and south-east Asian countries.
SARS resulted in governments instituting whole-of-government
approaches with clearly defined, tiered command structures toprepare for and respond to future outbreaks, with clear involvementof communities and transmission of information. Health protection
functions were consolidated under new centralized agencies.

Effective and high-level coordinating bodies were criticalto a country’s ability to adapt to changing information
Even though Ebola virus disease is a very different type of disease
to COVID-19, countries with that experience drew on it to rapidly
establish coordination structures, mobilize surge workforces andengage with communities.
National responses were most effective where decision-making
authority was clear, there was capacity to coordinate efforts acrossactors, including community leaders, and levels of government, andformal advisory structures were able to provide timely scientificadvice that was heeded. Effective and high-level coordinating
bodies were critical to a country’s ability to adapt to changing
information; in the context of a pandemic caused by a novel
pathogen, adaptability has been vital.
The strategies chosen by countries to respond to COVID-19 playedout in very different ways. In analysing national responses, thePanel has identified three distinct strategic approaches: aggressive
containment, suppression or mitigation. In addition, there are somecountries without any discernible or consistently applied strategy.

b The Panel has conducted a review of policy responses in 28 countries selected to represent
different regions and the best, worst and median outcomes, measured by deaths per
100 000 population.
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The aggressive containment strategy has been dominant in Asianand Pacific countries. Of the 28 country responses analysed in
depth by the Panel, those adopting aggressive containment include
China, New Zealand, Republic of Korea, Singapore and Thailand
and Viet Nam. Most of the countries that adopted this strategy
operationalized their national COVID-19 response through acoordinated and centralized governance structure.
Across all countries with successful responses, timely triage andreferral of suspected cases to ensure swift case identification andcontact-tracing, and providing designated isolation facilities, either
for all or for those unable to self-isolate, were key actions. Socialand economic support was instituted to promote widespread
uptake of public health measures. High-performing countries
developed partnerships on multiple levels across sectors and extragovernmentally, communicated consistently and transparently, andengaged with community health workers and community leaders aswell as the private sector.
Successful containment of COVID-19 has required comprehensive
approaches which align multiple health actions with public outreachand social and economic support. Prioritizing just one public healthintervention at the population level, such as mandatory face masks
or school and business closures, has not been effective.
Many countries fell in the middle ground. Their strategies aimed
for containment to the greatest extent possible but were often
inconsistent over time. Some countries put in place lockdowns whenincidence exceeded certain thresholds, or when hospital capacity

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was about to be saturated. Changes in lockdown policies weredifficult to time and often lagged behind fast-changing epidemic
dynamics. Border closure policies differed between countries.
Contact tracing programmes proved highly successful where they
were implemented stringently, early on, with coherent delivery
However, catching up on contact tracing that had been introduced
late and in settings of high community transmission often failed andwas abandoned.
In contrast, countries with the poorest results in addressing
COVID-19 had uncoordinated approaches that devalued
science, denied the potential impact of the pandemic, delayedcomprehensive action, and allowed distrust to undermine efforts.
Many had health systems beset by long-standing problems offragmentation, undervaluing of health workers and underfunding.
They lacked the capacity to mobilize quickly and coordinate
between national and subnational responses.
The denial of scientific evidence was compounded by a failureof leadership to take responsibility or develop coherent strategies
aimed at preventing community transmission. Leaders who
appeared sceptical or dismissive of emerging scientific evidence
eroded public trust, cooperation and compliance with publichealth interventions.
In many cases, national efforts were both catalysed and amplified
by regional responses. For example, the Africa Centres for Disease
Control, as an organ of the African Union, was able to coordinate
a continent-wide approach to the pandemic backed by requisite
political support from Heads of State and Government and ministers.

4.3.2 The crisis in supplies
Part of the story of the slide of COVID-19 from an outbreak intoa pandemic relates to issues of leadership, coordination anddecision-making at national level. But another part of the storyis the difficulties in which countries found themselves as theyscrambled to get hold of the equipment, supplies, diagnostic
tests, advice, funds and workforce they needed to respondto the exponentially growing COVID-19 caseload. There was
no international system that had created accessible stockpiles
sufficient for the scale of country needs, or that could trigger theflow of resources and step in to regulate orderly access.
In early February 2020, the Director-General of WHO warned ofdelays of 4–6 months in the supply of face masks and protective suits.
By March, the shortfall between needs and manufacturing capacity
was estimated at 40% (39). Stockpiles created in the wake of the2009 H1N1 influenza outbreak had been depleted; hoarding, pricegouging and fraud appeared in many countries; border restrictions
hampered the flow of supplies; and by April 2020 controls on theexport of medical supplies and medicines had been imposed by
75 countries (40). Furthermore, supply chains were overly dependent
on a few manufacturers or concentrated in a few supplier countries.
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Credit: Christine McNabNational and international efforts sought to overcome this supply
crisis, with mixed success. Countries which were able to establish
purchasing partnerships nationally and with neighbours fared best.
In conjunction with the African Union and Africa CDC, a partnershipplatform to increase purchasing power was established to achieve
greater leverage in the supplies market in a bid to avoid being
frozen out by richer countries. (c) At international level, the United
Nations and WHO launched the United Nations COVID-19 Supply
Chain System, which eventually channelled half of the essential
supplies reaching low- and middle-income countries. Local
research, development and manufacturing were used to bolster
supplies, ranging from personal protective equipment (PPE) to
test kits and developmental work on vaccines.
An early and continuing critical gap is in oxygen supplies, vital ina respiratory pandemic, and there is no clear lead agency devoted
to its delivery. This is not a new problem — up to half of all healthfacilities in resource-limited settings have persistently been foundto lack reliable oxygen supplies (41, 42).
The shortage of essential supplies had a major impact on healthworkers in the early stages of the response, contributing to thehigh death toll. Health workers have reported that their fearscAfrica Medical Supplies Platform (https://amsp.africa): “We help institutional healthcare
providers source critical equipment, fast”.

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at the outset of the pandemic were heightened by initial systems
failures, including a lack of evidence-based guidelines, shortagesof PPE, sudden lockdowns that disrupted normal operations, andan overwhelming sense that facilities were unprepared. (d)The agility with which countries were able to manage surge healthworkforce demands has been a key difference between successful
and struggling responses. The health systems that managed the
COVID-19 response better quickly mobilized, trained and reallocatedtheir health workforce with a combination of hiring new staff, using
volunteers and medical trainees and mobilizing retirees. They tookproactive steps to increase system capacity — in some cases with therapid construction of makeshift hospitals in places where COVID-19
was out of control, but also by extending telemedicine, postponing
elective medical procedures and supporting primary care.
Rapid research and development: while much of the early response
to COVID-19 involves missed opportunities and failure to act, there
are some areas in which early action was taken to good effect,
most notably in research and development (R&D) and, in particular,
vaccine product development.
The COVID-19 response benefited from years of effort to expand
capacities for R&D to address potential pandemics. Expertise andtechnology from decades of work — especially on HIV, Ebola andcancer vaccine research and immunology — were available andready to apply to the new virus.
In the wake of the Ebola epidemic in 2016, a new model for R&D
response to emerging pathogens likely to cause severe outbreaks
in the future was developed under WHO’s R&D Blueprint (43, 44). It
identified bottlenecks in international collaboration, encouraged
agreement on basic data-sharing principles, and sought more
efficient ways to conduct clinical trials in times of distress (45).
The Coalition for Epidemic Preparedness Innovations (CEPI)
was launched in 2017 as a non-profit organization funding basic
research and early clinical trials for a list of epidemic-prone
infectious diseases.
This infrastructure was deployed almost as soon as the COVID-19
alert was sounded. CEPI sought out and sponsored some of thefirst vaccine candidates (Moderna and Oxford University) as earlyas 20 January 2020, when there were fewer than 600 cases aroundthe world. A number of adaptive clinical trials were launched which
provided evidence quickly, for example the UK’s Recovery trial byJune 2020 had shown the effectiveness of dexamethasone, and thelack of clinical benefit of the use of hydroxychloroquine in COVID-19
disease (46). The R&D Blueprint encouraged adaptive clinical
trials and launched the Solidarity trial in mid-April 2020, which
exemplified an efficient and robust way to generate randomized
evidence using simple large trials.
d Source: Focus group discussions conducted for the Independent Panel Secretariat with a sample
of health workers from different disciplines and regions.
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Accompanying the global efforts were national measures to support
COVID-19 R&D, the largest of which was the United States federal
Biomedical Advanced Research and Development Authority, whose
cumulative investment in research, development, manufacturing
and procurement of COVID-related vaccines, therapeutics anddiagnostics was US$ 14 billion by November 2020 (47). Regulators
also raced to find ways to speed up clinical testing while maintaining
safety. Several national regulatory agencies, including the European
Medicines Agency, in India, the Food and Drug Administration in the
United States, and Health Canada approved emergency procedures
to expedite clinical testing and approval.
In April 2020, public health experts said the optimistic expectation
was that a COVID-19 vaccine was at least 12–18 months away (48).
However, by July, numerous vaccine candidates were alreadyin advanced clinical trials (49).

4.3.3 Lessons to be learnt from the early response
The Panel has analysed closely the early response to the COVID-19
outbreak, to examine whether responses to the outbreak bycountries and the international system could have been different,
and prevented it from escalating into the devastating pandemic
it became.
The Panel’s conclusion is that the declaration of a PHEIC, thehighest level of global concern specified in the international, legallybinding, health regulations did not lead to an urgent, coordinated,worldwide response. It was not until the number of COVID-19 cases
increased dramatically and COVID-19 had spread internationallythat governments took serious action to prevent transmission.

Figure 6: Personal Protective Equipment Prices (as of 15 July 2020)
Source: UNICEF Global COVID-19 Special Interim Report, August 2020.

Personal Protective Equipment Prices (as of 15 July 2020)$70

Pre-COVID Price
Average UNICEF price during COVID response
Maximum market prices during COVID response

60
50
40
30
20
10
0
Face mask(Pack 50)

Mask N95(Pack 10)

Nitrile gloves(Pack 100)

Coveralls

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Gowns

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February was a lost month of opportunity to contain the outbreak,even as the evidence of infections spreading globally was apparent.
For the Panel it is also clear that timing mattered — for a few
countries, early recognition of the COVID-19 threat and quick
responses kept the epidemic small. But even countries that acted
later have been able to gain and maintain success with adaptable
responses that are coordinated, multisectoral and science-based.
Countries that devalued science failed to build trust in their
response and pursued inconsistent strategies that left them lagging
behind the epidemic and with high infection and death rates.

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4.4 The failure to sustain the response in the faceof the crisis
4.4.1 National health systems under enormous stress

Many people with
underlying healthconditions couldn’t get
the care they needed.

Credit: Tuane Fernandes Silva

Health systems and health workers were not prepared for a
prolonged crisis. The COVID-19 pandemic has taken an enormous
physical and emotional toll on the world’s health workers. The
health systems which had been under-resourced and fragmented
over a long period prior to the pandemic were the least resilient.
Delivery of essential health services, including those for sexualand reproductive health, noncommunicable and communicablediseases, immunization, and other health programmes wereinterrupted, with wider impacts in low- and middle-income
countries. People with underlying conditions were neglected. People
in aged care were especially vulnerable to COVID-19 and for manyhigh-income countries, the huge wave of deaths in these facilities
showed profound flaws in protections against a new health threat
and in the way care for the elderly and vulnerable is provided.
As the COVID-19 pandemic progressed, graphic news footage wasbroadcast of thousands of distressed patients overwhelming healthfacilities around the world, many of which were woefully unprepared
for the surge. Ambulances queued, emergency rooms overflowed,
and hospital beds were dangerously oversubscribed. In Spain, as
an example, many intensive-care units operated at 200–300% of
capacity, and other countries felt similar strain.
Holding it all together were health professionals and other essential
workers on the front line — medical technicians, doctors and nurses,
border and quarantine staff, midwives and community workers,
food suppliers and cleaners — working hour after hour, often lacking
adequate protective equipment and patient supplies, watching
helplessly while patients died without loved ones by their sides, andworrying about their own health and families. Response measures
added to their stresses — as schools and day-care centres closed
down, parents who were essential workers found themselves having
to juggle impossible demands on their time.

4.4.2 Jobs at risk
In addition to health workers, the pandemic has also affected
other essential workers, including those self-employed, small andmedium sized entrepreneurs, those working in food shops, delivery
and transportation and cleaning, and at national and subnational
borders. Those involved in meat processing were at particular risk

Holding it all together were health professionals and otheressential workers on the front line —medical technicians,
doctors and nurses, border and quarantine staff, midwives
and community workers, food suppliers and cleaners
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of infection. Meat-packing plants provide favourable conditions forviral transmission, given their low temperature, metallic surfaces,
dense production of aerosols, noise levels requiring workers toshout, crowded working conditions and, often, limited accessby employees to sick leave.
The nature of the front line and the degree of risk to workers
reflects an income gradient, both between and within countries.
While those who could, and could afford to, have worked fromhome during the crisis, others, largely lower-income workers, kept
food supplies, transportation and deliveries functioning, risking
infection themselves.
The economic impact of COVID-19 has depended on the interplayof pre-existing structural conditions in economies, the amountof fiscal and governance space made available for mitigation
measures, and the nature and timing of decisions made in responseto the pandemic. Prior conditions mattered — there was much more
freedom to act and more choices were available in those places
where a robust and resilient health system existed, where social andeconomic protections were solid, and where governments, scientists
and citizens trusted each other to do their best.
An analysis of more than 80 countries shows that, where there werehigh levels of informal employment, mobility restrictions did not
reduce the number of cases — leading to the conclusion that stayat-home orders can only be successful when three conditions are
met: households have enough income to make ends meet throughthe lockdown period; workers have digital access to enable them towork remotely; and there is a level of trust in government sufficientfor orders to be complied with (50).
Many have lost their jobs and, in some cases, also their healthinsurance, creating a negative spiral of disease spread andseverity. Social protection floors — the set of guarantees for allof the population that every country should have in place, with

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nationally defined levels of income security through the life cycle
and access to health care (51) — recognize the intimate relationshipbetween universal health coverage and social protection. The
pandemic has underlined the inequities that result when countries
fall short of meeting these standards.
Community responses and local engagement have been vital
resources in the response. Where community structures, such as
cadres of community health workers, have been mobilized, they
have made a critical difference in establishing trust in government
instructions, extending services, and in relaying scientific information.
However, the potential for communities to shape the response at thedecision-making table has been severely neglected.
Similarly, women constitute almost 60% of the health workforce
and front-line workers, yet they were not included in most of the
COVID-19 response structures, thus increasing the equity gap for
an effective response.

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4.4.3 Vaccine nationalism
Vaccine access and distribution is a highly charged politicalissue and choice. As of now, a number of high-income countries,
including Australia, Canada, New Zealand, the United Kingdom,
across the European Union, and the United States, have been able
to secure vaccine doses that would be enough to cover 200% of
their populations (52).
A core mechanism to address global vaccine availability is COVAX,
launched by WHO and partners in April 2020 as the vaccines pillarof its Access to COVID-19 Tools Accelerator (ACT-A). Its initial aim
expressed in September 2020 was to purchase 2 billion COVID-19
vaccine doses by the end of 2021 and deliver them to people in
190 countries. By mid-March 2021, COVAX had shipped 30 million
doses to at least 54 countries (53, 54). At that time COVAX expected
approximately 1.8 billion doses to be available to 92 low- andmiddle-income countries before the end of 2021, covering 27%of their populations.
But these expectations must contend with uncertainties ofmanufacturing capacity, regulation, funding availability, final
contract terms and the readiness of countries to deliver theirnational COVID-19 vaccination programmes. Had COVAX had
sufficient and readily available early funding it would have been
better able to secure enough immediate supply to meet its aims (55).

Figure 7: Total COVID-19 vaccine doses per 100 people as of 21 April 2021
Source: World Health Organization Coronavirus (COVID-19) Dashboard. Data as of 21 April 2021.

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Credit: Angela Ponce

The immediate issue is how to reach a political agreement
for sharing and redistributing available doses of vaccine, andcommitted doses to come, based on what is best from a global
public health perspective with equity at the centre. There is anagreement that covering only one’s own population will not end the
pandemic, but the failure to move from that rhetoric to an actual
effective flow and allocation of vaccine doses as they become
available is a severe threat to the fight against COVID-19.
There is no definitive information source on the state of facilities
worldwide now ready and able to produce COVID-19 vaccine and inwhat quantities, nor of the raw materials required. Manufacturers in2020 were having difficulty even predicting how much vaccine they
could make for clinical trials, much less in bulk by the billions of doses.
Raw materials in thin supply include syringes and glass vials (56).
Aligning technology transfer, intellectual property andmanufacturing capacity could boost efforts to speed up vaccine
rollout. Manufacturing capacity, an effective regulatory environment
and equitable distribution are interdependent problems, all of which
can be solved.

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Progress in sharing know-how, licensing and intellectual property
has been slow. In May 2020, WHO set up the COVID-19 Technology
Access Pool (C-TAP) to pool knowledge, intellectual property anddata (57). Supported in principle by 41 high-, middle- and lowincome countries, it has received no contributions so far. A recent
push by South Africa and India at the World Trade Organization to
waive intellectual property rules and allow generic manufacturers
to make COVID-19 vaccines continues to run into opposition.
India — potentially among the world’s largest vaccine-makers —is itself lagging in vaccine production and delivery, and surges
in cases there have constrained its vaccine exports (58).
The Panel notes that COVID-19 has been a pandemic ofinequalities and inequities (59). Those with less social protection
were more likely to have pre-existing health conditions that madethem more vulnerable to COVID-19, and they were often also
more exposed to the virus owing to the nature of their work andtheir living conditions. When exposed to COVID-19, a lack of social
protection prevented vulnerable and sick people from staying
at home because of the risk of a loss of income.
Inequality has been the determining factor explaining why the
COVID-19 pandemic has had such differential impacts on peoples’
lives and livelihoods.

For the Panel it is clear that the combination of poor
strategic choices, unwillingness to tackle inequalities,
and an uncoordinated system created a toxic cocktail
which allowed the pandemic to turn into a catastrophic
human crisis.

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for transforming the international system forpandemic preparedness and response
The Panel believes that system-level change is needed to overcome
the manifest failure of the international system to prevent, contain,
and mitigate the impact of a pandemic. Pandemic preparedness andresponse have to function at national, regional and global levels, acrossdifferent sectors of social and economic life, and include government,
business and community.
The current pandemic needs to be stopped as quickly as possible.
Then measures in the recovery phase must be taken to ensure that sucha pandemic never happens again, by building forward better. The lost
ground in progress towards the Sustainable Development Goals needs
to be made up by redressing the interlocking impacts of the pandemic
on health, livelihoods, and inequality.
The Panel’s recommendations follow from the diagnosis we have madeof what went wrong at each stage of the pandemic, in preparedness,surveillance and alert and early and sustained response and from ourview of the leadership required to transform the system.
There is a need for:• Stronger leadership and better coordination at national,
regional and international level, including a more focused andindependent WHO, a Pandemic Treaty, and a senior Global HealthThreats Council.
• investment in preparedness now, and not when the next crisis hits,
more accurate measurement of it, and accountability mechanisms
to spur action;• an improved system for surveillance and alert at a speed that can
combat viruses like SARS-CoV-2, and authority given to WHO to
publish information and to dispatch expert missions immediately;• a pre-negotiated platform able to produce vaccines, diagnostics,
therapeutics and supplies and secure their rapid and equitabledelivery as essential global common goods;• access to financial resources, both for investments in
preparedness and to be able to inject funds immediately
at the onset of a potential pandemic.
The Panel calls on Member States to request the United Nations
Secretary-General to convene a special session of the United Nations
General Assembly to reach agreement on the reforms needed toensure that the world can prevent the next outbreak of a new pathogen
becoming another pandemic.
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1. Elevate leadership to prepare forand respond to global health threats
to the highest levels to ensure just,accountable and multisectoral action
The COVID-19 pandemic has laid bare the lack of high-level politicalleadership in coordinated global action against the pandemic, withresultant failures in securing agreement between governments insupport of common goals and alignment of efforts to tackle health,social and economic challenges. As a result, coherent global strategic
directions in pandemic response have not been set and linked tointernational agencies and regional institutions. Nor have the private
sector and civil society organizations been able to contribute to strategic
direction setting in an effective way.
The organic evolution of the international health system over recent
decades in order to address particular health problems has resulted inpockets of major progress but also created inefficiencies resulting fromunclear roles and responsibilities and an inability to leverage effectively
the comparative advantages of different actors. Global health crises
have whole-of-system impacts and require coordinated leadership from
WHO, the International Monetary Fund (IMF), World Bank, and the United
Nations Secretary-General. Similar coordination is required regionally.
At country level where there is a United Nations presence the Resident
Coordinator system provides United Nations system coordination in
support of countries.
The international system for pandemic preparedness and response
requires fundamental transformation, catalyzed by political leadershipat the highest level. That transformation needs to deliver synergies
between international, regional and national organizations, increased
pandemic preparedness and response capacities at all levels, andeffective monitoring and compliance systems.
The Panel is convinced that a Global Health Threats Council at themost senior level is vital to success in the future. The pandemic showssuch a body is long overdue. It would help secure high-level politicalleadership and ensure attention to pandemic prevention, preparedness
and response is sustained over time in the service of a vision of a world
without pandemics. The Council should be an inclusive and legitimate voiceof authority with the ability to utilise both accountability mechanisms andprovide access to financing to ensure preparedness as well as responseat the national, regional and global levels.
Any transformation of the international system will require more robustinternational governance for pandemic preparedness and response.
International legal instruments should support that goal. The Panelbelieves that a Framework Convention would be an opportunity
to address gaps in the international response, clarify responsibilities
between States and international organizations, and establish and
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reinforce legal obligations and norms. Mechanisms for financing,research and development, technology transfer, and capacity building
could also be enshrined in the Convention. Expeditious adoption of aPandemic Framework Convention should capitalize on political will at
the peak of global determination to avoid future pandemics and serveto accelerate governance reforms.
The commitment of Heads of State and Government to transformthe international system for pandemic preparedness and responsemust go together with their commitment to lead strong and effective
national implementation. It will dovetail with continued and enhanced
implementation of the 2030 Agenda and the Sustainable Development
Goals.

The Panel recommends
I.

Establish a Global Health Threats Council. The membership should beendorsed by a United Nations General Assembly resolution (see below
recommendations for a Special Session of the General Assembly
and Terms of Reference for a Global Health Threats Council). The
Council should be led at Head of State and Government level andthe membership should include state and relevant non-state actors,
ensuring equitable regional, gender and generational representation,with the following functions:a. Maintain political commitment to pandemic preparedness
between emergencies and to response during emergencies.
b. Ensure maximum complementarity, cooperation andcollective action across the international system at all levels.
c. Monitor progress towards the goals and targets set by
WHO, as well as against potentially new scientific evidence
and international legal frameworks, and report on a regularbasis to the United Nations General Assembly and the World
Health Assembly.
d. Guide the allocation of resources by the proposed new
finance modality according to an ability to pay formula.
e. Hold actors accountable including through peer recognition
and/or scrutiny and the publishing of analytical progressstatus reports.

VI. Adopt a Pandemic Framework Convention within the next 6 months,
using the powers under Article 19 of the WHO Constitution, andcomplementary to the IHR, to be facilitated by WHO and with theclear involvement of the highest levels of government, scientificexperts and civil society.
VII. Adopt a political declaration by Heads of State and Government at
a global summit under the auspices of the United Nations General
Assembly through a Special Session convened for the purpose andcommitting to transforming pandemic preparedness and response
in line with the recommendations made in this report.
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2. Focus and strengthen the independence,authority and financing of the WHO
The WHO has an indispensable leadership role in the international
system for prevention, preparedness and response to a global healthemergency such as a pandemic. The work of WHO during the COVID-19
pandemic has been at a substantively different scale and level comparedfor example to the initial period of the response to Ebola in west Africa in
2014. WHO must be central to the global health system. For many years,
it has been given new tasks without sufficient authority or resources toundertake them fully. In this pandemic, the efforts of its leadership andstaff have been unstinting but structural problems have been exposed.
WHO is and should be the lead health organization in the international
system, but it cannot do everything. It is imperative that the international
preparedness and response system works together at the global, regional,
and country levels as a well-defined and well-coordinated system insupport of countries where different actors’ comparative advantages
are maximized.
WHO should in its support to national governments be the convener,
but also in cases of emergencies it should strengthen its role as thecoordinator without, in most circumstances, also taking on delivery
functions (such as procurement and supply). WHO should focus onproviding strategic direction and analysis, and formulating norms,
standards and technical advice to ensure that countries have resilient
health systems that are prepared with the required response capacities
for health emergencies. In the case of emergencies WHO has animportant operational role to play providing technical advice
and support.
The quality, timing and clarity of the technical advice and direction WHO
provides to the world are of the utmost importance. Programmes should
be staffed with up-to-date, relevant, high quality experts, supportedby the necessary financial, organizational, and management systems.
Regional offices can play a key role in tailoring global advice more
specifically to local contexts. A core technical function of WHO is thetranslation of models of successful national response into strategies
that can be applied elsewhere.
The way that WHO is financed today has serious impacts on the quality ofthe organization’s performance. Its precarious financing is a major risk to
the integrity and independence of its work. Incremental attempts in recent
decades to improve the present funding model have not been successful.
While the WHO Director-General nominally has many of necessary formal
and legal authorities to make decisions, and guide and communicate withthe world concerning pandemics and health at large, in practice there
are challenges to the use of that authority. Global health is inevitablya politically charged domain and it is vital that WHO as an institution

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is strong enough to be able to perform with maximum independence.
The same degree of independence is also desirable for other institutions
across the multilateral system.
Governance needs to align with the expectations laid on the organization,
especially when it comes under the extreme stress of dealing with apandemic. Reform attempts directed towards the role of the Executive
Board have met with little success. The failure of the Board to perform
as an executive body, closely supporting and guiding the work of theorganization, has been evident during the current pandemic.

The Panel recommends
I.

Establish WHO´s financial independence, based on fully
unearmarked resources, increase Member States fees to 2/3 ofthe budget for the WHO base programme and have an organized
replenishment process for the remainder of the budget.

II.

Strengthen the authority and independence of the Director-General,
including by having a single term of office of seven years with nooption for re-election. The same rule should be adopted for Regional
Directors.

III. Strengthen the governance capacity of the Executive Board,
including by establishing a Standing Committee for Emergencies.
IV.

Focus WHO’s mandate on normative, policy, and technical guidance,
including supporting countries and regions to build capacity forpandemic preparedness and response and for resilient and equitable
health systems.

V.

Empower WHO to take a leading, convening, and coordinating rolein operational aspects of an emergency response to a pandemic,
without, in most circumstances, taking on responsibility for
procurement and supplies, while also ensuring other key functions of
WHO do not suffer including providing technical advice and support
in operational settings.

VI. Resource and equip WHO Country Offices sufficiently to respondto technical requests from national governments to support
pandemic preparedness and response, including support to build
resilient equitable and accessible health systems, UHC and healthier
populations.
VII. Prioritize the quality and performance of staff at each WHO level,and de-politicize recruitment (especially at senior levels) by adhering
to criteria of merit and relevant competencies.

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3. Invest in preparedness now to create
fully functional capacities at thenational, regional and global level
Pandemic preparedness has received insufficient political priority. It
has been largely confined to the health sector. The extent of pandemic
risk has not been appreciated in financial decision-making or in wholeof-government or organizational priority-setting at national, regional or
global levels.
An immediate opportunity to integrate pandemic risk awareness andpandemic preparedness with economic development would be toincorporate relevant pandemic considerations into existing instruments
used by the IMF and World Bank.
Multisectoral coordination of preparedness has been lacking. While theSendai Framework for Disaster Risk Reduction includes pandemic risk
in its purview, disaster risk reduction capacity-building has largely been
separated from health-sector pandemic preparedness efforts.
One consequence of the lack of priority given to pandemic preparedness
is a financing gap to support national preparedness planning andcapacity-building and global support functions. National pandemic
response plans have often not been strategic and have lacked realistic
financial mobilization plans.
The funding gap for preparedness exists globally and in countries
at all income brackets. While low- and middle-income countries mayneed international support to supplement their domestic resources forpandemic preparedness, high-income countries can meet all the required
costs from domestic resources.
Preparedness assessments were not robust, and in practice theyfailed to predict actual performance in COVID-19 responses. The use ofsimulation exercises was at best patchy and not systematically followed
up with remedial action. Animal and environmental health systems werelargely not integrated with human health protection systems. Explicit One
Health planning was not adopted at the top governance level nationally,
regionally or globally.
There was a lack of surge plans, rapidly deployable human resources,
stockpiles, and pre-positioning of essential supplies.
A new pathogen with pandemic potential could emerge at any time.
These gaps in preparedness need urgent rectification. While many
governments and regional and international organizations are focused on
the ongoing COVID-19 crisis, they may find it challenging to pay attention
to the measures needed to prepare better for future outbreaks. Those
future outbreaks may also be of very different pathogens with different

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implications. So, the shared learnings about the successes in responding
to COVID-19, and the hard-won lessons from failings, represent a
once-in-a-lifetime opportunity to get preparedness right to preventa catastrophic pandemic from arising again.

The Panel recommends
I.

WHO to set new and measurable targets and benchmarks forpandemic preparedness and response capacities.

II.

All national governments to update their national preparedness
plans against the targets and benchmarks set by WHO within six
months, ensuring that whole-of-government and whole-of-society
coordination is in place and that there are appropriate and relevant
skills, logistics and funding available to cope with future health crises.

III. WHO to formalize universal periodic peer reviews of national
pandemic preparedness and response capacities against the targets
set by WHO as a means of accountability and learning between
countries.
IV.

As part of the Article IV consultation with member countries, theIMF should routinely include a pandemic preparedness assessment,
including an evaluation of the economic policy response plans. The
IMF should consider the public health policy evaluations undertaken
by other organizations. Five-yearly Pandemic Preparedness
Assessment Programs should also be instituted in each member
country, in the same spirit as the Financial Sector Assessment
Programs, jointly conducted by the IMF and the World Bank.

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4. Establish a new international system
for surveillance, validation and alert
Epidemic intelligence is increasingly based on a constant process of
surveying tens of thousands of signals from open sources and identifying
and verifying potential public health threats. Advances in real-time
digitally based surveillance, supported by machine learning, havecreated an always-on system that rapidly identifies information ofconcern. In contrast, the alert, verification and notification processes
integral to the IHR (2005) require information to be methodically relayed
through the machinery of government nationally and then to WHO. The
methodical IHR-based process is not equipped to respond at a speed
commensurate with surveillance systems, and the lag between the two
is a critical point of system failure. This failure is especially evident if
containment of a fast-moving respiratory pathogen is at issue.
WHO Member States have been reluctant to give the organization andits Director-General the power to investigate and report immediatelyon potential outbreaks. Technical expert missions can be dispatched
to individual countries only with their permission, and a system of preauthorization of missions has not been established. Often lengthy
negotiations with governments for access by missions are required after
an outbreak has been notified.
The bias of the current system of pandemic alert is towards inaction —steps may only be taken if the weight of evidence requires them. Thisbias should be reversed — precautionary action should be taken on a
presumptive basis, unless evidence shows it is not necessary.
A PHEIC should serve as a clarion call for emergency pandemic response
across the world, with countries being attentive to the precise natureof the emergency and the potential threat it contains. Instead, theprocesses around a PHEIC declaration are more oriented to ensuringthat unwarranted trade and travel restrictions are not imposed. The IHR(2005) establish no obligations on States for action following declarationof a PHEIC.
In changing the system of alert to orient it towards speedy action, theincentive structures need to be addressed. At present, from local up tointernational level, public health actors only see downsides from drawing
attention to an outbreak that has the potential to spread. Incentives
must be created to reward early response action and recognize that
precautionary and containment efforts are an invaluable protection
which benefits all humanity.
Explicit performance standards should be attached to outbreak alert
and response. These performance standards have to address different
classes of emerging pathogen. Each of the steps leading up to andfollowing the alert should be predictable and trigger requisite response
action without delay.

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The Panel recommends
I.

WHO to establish a new global system for surveillance, based on fulltransparency by all parties, using state-of-the-art digital tools toconnect information centres around the world and including animaland environmental health surveillance, with appropriate protectionsof people’s rights.

II.

WHO to be given the explicit authority by the World Health Assembly
to publish information about outbreaks with pandemic potential on
an immediate basis, without requiring the prior approval of national
governments.

III. WHO to be empowered by the World Health Assembly to investigate
pathogens with pandemic potential in all countries with short-noticeaccess to relevant sites, provision of samples and standing multientry visas for international epidemic experts to outbreak locations.
IV.

Future declarations of a PHEIC by the WHO Director-General should
be based on the precautionary principle where warranted, as in thecase of respiratory infections. PHEIC declarations should be based on
clear, objective, and published criteria. The Emergency Committee
advising the WHO Director-General must be fully transparent in its
membership and working methods. On the same day that a PHEIC is
declared, WHO must provide countries with clear guidance on what
action should to be taken and by whom to contain the health threat.

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5. Establish a pre-negotiatedplatform for tools and supplies
ACT-A was launched on 24 April 2020 and evolved organically.
Its vaccines, diagnostics, therapeutics pillars, and health systems
connector are intended to be agile, collaborative partnerships rather
than hierarchical structures. While ACT-A was able to establish a
successful platform in many respects, the fact that it did not exist before
the COVID-19 pandemic and had to be created for that purpose isreflected in its shortcomings. Not all pillars of the initiative have beenequally successful, and a coherent, strategic, inclusive, and fully fundedframework has not been achieved, to this day. ACT-A is seen by somecountries and civil society as supply-driven and not sufficiently inclusive,with large donor countries and institutions having an asymmetricalinfluence on decision-making.
There is a lack of shared vision among all stakeholders, including bothcountries and manufacturers, that the therapeutics, vaccines anddiagnostics needed to counter pandemics are global health commons.
Without that shared vision, the “business-as-usual” approach prevails
dominated by the development and sale by global corporations ofproprietary products designed for wealthy countries, leaving therest of the world dependent on the goodwill of donors, development
assistance and charity to gain access — eventually — to life-saving healthtechnologies (60).
The alignment of international instruments should support such ashared vision, for example, by including the open licensing of vaccines,
therapeutics and diagnostics in the United Nations Educational, Scientificand Cultural Organization’s forthcoming Recommendation on OpenScience, an international standard-setting instrument that is currently
being negotiated with Member States for adoption in 2021.
Concentration of manufacturing capacity, and of trials and knowledge
generation, for vaccines, therapeutics, diagnostics and other essential
supplies in a small number of countries has been a major contributor
to inequity. While vaccine product development has been the mostsuccessful, there was a lack of end-to-end planning with R&D, clinical
trials and manufacturing processes guided by a goal and strategy for
equitable and effective access.
A pre-negotiated system to accelerate R&D and achieve equitable access
is vital to pandemic response and the development and delivery of
vaccines, therapeutics, diagnostics, and essential supplies. ACT-A provides
a valuable model. Lessons drawn from both its strengths and weaknesses
should guide the establishment of a permanent platform which can standin readiness for any future pandemic.
The Panel believes that a comprehensive review of the achievements,
financing, and governance of ACT-A should be conducted to makeit more robust and fit for the extended purpose it should assume.
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The current model of high-income-country dominated systems must betransformed to a global, inclusive approach, because it is the morally rightthing to do and because it is the only way to manage a global pandemic.
Critically, such a system needs to be able coordinate decision-making
globally; maintain effective relationships with vaccine and otherproduct manufacturers from both the public and the private sector andfrom all regions; strengthen global and local manufacturing capacity,
including long-term and sustained investment in technology transfer;and incorporate a financing mechanism that invests early in thedevelopment cycle in order to support rapid and equitable development,
manufacturing, and access.

The Panel recommends
I.

Transform the current ACT-A into a truly global end-to-end
platform for vaccines, diagnostics, therapeutics, and essential
supplies, shifting from a model where innovation is left to the market
to a model aimed at delivering global public goods. Governanceto include representatives of countries across income levels andregions, civil society and the private sector. R&D and all other relevant
processes to be driven by a goal and strategy to achieve equitableand effective access.

II.

Ensure technology transfer and commitment to voluntary licensing
are included in all agreements where public funding is invested inresearch and development.

III. Establish strong financing and regional capacities for
manufacturing, regulation, and procurement of tools for equitableand effective access to vaccines, therapeutics, diagnostics andessential supplies, and for clinical trials:
a. based on plans jointly developed by WHO, regional
institutions, and the private sector;
b. with commitments and processes for technology transfer,including to and among larger manufacturing hubs in eachregion; andc. supported financially by International Financial Institutions
and Regional Development Banks and other public andprivate financing organizations.

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6. Raise new international financing forthe global public goods of pandemic
preparedness and response“More money” is an easy response to any problem. But the Panel’s call isfor specific financing for specific purposes. In addition to funding needed
for the current response, and more and different funding for WHO, the
COVID-19 crisis has revealed two particular challenges in respect of the
global public good of effective pandemic preparedness and response:
insufficient funding of pandemic preparedness at national, regionaland global levels before the pandemic, and the slow flow of funding for
response once the PHEIC was declared.
It is a vital function of the international system for pandemic preparedness
and response to bridge two specific gaps that exist in poorer countries
for the delivery of the global public good of regular funding for
pandemic preparedness and fast funding for early response. Examples
of preparedness funding of this kind include helping countries andregions run simulation exercises and set up genomic sequencing facilities.
Examples of response funding would be expediting the purchase oftherapeutics and diagnostics or expanding testing.
It is necessary to think beyond aid and official development assistance(ODA) to finance global public goods. Pandemic preparedness and early
response capacity should be thought of as critical infrastructure elements
which cannot be allowed to fail, requiring stable and reliable financing inthe same way as other critical international systems such as finance andbanking, or security and peacekeeping.
The present international system for raising, channelling and spending
international resources for pandemic preparedness and response has adiversity of actors, mandates, and financing tools. We do not recommend
creating new implementing agencies. But we do believe that existing
implementing agencies need additional funding, directed towards thevital public goods they deliver.
Already there are successful examples in COVID-19 financing which area starting point for the comprehensive overhaul of financing which isneeded; for example the mobilisation and reallocation by the Global Fundto Fight AIDS, TB and Malaria of US$ 1 billion to meet urgent COVID-19
needs early in the pandemic and its recent addition of US$ 3.5 billion to
support COVID-19 responses, including testing, PPE and oxygen supplies.
Our determination is to ensure that these efforts are proactive andplanned, not reactive and rushed.

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The Panel recommends
I.

Create an International Pandemic Financing Facility to raise
additional reliable funding for pandemic preparedness and for
rapid surge financing for response in the event of a pandemic.
• The facility should have the capacity to mobilize long-term(10–15 year) contributions of approximately US$ 5–10 billion
annually to finance ongoing preparedness functions. It will
have the ability to disburse up to US$ 50 –100 billion at short
notice by front-loading future commitments in the event of
declaration of a pandemic. The resources should fill gaps
in funding for global public goods at national, regional andglobal level in order to ensure comprehensive and inclusive
pandemic preparedness and response.
• There should be an ability-to-pay formula adopted whereby
larger and wealthier economies will pay the most, preferablyfrom non-ODA budget lines and additional to establishedODA budget levels.
• The Global Health Threats Council will have the task ofallocating and monitoring funding from this instrument
to existing regional and global institutions, which cansupport development of pandemic preparedness andresponse capacities.
• Funding for preparedness could be pre-allocated according
to function and institution. Surge financing for response in
the event of a new pandemic declaration should be guided
by prearranged response plans for the most likely scenarios,
although flexibility would be retained to adapt based on
the threat.
• The Secretariat for the facility should be a very lean structure,with a focus on working with and through existing global andregional organizations.

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7. Countries to establish highest level
national coordination for pandemic
preparedness and response
National responses in a significant number of countries failed to getahead of the pandemic. Measures that were taken too late had all of thecosts but none of the benefits of early containment, resulting in a negative
feedback loop in which the economy was pitted against health.
Countries which successfully managed the disease took whole-ofgovernment and whole-of-society approaches, sought scientificguidance, engaged with community health workers and community
leaders, involved vulnerable and marginalized populations, also
in conflict-affected countries, and worked closely with subnational
governments. But where scientific advice was side-lined, and national
approaches were characterized by denial, delay, and distrust, the result
was uncoordinated and confused national efforts that were ineffective incurbing community transmission.
Building resilient and equitable societies requires a serious shift inmindsets. The extent to which the COVID-19 pandemic has exacerbatedinequalities is an emphatic demonstration of the interconnectedness ofsocial, economic, environmental and political factors in society. Healthprogrammes and COVID-19 responses need to recognize and act upongender, ethnic, and other inequalities. Both community and private-sector
actors have been viewed as conduits for resources to supplement thecore business of health systems, rather than as actors with a vital stake inpandemic outcomes and a right to a seat at the decision-making table.
Accomplishing a change of paradigm to a resilient, equitable and inclusive
system for pandemic preparedness and response is an inevitably political
exercise because it demands that respect for human rights and promotionof equality are brought to the foreground. Health and well-being require
the intersectional nature of disadvantage and exclusion to be tackled.

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The Panel recommends
I.

Ensure that national and subnational public health institutions
have multidisciplinary capacities and multisectoral reach and theengagement of the private sector and civil society. Evidence-based
decision-making should draw on inputs from across society.

II.

Heads of State and Government to appoint national pandemic
coordinators accountable to the highest levels of government, withthe mandate to drive whole-of-government coordination for bothpreparedness and response.

III. Conduct multisectoral active simulation exercises on a yearly basis
as a means of ensuring continuous risk assessment and follow-up
action to mitigate risks, cross-country learning and accountability
and establish independent, impartial and regular evaluation
mechanisms.
IV.

Strengthen the engagement of local communities as key actors
in pandemic preparedness and response and as active promotersof pandemic literacy, through the ability of people to identify,
understand, analyse, interpret, and communicate about pandemics.

V.

Increase the threshold of national health and social investments
to build resilient health and social protection systems, groundedin high-quality primary and community health services, universal
health coverage and a strong and well-supported health workforce,
including community health workers.

VI. Invest in and coordinate risk communication policies and strategies
that ensure timeliness, transparency, and accountability, and workwith marginalized communities, including those who are digitally
excluded, in the co-creation of plans that promote health and wellbeing at all times, and build enduring trust.

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Actions that together will transformthe international system for pandemic
preparedness and response
The transformation of the international system for pandemic
preparedness and response which the Panel recommends will fail if
it is approached piecemeal. The lesson from previous recommendations
for change following earlier pandemics is that change will only result
from the adoption and implementation of inter-linked and interdependentmeasures. Just as pandemic preparedness itself is undone by failure in
the weakest link in the chain, so too recommendations for change will
fail if the hardest problems are set aside.
The Panel has assessed the set of recommendations it has proposed
against one criterion only: if they had been in place, would they havestopped the COVID-19 pandemic? We believe the answer is yes, andtherefore urge their implementation as a whole and in a timely manner.
The Panel’s recommendations aim to equip countries and theinternational system to prevent an outbreak from becoming a pandemic
and, if a pandemic does occur, to prevent it becoming a global healthand socioeconomic crisis.

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6. A roadmap forward
The Panel has made bold, considered, and pragmatic recommendations.
The stakes are too high for these to be ignored or postponed. They
deserve debate and may be challenged, but they must not be put off
for some “better” or more convenient time. It is in the interests of every
leader to act now. We are confident of the way we have carried out thetask assigned to us. The Panel has conducted its work independently andimpartially. We have made clear the focus on data, facts and science as
the basis for our recommendations.
The shelves of storage rooms in the United Nations and Member State
capitals are full of the reports of previous reviews and evaluations that
could have mitigated the global social and economic crisis in which
we find ourselves. They have sat ignored for too long. This time, it
must be different. This Panel’s findings are lessons to be learnt and therecommendations a springboard for action.
Implementation should start now and will help open up the many
pathways to recovery worldwide. The pandemic is not yet over, and its
social and economic consequences will continue to be felt for years.
This pandemic has shown us that this is not only a health crisis requiring
medical solutions: its impact has gone far beyond the health sector andtherefore must involve whole-of-government and whole-of-society
political decision-making and investment.
The coming weeks and months require concerted action by different
actors in a range of settings:• National governments taking responsibility both at home
but also regionally and at the global level, both demonstrating
and demanding accountability;• The World Health Assembly in its carriage of governanceresponsibility for WHO;• Heads of State and Government in a global summit,
as recommended;• Regional political bodies in their proximity to member states
giving them a great opportunity for rapid decisions and sharing
of information, successes and failures, based on a shared regional
context and histories of work together;• Other structures, such as the G7, G20 and G77, and the Bretton
Woods institutions, as catalysts for political and financial measuresand for the implementation of the solutions and recommendations
identified.

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A timetable for immediate action
Who needs to do what, when
ActionMain actor

When

Apply non-pharmaceutical public health measuressystematically and rigorously in every country at the scale
the epidemiological situation requires. All countries tohave an explicit strategy agreed at the highest level ofgovernment to curb COVID-19 transmission.

National governments

Immediately

High income countries with a vaccine pipeline foradequate coverage should, alongside their scaleup, commit to provide to the 92 low and middle
income countries of the Gavi COVAX Advance Market
Commitment, at least one billion vaccine doses no later
than 1 September 2021 and more than two billion doses by
mid-2022, to be made available through COVAX and othercoordinated mechanisms.

National governments

G7 countries to commit to providing 60% of the US$ 19
billion required for ACT-A in 2021 for vaccines, diagnostics,
therapeutics and strengthening health systems with theremainder being mobilised from others in the G20 andother higher income countries. A formula based on ability
to pay should be adopted for predictable sustainable,
and equitable financing of such global public goods on an
ongoing basis.

G7, G20 and national
governments of highincome countries,
foundations

Immediately

WTO and WHO to convene major vaccine producing
countries and manufacturers to get agreement on
voluntary licensing and technology transfer arrangements
for COVID-19 vaccines (including through the Medicines
Patent Pool (MPP)). If actions do not occur within 3months, a waiver of TRIPS intellectual property rights
should come into force immediately.

WTO, WHO andvaccine- producing
countries andmanufacturers

Immediately

Production of and access to COVID-19 tests andtherapeutics, including oxygen, scaled up urgently in
low- and middle-income countries with full funding of
US$ 1.7 billion for needs in 2021 and the full utilization of
the US$3.7 billion in the Global Fund’s COVID-19 Response
Mechanism Phase 2 for procuring tests, strengthening
laboratories and running surveillance and tests.

Test- and therapeuticsproducing countries
and manufacturers /GFATM

Immediately

WHO to develop immediately a road map for the
short-term and within three months scenarios for the
medium- and long-term response to COVID-19, with clear
goals, targets and milestones to guide and monitor the
implementation of country and global efforts towards
ending the COVID-19 pandemic.

WHO

Immediately

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Immediately(& no later than
1 September 2021)

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Recommendations for building the future —Who needs to do what, when
1. Elevate political leadership for global health to the highest
levels to ensure leadership, financing and accountability
Actions
Establish a Global Health Threats Council. The
membership should be endorsed by a UN General
Assembly resolution (see below recommendations for aSpecial Session of the UNGA). The Council should be led at
Head of State and Government level and the membershipshould include state and relevant non-State actors,
ensuring equitable regional, gender and generational
representation, with the following functions;

Main actor
UNGA

When
Q4 2021(UNGA Special
Session)• maintain political commitment to pandemic
preparedness between emergencies and to response
during emergencies;• ensure maximum complementarity, co-operationand collective action across the international system
at all levels;• monitor progress towards the goals and targets
set by the WHO, as well as against potentially
new scientific evidence and international legal
frameworks, and report on a regular basis to theUnited Nations General Assembly and the World
Health Assembly;• guide the allocation of resources by the proposed
new finance modality according to an ability to
pay formula;• hold actors accountable including through peer
recognition and/or scrutiny and the publishingof analytical progress status reports.
Adopt a Pandemic Framework Convention within thenext 6 months, using the powers under Article 19 of
the WHO Constitution, and complementary to the IHR,
to be facilitated by WHO and with the clear involvementof the highest levels of government, scientific experts
and civil society.

WHO / national
governments

Adopt a political declaration by Heads of State andGovernment at a global summit under the auspicesof the UN General Assembly as a Special Session
convened for the purpose and committing totransforming pandemic preparedness and response
in line with the recommendations made in this report.

United Nations
General Assembly

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Q4 2021(UNGA Special
Session)

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2. Focus and strengthen the authority and financing of WHO
Actions

Main actor

When

Establish WHO´s financial independence, based on fully
unearmarked resources, increase Member States fees to
2/3 of the budget for the WHO base programme and havean organized replenishment process for the remainder ofthe budget.

WHA decision

May 2022

Strengthen the authority and independence of the
Director-General, including by having a single term ofoffice of seven years with no option for re-election. The
same rule should be adopted for Regional Directors.

WHA decision

May 2022

Strengthen the governance capacity of the Executive
Board, including by establishing a Standing Committee
for Emergencies.

WHA decision

May 2022

Focus WHO’s mandate on normative, policy, and technicalguidance, including supporting countries to build capacity
for pandemic preparedness and response and for resilientand equitable health systems.

WHA decision

May 2022

Empower WHO to take a leading, convening, andcoordinating role in operational aspects of an emergency
response to a pandemic, without, in most circumstances,taking on responsibility for procurement and supplies,
while ensuring other key functions of WHO do not suffer
including providing technical advice and support inoperational settings.

WHA decision

May 2022

Resource and equip WHO Country Offices sufficiently torespond to technical requests from national governments
to support pandemic preparedness and response,
including support to build resilient health systems, UHC
and healthier populations.

WHO Secretariat

Immediately

Prioritize the quality and performance of staff at each
WHO level, and de-politicize recruitment (especiallyat senior levels) by adhering to criteria of merit andrelevant competencies.

WHO Secretariat

Short-term

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3. Invest in preparedness now to create fully functional
capacities at the national, regional and global level
Actions

Main actor

When

WHO to set new and measurable targets and benchmarks
for pandemic preparedness and response capacities.

WHO / national
governments

Q3-4 2021

All national governments to update their national
preparedness plans against the targets and benchmarks
set by WHO within six months, ensuring that whole-ofgovernment and whole-of-society coordination is inplace and that there are appropriate and relevant skills,
logistics, and funding available to cope with future
health crises.

National governments

Within 6 months

WHO to formalize universal periodic peer reviewsof national pandemic preparedness and response
capacities against the targets set by WHO as a means ofaccountability and learning between countries.

WHO / national
governments

Q4 2021

As part of the Article IV consultation with member
countries, the IMF should routinely include a pandemic
preparedness assessment, including an evaluation of theeconomic policy response plans. The IMF should consider
the public health policy evaluations undertaken by otherorganizations. Five-yearly Pandemic Preparedness
Assessment Programs should also be instituted in eachmember country, in the same spirit as the Financial Sector
Assessment Programs, jointly conducted by the IMF and
the World Bank.

International Monetary
Fund (IMF)

Q3-4 2021

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4. Establish a new agile system for surveillance,
validation and alerts
Actions

Main actor

When

WHO to establish a new global system for surveillance
based on full transparency by all parties, using stateof-the-art digital tools to connect information centres
around the world and include animal and environmental
health surveillance, with appropriate protections ofpeople’s rights.

WHO Secretariat

Q4 2021

WHO to be given the explicit authority by the World
Health Assembly to publish information about outbreaks
with pandemic potential on an immediate basis without
requiring the prior approval of national governments.

WHA decision

May 2021

WHO to be empowered by the World Health Assembly
to investigate pathogens with pandemic potential in
all countries with short-notice access to relevant sites,
provision of samples, and standing multi-entry visas forinternational epidemic experts to outbreak locations.

WHA decision

May 2021

Future declarations of a PHEIC by the WHO DirectorGeneral should be based on the precautionary principle,
where warranted, as in the case of respiratory infections.
PHEIC declarations should be based on clear, objective andpublished criteria. The Emergency Committee advising
the WHO Director-General must be fully transparent in its
membership and working methods. On the same day a
PHEIC is declared, WHO must provide countries with clear
guidance on what action should to be taken and by whomto contain the health threat.

WHA decision

May 2022

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5. Establish a pre-negotiated platform for tools and supplies
Actions

Main actor

WhenTransform the current ACT-A into a truly global end-toend platform for vaccines, diagnostics, therapeutics, andessential supplies, shifting from a model where innovationis left to the market to a model aimed at delivering global
public goods. Governance to include representatives ofcountries across income levels and regions, civil society,and the private sector. R&D and all other relevant
processes to be driven by a goal and strategy to achieveequitable and effective access.

National governments/
member states

Medium-term

Ensure technology transfer and commitment to voluntary
licensing are included in all agreements where publicfunding invested in research and development.

National governments

Medium-term

Establish strong financing and regional capacities for
manufacturing, regulation, and procurement of tools forequitable and effective access to vaccines, therapeutics,
diagnostics, and essential supplies, and for clinical trials:

National governments /WHO / IFIs /regional institutions /private sector

Medium-term• based on plans jointly developed by WHO, regional
institutions, and the private sector,• with commitments and processes for technology
transfer, including to and among larger
manufacturing hubs in each region,• supported financially by International Financial
Institutions and Regional Development Banks andother public and private financing organizations.

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6. Raise new international financing for the global public
goods of pandemic preparedness and response
Actions

Main actor

When

Create an International Pandemic Financing Facility
to raise additional reliable financing for pandemic
preparedness and for rapid surge financing for responsein the event of a pandemic.

G20 andmember states

Before the endof the year

The facility should have the capacity to mobilize long-term(10-15 year) contributions of approximately US$5-10 billion
per annum to finance ongoing preparedness functions.
It will have the ability to disburse up to US$50-100 billion
at short notice by front loading future commitments inthe event of a pandemic declaration. The resources
should fill gaps in funding for global public goods atnational, regional and global level in order to ensurecomprehensive pandemic preparedness and response.
There should be an ability-to-pay formula adopted
whereby larger and wealthier economies will pay
the most, preferably from non-ODA budget lines andadditional to established ODA budget levels.
The Global Health Threats Council will have the task ofallocating and monitoring funding from this instrument
to existing institutions, which can support development ofpandemic preparedness and response capacities.
Funding for preparedness could be pre-allocatedaccording to function and institution. Surge financing
for response in the event of a new pandemic declaration
should be guided by prearranged response plans for themost likely scenarios, though flexibility would be retained
to adapt based on the threat.
The Secretariat for the facility should be a very lean
structure, with a focus on working with and throughexisting global and regional organizations.

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7. Put in place effective national coordination for pandemic
preparedness and response based on lessons learned
and best practice
Actions

Main actor

When

Ensure that national and subnational public healthinstitutions have multidisciplinary capacities andmultisectoral reach and the engagement of the private
sector and civil society. Evidence-based decision-making
should draw on inputs from across society.

National governments

Medium-term

Head of States and Government to appoint national
pandemic coordinators accountable to the highest
evels of government with the mandate to drive wholeof-government coordination for both preparedness
and response.

National governments

Short-term

Conduct multi-sectoral active simulation exercises
on a yearly basis as a means of ensuring continuous
risk assessment and follow-up action to mitigate
risks, cross-country learning, and accountability,and establish independent, impartial, and regular
evaluation mechanisms.

National governments

Medium-term

Strengthen the engagement of local communities as key
actors in pandemic preparedness and response and as
active promoters of pandemic literacy, through the abilityof people to identify, understand, analyse, interpret, andcommunicate about pandemics.

National governments

Medium-term

Increase the threshold of national health and social
investments to build resilient health and social protection
systems, grounded in high-quality primary and community
health services, universal health coverage, and a strong
and well supported health workforce, including community
health workers.

National governments

Medium-term

Invest in and co-ordinate risk communication policies
and strategies that ensure timeliness, transparency, andaccountability, and work with marginalized communities,
including those who are digitally excluded, to build trust
and resilience, in the co-creation of plans that promotehealth and wellbeing at all times, and build enduring trust.

National governments

Short-term

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Terms of reference for the
Global Health Threats Council
Purpose:
The role of the Global Health Threats Council (the Council) will be to ensurethat high level political leadership and attention to pandemic prevention,
preparedness and response are sustained over time in the service of avision of a world without pandemics. The council will be an inclusive andlegitimate voice of authority with the ability to utilise both accountability
mechanisms and provide access to financing to ensure preparedness aswell as response at the national, regional and global levels.

Background:
The COVID-19 pandemic has demonstrated insufficient high-level politicalleadership; engagement across health, social and economic sectors; andagreement between governments. This has resulted in the failure to set
coherent global strategic directions in pandemic response and link themto international agencies and regional institutions. Nor have the private
sector and civil society organizations been able to contribute to strategic
direction setting in an effective way.
The organic evolution of the international health system over recent
decades in order to address particular health problems has resulted inpockets of major progress but also created inefficiencies resulting fromunclear roles and responsibilities and an inability to leverage effectively
the comparative advantages of different actors.
A key finding of the Panel is that accountability for pandemic
preparedness and response has been lacking across the system. National
governments are the primary duty-bearer in pandemic response, and thelack of accountability has been accompanied by a failure to learn frommistakes and take up the opportunity for learning between countries.
The Independent Panel on Pandemic Preparedness and Response
concluded that a transformation of the international system for pandemic
preparedness and response is needed, catalysed by political leadership at
the highest level.
The commitment of Heads of State and Government to a transformof the international system for pandemic preparedness and responsemust go together with their commitment to lead strong and effective
national, regional and global implementation. This within the frameworkof continued and enhanced implementation of the 2030 Agenda and theSustainable Development Goals.
The international system is the sum of national action and the connective
tissue of regional and global learning, cooperation and support for filling
gaps. Confidence in the collective determination to make a safer andhealthier world is the force that can conquer the threat pandemics poseto humanity’s future.
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Functions:• Elevate and maintain political commitment to pandemic prevention,
preparedness and response over time in the service of a vision of aworld without pandemics.
• Monitor progress towards the goals and targets set by WHO, as well
as against potentially new scientific evidence and international legal
frameworks.
• Draw the world’s attention to gaps in pandemic preparedness andresponse through high level advocacy and reporting to the UN
General Assembly, the World Health Assembly and the IMF board.
• Contribute to the mobilisation of funding and oversee the allocationof resources by the International Pandemic Financing Facility.
• Hold actors accountable including through peer recognitionand pressure as well as the publishing of analytical progressstatus reports.

Establishment:• The Council shall be established through a political declarationof the UN General Assembly Special Session on the COVID-19
Pandemic as an independent body. The negotiation of thedeclaration to be facilitated by two Member States.
• The UN General Assembly through the Resolution to appoint two
Co-Chairs for the Council and the G20 shall be invited to nominatea Co-Chair.
• The Three Co-Chairs to put forward suggestions for the remaining
Council members according to these Terms of Reference, for the
UN General Assembly to endorse.

Membership:
The council shall consist of 18 members and 3 co-chairs and shall becomposed as follows:[Co-chairs, at least one being a woman]:
1. Nominee of UNGA #1
2. Nominee of UNGA #2
3. Nominee of G20[Members]:
1. Two Asia Pacific Representatives
2. Two Western Europe and Other Representatives(including North America (USA and Canada)
3. Two African Representatives
4. Two Eastern European Representatives
5. Two Latin American and Caribbean Representatives
6. Three civil society representatives
7. Three private sector representatives
8. Two prominent global citizens or experts
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Duration:
Member terms will initially be either for three years, with flexibility
for early termination or renewability for a second three-year term, onagreement of the co-chairs. To provide for continuity of the Group’s workand ensure that the complete membership does not turn over at any one
point, the terms of the members not serving as ex-officio will be staggeredwith half of the members being offered an initial 2-year term and half a
3-year term. If a Head of State or Minister who is a member of the Council
ceases to hold office during his/her term, then a vacancy will be created
to be filled with another government representative not necessarily fromthe same country.
Selection criteria:• Council members shall be at the level of Head of Stateor Government. They could be the chairs of regional
political entities.
• Representatives of the private sector and civil society
will be at the head of organisation level with a high public
profile and a track record of working on relevant issues.
• Priority will be given to ensuring gender and age balance
in selection of both government and non-governmental
council members.

Relationships:
The Council will engage with key relevant partners of the international
system for pandemic preparedness and response including the World
Health Organisation, the United Nations, the International Financial
Institutions (including the regional development banks), civil society
and private sector.
The UN Secretary-General, the Director-General of WHO, the Executive
Director of IMF and the President of the World Bank Group will be
strategic and key leaders for the Council to interact with.

Ways of working:• The Council shall meet monthly during the current pandemic
with the ability to call additional meetings on an ad hoc basis asrequired.
• When feasible, the Council will shift to a focus on ensuring continued
work with less frequent meetings of the Council and regular sessionsof surrogates as determined by the Council.
• In times without a crisis the work shall focus on preparedness
and monitoring progress.
• Strive for inclusive multi-stakeholder engagement with Member
States, UN agencies, international and intergovernmentalorganizations and regional entities, civil society, the private
sector, researchers and other key stakeholders.

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The Council shall benefit from the Universal Periodic Peer
Review outcomes.
• The Council shall support the United Nations Secretary-General inconvening a High-Level Meeting of the UN General Assembly every
year to review global progress.
• The Council shall be supported by a lean independent secretariat
located in Geneva with the ability to draw upon technical expertisefrom the WHO, the UN and the IFIs as necessary.

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7. About the Panel and its work
The Independent Panel has worked steadily to fulfil its
vision to be trusted as an independent, evidence-based,
impartial, respectful and diverse body the world can rely
on to make bold recommendations which help safeguard
every person’s health, economic and social well-being.
The mission of the Panel has been to provide an evidence-based path forthe future, grounded in lessons of the present and the past to ensure thatcountries and global institutions, including WHO, can prevent an outbreakfrom becoming a pandemic; and if a pandemic occurs, to prevent thatfrom becoming a global health and socioeconomic crisis.
The Panel was established by the Director-General of WHO in response
to World Health Assembly resolution WHA73.1.

The Panel’s Co-Chairs, Her Excellency Ellen Johnson Sirleaf, former
President of Liberia and Nobel Laureate, and the Right Honourable
Helen Clark, former Prime Minister of New Zealand, were appointed
by the Director-General. The Co-Chairs were then mandated to selectpanellists, establish their terms of reference and recruit an independent
Secretariat. The Co-Chairs announced the full membership of the Panelon 3 September 2020.
The Panel comprises people with the experiences and expertise tofocus on pandemics, health and the broader impacts of COVID-19.
Their mix of skills and expertise covers a wide range of areas including
infectious disease, global and national health policy and financing,
public administration, outbreaks and emergencies, economics, youth
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advocacy and the well-being of women and girls. Panellists also shareknowledge of the international system, including WHO, and other relevantinternational processes.
The Panel was charged with reviewing the spread, actions and responses
to the COVID-19 pandemic, compile facts, distil lessons and makeevidence-based recommendations to ensure countries and global
institutions, including WHO, can more effectively address health threats.
The Panel has taken a systematic, rigorous and comprehensive
approach to its work and has placed an emphasis on listening andlearning from others. Since mid-September, the Panel has conductednumerous literature reviews, its own original research, has learned fromdozens of experts in round-table discussions and in-depth interviews,
has heard directly from people working on the front line of the pandemic
in town-hall style meetings, and has invited contributions from anyone
wishing to make one. The Panel has benefited from interactions with
the Global Preparedness Monitoring Board, the IHR Review Committee
and the Independent Oversight and Advisory Committee. The Panelhas met formally six times, and several times in subgroups to discussspecific areas.
The Independent Panel has valued openness and transparency
throughout, publishing news summaries and meeting reports shortly after
each meeting. The Secretariat has operated in an open-door manner andwelcomed conversations with anyone who has wished to speak to it.
At its second meeting on 20–21 October 2020, the Panel established a
Program of Work, which includes four interconnected themes: to build on
the past by learning from previous epidemics and pandemics, including
the extent to which lessons and recommendations from these have been
applied; review the present, examining why and how COVID-19 became a
global pandemic, including building an authoritative chronology of facts
and actions by countries, regional and international actors; understandthe impact of COVID-19 on people’s health and on health systems,
including the role of communication and community resilience and thesignificant socioeconomic impact; and identify gaps in the international
system and recommend changes for the future.
The Program of Work laid out specific questions for review, and the Panelhas studied these through:• desk reviews of selected topics to provide background reports
to the Panel;• semi-structured in-depth interviews with key actors from national
governments, academia, international organizations, including
WHO, civil society, health workers and subject-matter experts;• requests for information to WHO through a repository establishedby the Panel;

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to a wide range of resource persons who are knowledgeable andexperienced on different aspects of the Program of Work.
Topics included:1.

A future international system

2. WHO Financing
3. Essential Supplies
4. From Science to policy
5. Access to Vaccines
6. Socioeconomic impact — regional dimensions
7. Socioeconomic impact — global perspectives
8. Private sector roundtable
9. National Responses
10. Therapeutics and Diagnostics
11. Mobilizing Across Generations to Realize Healthand Social System Reforms
12. Human Rights
13. Communication and Community Engagement

14. Sustaining and Strengthening Cities During a Pandemic:
A Roundtable Discussion with Mayors
15. Digital solutions• papers on key topics relevant to each of the sections, commissionedby the Panel;• a public call for contributions: Member States, academics, civilsociety and front-line workers were invited to contribute theirexperiences and ideas through the Panel’s website, both on the
Program of Work and on the chronology; more than 90 submissions
had been made at time of publication of the present report;• open webinars EXCHANGE inviting specific groups and themes totalk about their experiences, lessons and ideas for future with Panelmembers; these attracted hundreds of participants from aroundthe world, including speakers from remote areas; recordings andreports from these meetings are available on the Panel’s website:
1.

Learning from nurses on the front line of COVID-19

2.

COVID 19: delivering sexual and reproductive healthand rights services in crisis settings
3. Youth on the front lines of COVID-19
4. Learning from midwives at work during a pandemic
5. The gendered impact of COVID-19
6. Noncommunicable diseases: affecting and affectedby COVID-19

Reporting to WHO’s governing bodies
The Independent Panel reported to the WHO Executive Board Special
Session on 5–6 October 2020, to the resumed 73rd World Health
Assembly in November 2020, to the WHO Executive Board in January2021; it will present this report to the Seventy-fourth World Health
Assembly in May 2021.
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Members of the Independent Panel
The members of the Independent Panel for Pandemic Preparedness
and Response are:
• Rt Hon. Helen Clark, former Prime Minister of New Zealand(Co-Chair)• H.E. Ellen Johnson Sirleaf, former President of Liberia
and Nobel Laureate (Co-Chair)• Mauricio Cárdenas, Senior Scholar, Center on Global Energy Policy
at Columbia University and former Finance Minister of Colombia• Aya Chebbi, African Union Special Envoy on Youth, diplomat,
pan-African activist and feminist, from Tunisia• Mark Dybul Professor at Georgetown University and former headof the Global Fund to Fight AIDS, Tuberculosis and Malaria (GlobalFund) and the President's Emergency Plan For AIDS Relief, fromthe United States• Michel Kazatchkine, Professor of Medicine and global healthdiplomat from France; and a former head of the Global Fund
• Joanne Liu, Canadian physician, Professor at McGill University
and former International President of MSF, including during
the response to Ebola• Precious Matsoso, former Director-General of Health fromSouth Africa, and former Chair of the Independent Oversightand Advisory Committee for the WHO Emergencies Programme• David Miliband, President and Chief Executive Officer of theInternational Rescue Committee, and former Foreign Secretaryof the United Kingdom• Thoraya Obaid, former Executive Director of the United Nations
Population Fund (UNFPA)• Preeti Sudan, Former Secretary of Health of India, and former ViceChair of the Partnership for Maternal, Newborn and Child Health• Ernesto Zedillo, Former President of Mexico and economist, Directorof the Yale Center for the Study of Globalization, Yale University,• Zhong Nanshan, Professor of the Department of Respiratory
Disease, Guangzhou Medical University, China and Directorof the National Clinical Research Center for Respiratory Disease
The Independent Panel has been supported by a Secretariat headed
by Anders Nordstrom and including Alexandra Phelan, Celeste Canlas,
Christine McNab, Helena Legido-Quigley, Jane Saville, Marjon Kamara,
Mathias Bonk, Michael Bartos, Michael Dumiak, Mike Kalmus Eliasz, Nellie
Bristol, Rosemary McCarney, Salma Abdalla and Shun Mabuchi. George
Werner served as advisor to Co-Chair H.E. Ellen Johnson Sirleaf, together
with Raj Panjabi until 31 January 2021, and Sudhvir Singh as advisor to
Co-Chair the Rt. Hon. Helen Clark.

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The Independent Panel documents
The Independent Panel published the following final documents
in May 2021.

The main report
COVID-19: Make it the Last Pandemic
COVID-19: Make it the Last Pandemic: A Summary

The companion narrative
How an Outbreak Became a Pandemic: The defining momentsof the COVID-19 pandemic

Background documents
1. Learning from the past
2. The Chronology
3. From Science to Policy
4. National and sub-national responses
5. Access to vaccines, diagnostics and therapeutics
6. Scaling up Vaccine Production Capacity: Legal Challenge
7. Access to Essential Supplies
8. Impact on Essential Health Services
9. The Social impact
10. Community involvement
11. Human Rights
12. Understanding Communication
13. The Economic impact
14. International financing
15. WHO – an institutional review
16. International Treaties and Conventions

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Acknowledgements
The Independent Panel for Pandemic Preparedness and Response
would like to thank the following for their contributions to its workand to this final report:

WHO

The Independent Panel would especially like to thank WHO and its staff
at all levels of the Organization for their continued support and important
contributions throughout the process. We extend our deep appreciation
to WHO´s leadership team: Tedros Adhanom Ghebreyesus, Zsuzsanna
Jakab, Ahmed Al Mandhari, Carissa Etienne, Takeshi Kasai, Hans Kluge,
Matshidiso Moeti, Poonam Singh, Mike Ryan, Soumya Swaminathan,
Jaouad Al-Mahjour, Socé Fall, Mariangela Simão, Catharina Boehme,
Jane Ellison, Peter Ben Embarek, Maria van Kerkhove, Scott Pendergast,
Bernhard Schwartländer, Tim Armstrong, Ian Smith, Raul Thomas,
Gauden Galea, Imre Hollo, Gabriella Stern.
In addition, our special thanks go to the WHO staff members supporting
the Panel directly through the WHO COVID19-Repository, the IHRSecretariat, the IHR Review Committee, the Independent Oversight andAdvisory Committee for the WHO Health Emergencies Programme (IOAC),
STAG-IH, GOARN among others.

National Governments

The Panel would also like to extend its warm gratitude to all national
governments supporting the work by participating in the Panel´sactivities and by contributing important information to the Panel´s work.
The Panel is also very grateful for the continued and essential support
by the Ministries of Health, the diplomatic missions in Geneva and New
York, as well as a number of Member State groups at the global andregional level such as the African Union, Asia-Pacific Group, CARICOM,
Commonwealth, ECOWAS, European Commission, GRULAC, G7, G20, G77
and the United Nations.

International and regional organizations and partnerships

The Panel would like to extend its gratitude to the following organizations:
Africa CDC, African Development Bank, Asian Development Bank,
Center for Global Development, Chatham House, CIVICUS, Club deMadrid, Economic Commission for Africa, European Commission,
European Council, Exemplars in Global Health, Foreign Ministries
Science & Technology Advice Network, Gavi, Global Fund to Fight
AIDS, Tuberculosis and Malaria, Global Health Law Consortium,
Global Preparedness Monitoring Board, Graduate Institute ofInternational and Development Studies, Helsinki Policy Forum,
Human Rights Council, International Monetary Fund, Islamic
Development Bank, Organisation for Economic Co-operation
and Development, Overseas Development Institute, Pan-European
Commission on Health & Sustainable Development, The Elders, UNAIDS,
UNDP, UN Foundation, UNFPA, UNICEF, University of Essex, University of
San Francisco, World Bank and the World Trade Organization.

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Individual leaders and experts (in alphabetical order)

The Panel would like to thank the following experts, who actively
participated either in interviews or roundtable discussions and webinars,
to provide helpful input to the work.
Lucia Abascal-Miguel, Omar Abdi, Hala Abou-Taleb, Anurag Agrawal,
Lav Agrawal, Yvonne Aki-Sawyerr, Ayoade Alakija, Alice Albright, Pascale
Allotey, Andrew Rodgerson, Beth Arthy, Elhadj As Sy, Miguel Asqueta
Sonoar, Abdullah Assiri, Chris Atim, Sobel Aziz, Ombretta Baggio, Tarun
Bajal, Forrest Barker, Rafa Bengoa, Wilson Benia, Christoph Benn,
Seth Berkley, Alvaro Bermejo, Arnaud Bernaert, Mandeep Bhandari,
Gro Harlem Brundtland, Ann Burton, Flavia Bustreo, Luisa Cabal, Ana
Carapichano, Sergio Carmona, Yasumin Chandani, Sabrina Chao, Sarah
Cliffe, Awa Coll-Seck, Francesca Colombo, Marlene Cuco, Katie Dain,
Brett Davidson, Brice de la Vingne, Roopa Dhatt, Abdoulaye Mar Dieye,
Kirill Dmitriev, , Grace Dubois, Philippe Duneton, Stuart Dymond, Ayman
El-Mohandes, Chris Elias, Ahmed Elkhodary, Maria Eugenia Esandi, Aicha
Evans, Tim Evans, Jeremy Farrar, Adebayo Fayoyin, Warren Feek, GabriellaFesus, Jane Fieldhouse, Josep Figueras, Helga Fogstad, Lisa Forman, Julio
Frenk, Garth Frizzell, Rob Fyfe, Sarah Gallalee, Urvashi Gandhi, Raman
Gangakhedkar, George Gao, Chris Gentle, Amandeep Singh Gill, Githinji
Gitahi, Peter Gluckman, Susan Goldstein, Eduardo González-Pier, Nimisha
Goswami, Julia Greenberg, Leith Greenslade, Karen Grepin, Trevor Gunn,
Assad Hafeez, Shanelle Hall, Richard Hatchet, Ricardo Hausmann, Sahar
Hegazi, Lutz Hegemann, Myriam Henkens, David Heymann, Timothy Fish
Hodgson, Steven Hoffman, Peter Horby, Richard Horton, Didier Houssin,
Mike Howard, Todd Howland, Vivian Hsu, Paul Hunt, Chikwe Ihekweazu,
Dean Jamison, Garth Japhet, Tomas Jensen, Zhang Jixian, Cedric Jo, Etleva
Kadilli, Benoit Kalasa, Joumana Kalot, Jean Baptiste Kambale Kiyana,Adam Kamradt-Scott, Sami Kanaan, Natalia Kanem, Abdool Karim Salim,
Rajat Khosla, Ilona Kickbusch, Jim Kim, Jeff King, Jeni Klugman, Naomi
Komuro, Gerard Krause, Adam Kucharski, Björn Kümmel, Stephen Landry,
Kelley Lee, Vivian Lin, Carlos Lopes, Luis Felipe Lopez-Calva, Nora Lustig,
John Lysa, Carlos Magariños, Ira Magaziner, Patrice Matchaba, Pascal
Mailu, Allan Maleche, Alex Marianelli, Gustavo Matta, Collin McCliff, Jim
McLay, Lori McDougall, Jaime Miranda, Zweli Mkhizi, David Nabarro,
Stefan Nachuk, Aurélia Nguyen, John Nkengasong, Jennifer Nuzzo,
Abraham Nyenswah, Stephen O’Brien, Ilse Oehler, Jean Oelwang, Abdi
Omar, Ben Embarek, Zulma Ortiz, Trygve Ottersen, Sally Pairman, Eric
Parrado Herrera, Muhammad Pate, Vinod Paul, Paola Pereznieto, Sam
Phiri, Philippe Poinsot, David Prieto-Alhambra, Claudio Providas, Jonathan
Quick, Enrique Razon, Charlotte Renard, Carolyn Reynolds, Carlos delRio, John Arne Rottingen, Mariano Sánchez-Talanquer, Kelly Sanders,Peter Sands, Jagjeet Sareen, Yasuyuki Sawada, Lina Sayed, Neelam
Sekhri Feachem, Jaime Sepulveda, Elizabeth Serlemitsos, Mehr Shah,Sangeeta Shashikant, Elaina Shekhter, Kristen Silverberg, Kenji Shibuya,Vera Songwe, Oleg Sonin, Devi Sridhar, Stephen Cahill, Serge Stinckwich,
Nathalie Strub-Wourgaft, Marion Subah, Caroline Sugg, Thiagarajan
Sundararaman, Keizo Takemi, Pauline Tamesis, Norihisa Tamura, Viroj
Tangcharoensathien, Martin Taylor, Yik Ying Teo, Beth Thompson, Ellen
T´Hoen, Eloise Todd, Els Torreele, Tahir Turk, Jair Vega, Andrès Velasco,
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Stefano Vella, Silvio Waisbord, Linfa Wang, Clare Wenham, Alejandro
Werner, Greg Widmyer, Andrew Witty, John Wong, Prashant Yadav,
Eduardo Yeyati-Levy, Yik Ying Teo, Cho Young-Shik, Victor Zamora,
Darin Zehrung, Wenhong Zhang, Shi Zhengli

Panel and secretariat support

The Panel would also like to thank the following researchers, consultants
and sherpas for supporting the work of the panel:
Salma Al Rashid, Eva Barboni and Atalanta team, Jacob Berah, Elin
Bergstrom, Olivia Biermann, Beatrice Bonami, Alvin Qijia Chua, Kathryn
Dickson, Chuan De Foo, Bushra Ebadi, Cornelia Green, Rosie Hardacre,
Victoria Haldane, Ines Hassan, Michelle Hopgood, Tom Hughes, Margaret
Jamieson, Anne-Sophie Jung, Abraar Karan, Sachi Kojima, Shaffi Koya,
Irene Laochaisri, Rachel Neil, Cody Nolan, Rose Olson, Tristana Perez,
Priya Pillai, Elizabeth Radin, Rohit Ramchandani, Omer Saad, Pami
Shrestha, Carl Fred Sjoland, Ron Sloan, Leimapokpam Swasthicharan,
Melisa Mei Jin Tan, See Mieng Tan, Monica Verma, Shishi Wu.

Exchanges and Online Submissions

The Panel hosted six Exchange webinars to learn directly from people
working on the frontline from around the world people participatingin panel discussions with hundreds ‘in the virtual audience’: Nurses
on the Frontline, Delivering SRHR in Crises Settings, Youth on the
Frontlines, Midwives at Work, The Gendered Impact, Noncommunicable
Diseases. The Panel would like to especially thank all of these “frontline”
participants for their valuable input. The Panel would also like to thankorganizations that helped to bring people together. With thanks to: C40
Cities, the Communication Initiative, the International Council of Nurses,
the International Confederation of Midwives, International Planned
Parenthood Federation, NCD Alliance, Nursing Now, The Partnership for
Maternal, Newborn & Child Health, the Pandemic Action Network, United
Cities and Local Governments, the White Ribbon Alliance, Women in
Global Health and the World Health Professionals Alliance.
The Panel would also like to thank more than 100 experts, groups, officials
and advocates, who submitted their valuable input through the online
submission system.

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References1

WHO coronavirus (COVID-19) dashboard. In: World Health Organization [website]. Geneva:
World Health Organization; 2021 (https://covid19.who.int/, accessed 29 April 2021).

2

Amnesty International. COVID19: health worker death toll rises to at least 17,000. In: Amnesty
International [website]. London: Amnesty International; 2021 (https://www.amnesty.org/
en/latest/news/2021/03/covid19-health-worker-death-toll-rises-to-at-least-17000-asorganizations-call-for-rapid-vaccine-rollout/, accessed 26 April 2021).

3

Gopinath G. A long, uneven and uncertain ascent. In: IMFblog [blog]. Washington (DC):International Monetary Fund; 2020 (https://blogs.imf.org/2020/10/13/a-long-uneven-anduncertain-ascent/, accessed 29 April 2021).

4

UNESCO figures show two thirds of an academic year lost on average worldwide due to
Covid-19 school closures. In: United Nations Educational, Scientific and Cultural Organization[website]. Paris: United Nations Educational, Scientific and Cultural Organization; 2021
(https://en.unesco.org/news/unesco-figures-show-two-thirds-academic-year-lost-averageworldwide-due-covid-19-school, accessed 26 April 2021).

5

COVID-19: a threat to progress against child marriage. In: United Nations Children’s Fund[website]. New York: United Nations Children’s Fund; 2021 (https://data.unicef.org/resources/
covid-19-a-threat-to-progress-against-child-marriage/, accessed 26 April 2021).

6

COVID-19 and ending violence against women and girls. In: UN Women [website]. New York:
United Nations; 2021 (https://www.unwomen.org/-/media/headquarters/attachments/
sections/library/publications/2020/issue-brief-covid-19-and-ending-violence-againstwomen-and-girls-en.pdf?la=en&vs=5006. accessed 29 April 2021).

7

World economic situation and prospects 2021. In: United Nations Department of Economic
and Social Affairs [website]. New York: United Nations; 2021 (https://www.un.org/en/worldeconomic-situation-and-prospects-2021, accessed 29 April 2021).

8Over 11 million girls may not go back to school after the COVID-19 crisis. In: United Nations
Educational, Scientific and Cultural Organization [website]. Paris: United Nations Educational,
Scientific and Cultural Organization; 2021 (https://en.unesco.org/covid19/educationresponse/
girlseducation, accessed 29 April 2021).

9

COVID-19 market dashboard. In: United Nations Children’s Fund [website]. New York: United
Nations Children’s Fund; 2021 (https://www.unicef.org/supply/covid-19-vaccine-marketdashboard, accessed 26 April 2021).

10

COVID-19 Strategic preparedness and response plan.Geneva: World Health Organization;
2021. Licence: CC BY-NC-SA 3.0 IGO.

11

Coronavirus disease 2019 (COVID-19) situation report –79, 8 April 2020. In: World HealthOrganization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/docs/
default-source/coronaviruse/situation-reports/20200408-sitrep-79-covid-19.pdf, accessed
26 April 2021).

12

Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003 In:
World Health Organization [website]. Geneva: World Health Organization; 2015 (https://www.
who.int/publications/m/item/summary-of-probable-sars-cases-with-onset-of-illness-from-1november-2002-to-31-july-2003, accessed 26 April 2021).

13

SARS: how a global epidemic was stopped. Geneva: World Health Organization; 2006
(https://apps.who.int/iris/bitstream/handle/10665/207501/9290612134_eng.pdf, accessed
26 April 2021).

14

Assessing the impact and costs of SARS in developing Asia. In: Asian Development Outlook
2003 Update. Manila, Asian Development Bank, 2003 (https://www.adb.org/sites/default/files/
publication/30245/ado-2003-update.pdf, accessed 26 April 2021).

15

MERS shows vulnerability is universal. In: World Health Organization [website]. Geneva: World
Health Organization; 2018 (https://www.who.int/westernpacific/news/feature-stories/detail/mers-shows-vulnerability-is-universal, accessed 26 April 2021).

16

Commission on a Global Health Risk Framework for the Future; National Academy of Medicine,
Secretariat. The case for investing in pandemic preparedness. In: The neglected dimension of
global security: a framework to counter infectious disease crises. Washington (DC): National
Academies Press (US); 2016 (http://www.ncbi.nlm.nih.gov/books/NBK368391/, accessed 26
April 2021).

COVID-19: Make it the Last Pandemic by The Independent Panel for Pandemic Preparedness & Response

83 of 86

17

Global Preparedness Monitoring Board. A world at risk: annual report on global preparedness
for health emergencies. Geneva: World Health Organization; 2019 (https://apps.who.int/gpmb/
assets/annual_report/GPMB_annualreport_2019.pdf, accessed 26 April 2021). Licence: CC BYNC-SA 3.0 IGO.

18

World Health Organization. Average of 13 International Health Regulations core capacity
scores, SPAR version. In: World Health Organization [website]. Geneva: World HealthOrganization; 2021 (https://www.who.int/data/gho/data/indicators/indicator-details/GHO/average-of-13-international-health-regulations-core-capacity-scores-spar-version, accessed
26 April 2021).

19

World Health Organization. e-SPAR Public. In: World Health Organization [website]. Geneva:
World Health Organization; 2021 (https://extranet.who.int/e-spar/#capacity-score, accessed
26 April 2021).

20

Haider N, Yavlinsky A, Chang Y-M, Hasan MN, Benfield C, Osman AY et al. The Global Health
Security index and Joint External Evaluation score for health preparedness are not correlatedwith countries’ COVID-19 detection response time and mortality outcome. Epidemiol Infect.
2020;148:e210. doi:10.1017/S0950268820002046 pmid: 32892793

21

Global Preparedness Monitoring Board, A world in disorder: Global Preparedness Monitoring
Board annual report 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/
gpmb/assets/annual_report/2020/GPMB_2020_AR_EN_WEB.pdf, accessed 25 April 2021).
Licence: CC BY-NC-SA 3.0 IGO.

22

Milanovic B. Beware of mashup indexes: how epidemic predictors got it all wrong. In:
Globalinequality [blog, 19 April 2021] (https://glineq.blogspot.com/2021/01/beware-ofmashup-indexes-how-epidemic.html, accessed 25 April 2021).

23

Fukuyama F. The pandemic and political order. Foreign Aff. July/August 2020 (https://www.
foreignaffairs.com/articles/world/2020-06-09/pandemic-and-political-order, accessed 25
April 2021).

24Bell J. The U.S. and COVID-19: leading the world by GHS Index score, not by response. In: Atomic
Pulse [website, 21 April 2020]. Washington (DC): Nuclear Threat Initiative; 2020 (https://www.nti.
org/analysis/atomic-pulse/us-and-covid-19-leading-world-ghs-index-score-not-response/,
accessed 25 April 2021).

25

Air transport, passengers carried. In: Data [website]. Washington (DC): World Bank; 2021
(https://data.worldbank.org/indicator/IS.AIR.PSGR, accessed 25 April 2021).

26

30x30: eight steps to protect the best on earth. In: The Nature Conservancy [website]. Arlington(VA): The Nature Conservancy; 2019 (https://www.nature.org/en-us/what-we-do/our-insights/
perspectives/thirty-percent-protect-best-biodiversity-on-earth/, accessed 26 April 2021).

27

de Wit W, Freschi A, Trench E. Covid 19: urgent call to protect people and nature. Gland: WWF
International; 2020 (https://c402277.ssl.cf1.rackcdn.com/publications/1348/files/original/
FINAL_REPORT_EK-Rev_2X.pdf, accessed 26 April 2021).

28

WHO-convened global study of origins of SARS-CoV-2: China part. In: World HealthOrganization [website]. Geneva: World Health Organization; 2021 (https://www.who.int/
publications/i/item/who-convened-global-study-of-origins-of-sars-cov-2-china-part,
accessed 25 April 2021).

29

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y et al. Early transmission dynamics in Wuhan,
China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020;382(13):1199–207(https://www.nejm.org/doi/pdf/10.1056/nejmoa2001316, accessed 26 April 2021).

30 Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y et al. Clinical features of patients infected with 2019
novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506 (https://doi.org/10.1016/
S0140-6736(20)30183-5, accessed 25 April 2021).
31

Cohen J Chinese researchers reveal draft genome of virus implicated in Wuhan pneumonia
outbreak , Science 2020 doi:10.1126/science.aba8829

32

Novel coronavirus (2019-nCoV) situation report -3, 23 January 2020. In: World HealthOrganization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/docs/
default-source/Coronaviruse/situation-reports/20200123-sitrep-3-2019-ncov.pdf, accessed
25 April 2021).

33

Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19). Geneva:
World Health Organization; 2020 (https://www.who.int/docs/default-source/coronaviruse/
who-china-joint-mission-on-covid-19-final-report.pdf, accessed 25 April 2021).

34

WHO Director-General’s statement on IHR Emergency Committee on Novel Coronavirus(2019-nCoV). In: World Health Organization [website]. Geneva: World Health Organization;2020 (https://www.who.int/director-general/speeches/detail/who-director-general-sstatement-on-ihr-emergency-committee-on-novel-coronavirus-(2019-ncov), accessed
25 April 2021).

COVID-19: Make it the Last Pandemic by The Independent Panel for Pandemic Preparedness & Response

84 of 86

35

Report by the Director-General. Geneva: World Health Organization; 2020 (EB146/2;
https://apps.who.int/gb/ebwha/pdf_files/EB146/B146_2-en.pdf, accessed 26 April 2021).

36 Monto AS. Reflections on the Global Influenza Surveillance and Response System (GISRS) at
65 years: an expanding framework for influenza detection, prevention and control. Influenza
Other Respir Viruses. 2018;12(1):10–2 (https://doi.org/10.1111/irv.12511, accessed 26 April 2021).
37

WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020.
In: World Health Organization [website]. Geneva: World Health Organization; 2020
(https://www.who.int/director-general/speeches/detail/who-director-general-s-openingremarks-at-the-media-briefing-on-covid-19---11-march-2020, accessed 25 April 2021).

38

Statement on the second meeting of the International Health Regulations (2005) Emergency
Committee regarding the outbreak of novel coronavirus (2019-nCoV). In: World HealthOrganization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/newsroom/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-healthregulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus(2019-ncov), accessed 26 April 2021).

39

WHO Director-General’s opening remarks at the media briefing on 2019 novel coronavirus –7 February 2020. In: World Health Organization [website]. Geneva: World Health Organization;2020 (https://www.who.int/director-general/speeches/detail/who-director-general-sopening-remarks-at-the-media-briefing-on-2019-novel-coronavirus---7-february-2020,
accessed 26 April 2021).

40 Nkengasong J. Let Africa into the market for COVID-19 diagnostics. Nature. 2020;580(7805):565.
doi:10.1038/d41586-020-01265-0 pmid: 32346145.
41

Houdek J. Clinton Health Access Initiative. Closing the oxygen access gap: breathing new life
into a neglected therapy – Clinton Health Access Initiative. In: Clinton Health Access Initiative[website]. Boston (MA): Clinton Health Access Initiative; 2020 (https://www.clintonhealthaccess.
org/closing-the-oxygen-access-gap-breathing-new-life-into-a-neglected-therapy/,
accessed 26 April 2021).

42

Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA et al. Global Surgery 2030:
evidence and solutions for achieving health, welfare, and economic development. Lancet.
2015;386(9993):569–624 (https://www.thelancet.com/journals/lancet/article/PIIS01406736(15)60160-X/fulltext, accessed 26 April 2021).

43

An R&D blueprint for action to prevent epidemics: plan of action. Geneva: World HealthOrganization; 2016 (https://www.who.int/blueprint/about/r_d_blueprint_plan_of_action.pdf,
accessed 26 April 2021).

44 Kieny MP, Rottingen J-A, Farrar J. The need for global R&D coordination for infectious diseases
with epidemic potential. Lancet. 2016;388(10043):460–1 (https://www.thelancet.com/journals/
lancet/article/PIIS0140-6736(16)31152-7/fulltext, accessed 26 April 2021).
45 Lurie N, Keusch GT, Dzau VJ. Urgent lessons from COVID 19: why the world needs a standing,coordinated system and sustainable financing for global research and development. Lancet.
2021;397(10280):1229–36. doi:https://doi.org/10.1016/S0140-6736(21)00503-1.
46 Results. In: Randomised Evaluation of COVID-19 Therapy (RECOVERY) [website]. Oxford:
Nuffield Department of Population Health; 2021 (https://www.recoverytrial.net/results,
accessed 29 April 2021).
47

Rizvi Z.BARDA Funding Tracker: tracker details billions in taxpayer funds supporting COVID-19
R&D efforts. Public Citizen. 2 November 2020 (https://www.citizen.org/article/barda-fundingtracker/, accessed 26 April 2021).

48 Covid-19 vaccine is 12 to 18 months away, Harvard’s Jha says. Bloomberg TV. 21 April 2020
(https://www.bloomberg.com/news/videos/2020-04-21/covid-19-vaccine-is-12-to-18-monthsaway-harvard-s-jha-says-video, accessed 26 April 2021).
49 Phase 3 clinical trial of investigational vaccine for COVID-19 begins. In: National Institutes of
Health [website]. Bethesda (MD); National Institutes of Health; 2020 (https://www.nih.gov/
news-events/news-releases/phase-3-clinical-trial-investigational-vaccine-covid-19-begins,
accessed 26 April 2021).
50 David AC, Pienknagura S. On the effectiveness of containment measures in controlling the
COVID-19 pandemic: the role of labour market characteristics and governance. Appl Econ Lett.
2020;0(0):1–7.
51

Social protection floor. In: International Labour Organization [website]. Geneva: International
Labour Organization; 2021 (https://www.ilo.org/secsoc/areas-of-work/policy-developmentand-applied-research/social-protection-floor/lang--en/index.htm, accessed 26 April 2021).

52

The race for global COVID-19 vaccine equity. In: Launch and Scale Speedometer [website].
Durham (NC): Duke Global Health Innovation Center; 2021 (https://launchandscalefaster.org/
COVID-19, accessed 26 April 2021).

COVID-19: Make it the Last Pandemic by The Independent Panel for Pandemic Preparedness & Response

85 of 86

53

First COVID-19 COVAX vaccine doses administered in Africa. In: World Health Organization[website]. Geneva: World Health Organization; 2021 (https://www.who.int/news/item/01-032021-first-covid-19-covax-vaccine-doses-administered-in-africa, accessed 26 April 2021).

54 COVAX vaccine roll-out. In: Gavi, the Vaccine Alliance [website]. Geneva: Gavi; 2021
(https://www.gavi.org/covax-vaccine-roll-out, accessed 26 April 2021).
55 Covax: how will Covid vaccines be shared around the world? BBC News. 8 April 2021
(https://www.bbc.com/news/world-55795297, accessed 26 April 2021).
56 Foley KE. Syringe shortages are causing Pfizer vaccine bottlenecks. In: Quartz [website].
New York: Quartz; 2021 (https://qz.com/1976718/syringe-shortages-are-causing-pfizervaccine-bottlenecks/, accessed 26 April 2021).
57

Knowledge Ecology International. WIPO side event: appraising progress of WHO’s COVID-19
Technology Access Pool (C-TAP). In: YouTube [social media]. 23 September 2020
(https://www.youtube.com/watch?v=bRFC-Baw_ec, accessed 26 April 2021).

58 Rich, developing nations wrangle over COVID vaccine patents. Reuters. 10 March 2021
(https://www.reuters.com/article/us-health-coronavirus-wto-idUSKBN2B21V9, accessed
26 April 2021).
59 Maani N, Abdalla SM, Galea S. Avoiding a legacy of unequal non-communicable disease
burden after the COVID-19 pandemic. Lancet Diabetes & Endocrinology. 2021;9(3):133–5(https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00026-7/fulltext,
accessed 26 April 2021).
60 Torreele E, Kazatchkine M, Mazzucato M. Preparing for the next pandemic requires publichealth focused industrial policy. In: The BMJ Opinion [blog]. 1 April 2021 (https://blogs.bmj.
com/bmj/2021/04/01/preparing-for-the-next-pandemic-requires-public-health-focusedindustrial-policy/, accessed 26 April 2021).

COVID-19: Make it the Last Pandemic by The Independent Panel for Pandemic Preparedness & Response

86 of 86