A FRAGILE STATEOF PREPAREDNESS
2023 REPORT ON THE STATE OF
THE WORLD’S PREPAREDNESSA Fragile State of Preparedness: 2023 Report on the Stateof the World's Preparedness©World Health Organization 2023. Acting as the hostorganization for the Global Preparedness Monitoring
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Cover image: Q'eswachaka Bridge over the Apurímac river, Cusco, Peru, July 2019. Situated 3,700 metres above sea level, the 500-year-old rope
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CONTENTS
1

Foreword 										4

2Executive summary 									5

3	Context: a more challenging environment for preparedness 				

9

4State of the world’s preparedness in 2023 						

12Assessing the status of 30 indicators from the GPMB Monitoring Framework		

13

4.1	
Monitoring and accountability							144.2Financing									144.3Global governance								174.4	Research and development, and access to medical countermeasures		

18

4.5

Inclusivity and community empowerment 					

20

4.6

Adoption of One Health approaches						224.7Multisectoral coordination							24State of preparedness: conclusions 							255	Moving ahead: recommendations for action 						29Recommendation 1									29Recommendation 2									31Recommendation 3	 								34Recommendation 4									36
6Conclusions and next steps 								38GPMB purpose and membership 							40Abbreviations 										42Acknowledgements 									44References										45

3

1FOREWORD

Dear Reader,
Four years ago, the Global Preparedness Monitoring Board warned that unless the cycle of panic and neglectthat has characterized previous health emergencies was broken, the world would face a devastating pandemic
caused by a fast-moving respiratory pathogen. That prediction could not have been more accurate or more
timely. The world stumbled into the COVID-19 pandemic unprepared, doing too little too late. Even the lifesaving vaccines, developed in record time, did not reach most of the world’s population before the virus did.
Today, we find that despite some improvement, preparedness remains perilously fragile. We know in theory
how to stop a pandemic in its tracks, but in practice, the gaps in preparedness leave us dangerously exposed
to a future threat. Competing priorities, geopolitical tensions, and pervasive mistrust are weakening the resolve
needed to close these gaps.
Using our new monitoring framework, the GPMB has canvassed experts to assess the state of preparedness.
It shows many achievements in the wake of COVID-19 but also critical shortcomings. We are deeply concernedthat the international community has failed to secure financing at the scale needed for pandemic prevention,
preparedness and response (PPPR), and to institutionalize independent monitoring. These failures are the‘canary in the coal mine’: they signal that the world has not yet taken sufficient measures to head off future
threats.
The initiatives underway to strengthen preparedness gaps will founder without the right resources andcommitment. Efforts must be redoubled to successfully negotiate a framework for PPPR with the binding force
of international law that will commit States to action; to raise funds from both the public and private sectors
on the basis of ability to pay, that can be deployed where and when they are needed; to build research anddevelopment (R&D) capacities over the long term to overcome the access divide; and to strengthen coordination
across the many sectors that are engaged in PPPR.
Equity is not a ‘nice to have’ embellishment of global preparedness, it is its beating heart. Global security will
be reached only when everyone regardless of geography is valued and assured equal access.
The state of the world’s preparedness is fragile, but it is not hopeless. This Report sets out specific measures,
many of which are in progress, which will repair preparedness. By the time the GPMB makes its next annual
report, we hope to see a world of preparedness transformed.

Ms Kolinda Grabar-Kitarović

Ms Joy Phumaphi

GPMB Co-Chair and former
President of Croatia

GPMB Co-Chair and former
Minister of Health of Botswana

4

2

EXECUTIVE SUMMARY

Key messages
1

The world’s capacity to deal with a potential new pandemic threat remains inadequate.

2

The GPMB Monitoring Framework has revealed significant weaknesses or declining capacities
in several critical areas of preparedness, including global coordination of R&D, efforts to address
misinformation, community engagement, participation of low- and middle-income countries indecision-making, domestic and international financing of preparedness, independent monitoring,and meaningful involvement of relevant actors. Where there are signs of improvement, they are
fragile, and in urgent need of reinforcement.

3

The trust deficit between countries and between communities is a significant impediment to progressin strengthening preparedness. Urgent steps are needed to build trust through operationalizing
principles of equity, leadership and accountability, and coherence within all measures to strengthen
pandemic prevention, preparedness and response (PPPR).

4

Evidence-based monitoring, including independent monitoring, is essential to increase effectiveness,ensure accountability, and build trust.

5

PPPR financing requires fundamental reform to free it from the limitations of development assistanceand place it on a sustainable footing, based on burden-sharing. Strengthening PPPR requires
ensuring sustainable financing for WHO and other international organizations working on PPPR.

6Strengthening regional capacities for R&D, manufacturing and supply will help to address theinequities in global access to medical countermeasures.

7

There is a need to strengthen mechanisms for coordination across the many sectors that play a keyrole in PPPR, nationally, regionally and globally.

5

Momentum and commitment to strengthen PPPR is fading, leaving the world dangerously exposed to thenext pandemic. The United Nations General Assembly High-level Meeting on PPPR in September 2023
reiterated the need for stronger preparedness, but fell short of setting firm targets and made no commitment
to independent evidence-based monitoring.1 The Intergovernmental Negotiating Body working towards a
new convention, agreement or other international instrument on PPPR under the WHO constitution is due topresent its outcomes to the World Health Assembly in May 2024. This legally binding instrument will be central
to stronger preparedness, and WHO Member States need to maintain their resolve to deliver an ambitious,
comprehensive and effective WHO Pandemic Agreement.
The trust deficit between and within countries is a key barrier to improving preparedness. Restoring trust is along-term exercise, but trust-building measures that can begin now include making governance more inclusive,engaging civil society, taking preparedness closer to the populations most in need, and investing in monitoringas the foundation of mutual accountability.
The GPMB Monitoring Framework for Preparedness, published in May 2023, provides a robust, evidence-based
methodology to assess global preparedness.2 It is being applied for the first time in this Report, reporting on
the 30 of its full 90 indicators most pertinent to equity, leadership and accountability, and coherence.
Across the indicators reviewed, the assessment shows that capacities are inadequate. There are particular
weaknesses in global R&D coordination, addressing the impact of misinformation, providing financing andincluding all actors in governance. Some improvements following COVID-19 have been seen in relation to
global information platforms, community engagement, independent monitoring and regional laboratory
capacity. Weaknesses in the global financing system for PPPR and the failure of international commitment tostrengthening independent monitoring will weaken future prospects for effective PPPR.
Main findings from the GPMB’s assessment of preparedness include that:•

Monitoring and accountability has been insufficiently resourced and institutionalized. There is a needfor independent monitoring to complement self-assessment and peer review, at all levels, nationally,
regionally and globally.

•

Global financing of PPPR is woefully inadequate, inefficient, uncoordinated, and insufficiently aligned
to country needs and processes. Countries struggle to make investments in PPPR due to shrinking
budgetary spaces. The creation of a Pandemic Fund has been a welcome addition but its available
funding is far short of the US $10 billion originally proposed for such a fund.

•Global governance of PPPR is evolving with key developments including the negotiations of a WHO
Pandemic Agreement, and potential amendments to International Health Regulations, but progresshas been slow.

•

Limited national and regional R&D capacities leave countries dependent on a global system thatcannot ensure innovation is delivered equitably. Global coordination of pandemic-related R&D is weak.

•Misinformation and disinformation contribute to the global trust deficit. Yet there is currently no global
mechanism to effectively address health-related misinformation and disinformation.

•

Initiatives to enhance community engagement made during COVID-19 are at risk now that the urgencyof the crisis has faded.

•

A One Health approach has not been integrated effectively into preparedness.

•

Global coordination has critical weaknesses including coordination across sectors beyond health,equal participation of all countries, and a lack of mechanisms for the consistent inclusion of civil society
and the private sector.
6

The way forward
Global, regional and national leaders need to fully institutionalize preparedness measures that work in thecollective interests of all. Strengthening preparedness goes hand in hand with global efforts towards theSustainable Development Goals (SDGs), and many of the gaps in pandemic preparedness are shared withthe areas that have been most challenging in progress towards the SDGs.
The GPMB has identified four key priorities to repair the weaknesses in global preparedness: strengthen
monitoring and accountability; reform the global financing system for PPPR; achieve more comprehensive,
equitable and robust R&D and supply chains; and enhance multisectoral, multistakeholder engagement.

Recommendation 1: Strengthen PPPR monitoring and accountability by improving
national monitoring, investing in better data and evidence collection, and strengthening
global multisectoral independent monitoring.
Mechanisms for self-assessment, peer review and independent monitoring are needed to strengthen monitoring
and accountability at the local, national, regional and global levels, and support countries, organizations andactors to be more resilient. Monitoring should be integrated into the governance of PPPR, most importantlyin the WHO Pandemic Agreement. Strong multisectoral independent monitoring is needed to provide broad,independent, evidence- and science-based analysis. The values of objectivity, transparency, impartiality, equity
and impact need to be embedded in the structures and mechanisms for monitoring. Beyond assessing dataand information, independent monitoring must be able to propose solutions and make recommendations tostrengthen PPPR.

Recommendation 2: Strengthen the global financing system for PPPR by addressing
immediate funding gaps and reforming the global financing system to enable greater
national investments and bolster international financing through new modalities andsources of financing.
The global financing system for PPPR requires comprehensive reform to make it fit for purpose. This will
require addressing urgent funding gaps and aligning the system around national priorities and needs, but also
identifying new ways to bolster national and international financing, including tapping private sector funding
streams. International financing must be expanded through Overseas Development Assistance (ODA) and nonODA sources to meet identified needs; the fiscal space for domestic resource mobilization must be expandedin those countries where it is lacking; grant, loan and debt relief modalities must be aligned; and predictability
and timeliness must be ensured across long-term prevention and preparedness capacity-building as well as
immediate response and surge financing needs.

Recommendation 3: Establish baseline regional capabilities to drive more equitable
and robust R&D and supply chains.
Within every region, baseline manufacturing capacity is needed for medical countermeasures, early detection
and One Health surveillance systems and laboratories, capacity to track and shape pandemic-relevantsocial and economic trends, and agile stock management across pandemic response needs. These regional
capacities should be component elements of a global approach that promotes strategic coherence andcoordination. Long-term investment in building more equitable R&D capabilities is needed, building on the7growing efforts of many middle-income countries. Regional ecosystems will need to be embedded in a global
framework for R&D and access to medical countermeasures to support global prioritization and coordinationof R&D, information sharing across countries, capacity-building and technology transfers, and equitable accessto medical countermeasures.

Recommendation 4: Develop a new approach to multisectoral, multistakeholder
engagement for pandemic prevention, preparedness and response.
Multisectoral preparedness and cooperation should be strengthened through engagement of sectors outsideof health as well as civil society and the private sector. A new structured and coordinated approach which ismultisectoral and multistakeholder in character is needed to support a more integrated, coherent response topandemics and health emergencies.

83	CONTEXT: A MORE CHALLENGINGENVIRONMENT FOR PREPAREDNESSIn the wake of the COVID-19 pandemic, there was consensus that the world needed much stronger pandemic
preparedness and response. That consensus has yet to result in action at the necessary scale, or with the unityof purpose and urgency it requires. Momentum and commitment are ebbing away just when they are mostneeded, leaving the world even more dangerously exposed to the next pandemic.
In the GPMB’s February 2023 Manifesto for Preparedness we issued a checklist for global preparedness reform.
We anticipated that the United Nations High-Level meeting would elevate PPPR to the highest priority, createa shared multisectoral agenda, and affirm the importance of independent evidence-based monitoring. While
the political declaration3 adopted by the UN General Assembly on 5 October was a welcome commitment tostrengthened preparedness and response, it fell short of the necessarily ambitious agenda called for by the GPMB.
The focus for strengthening PPPR is now on the negotiation of a convention, agreement or other international
instrument, under the WHO constitution. The Intergovernmental Negotiating Body established for this purposeby the special session of the World Health Assembly in December 2021 will present its outcomes to the World
Health Assembly in May 2024. However, progress has been slow and fundamental differences remain in several
key areas of the proposed WHO Pandemic Agreement.
The emergency footing that countries were on at the height of the COVID-19 pandemic has abated, countries
have integrated responses into routine public health efforts and COVID-19 ceased to be a Public Health
Emergency of International Concern (PHEIC) in May 2023. This has led countries to become complacent.
However, there is still a risk that COVID-19 will surge again, or that viral variants will emerge that can evadethe protections of vaccines and natural immunity.
Aside from COVID-19, zoonotic spillover events are frequent, with the One Health High-Level Expert Panelrecommending that much more attention needs to be paid to preventing these events from occurring at source.4
In 2023, the world has faced the Mpox PHEIC, an outbreak of Ebola Zaire in Uganda, simmering Nipah virus
outbreaks in South Asia and a cholera upsurge in several countries due to underdevelopment, poverty andconflict, and amplified by an upsurge of extreme climate events such as flooding.5 Meanwhile, avian influenza
continues to expand its geographic reach, incidence, impact, susceptible species and virus genetic diversity.
The risk of pandemics remains an ever-present threat.
Myriad crises are competing for global political attention. The impacts of climate change are being felt acutely
and the world is struggling to meet the collective goal of limiting global warming to 1.5 degrees Celsius above
pre-industrial levels. War and conflict continue to drain resources and cause acute suffering in many partsof the world. Heightened food insecurity and inflationary pressures have exacerbated a cost of living crisis,
already fuelled by post-pandemic inflationary pressure.
The impact of the competition for global attention has contributed to the relative lack of resources for PPPR.
The newly established Pandemic Fund has fallen short of the US $10 billion proposed by the G20 High-Level
Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response.6 The valueof country proposals’ total funding needs exceeded by 23 times the amount allocated in the Fund’s first roundof grants in May 2023.7 Other global mechanisms to finance preparedness and pandemic countermeasures,such as the Coalition for Epidemic Preparedness Innovations (CEPI) and the Global Alliance for Vaccines and
Immunisation (GAVI), have also struggled to meet their recent replenishment goals.
The shadow falling over all these efforts is an ever-widening gulf in trust.

9

Figure 1: Median deaths averted by vaccinations per 10 000 people by country in the first year of
COVID-19 vaccination

Source: Watson OJ, Barnsley G, Toor J, Hogan AB, Winskill P and Ghani AC. Global impact of the first year of COVID-19 vaccination: a mathematicalmodelling study. The Lancet Infectious Diseases, 2022, 22:1293–1302. https://doi.org/10.1016/S1473-3099(22)00320-6

Trust between countries is at a low ebb, not only due to geopolitical rivalries but also the profounddisappointment by many countries that when the COVID-19 pandemic was raging, countries used theireconomic power to put self-interest ahead of global solidarity. The disparity was evident in lives saved in thefirst year of vaccine access, with 66 deaths per 10,000 people averted in high-income and upper-middleincome countries, but only 2.7 per 10,000 population in low-income countries where coverage reached just
3.6% (Figure 1 above).8
Amongst people across the world, the social and economic shock of the pandemic, combined with the costof living crisis, has fuelled mistrust of institutions, and has driven deep polarization in societies.9 Political
populism has amplified and exploited mistrust for short-term political gain, with unpredictable results. The
GPMB’s concerns in its 2021 Annual Report about a fragmented and broken world have not been alleviated,
they have heightened.
The SDGs represent a shared blueprint for peace and prosperity for people and the planet and the essenceof strengthened preparedness is embedded across many of the Goals. The commitment of countries atthe High-level Political Forum on Sustainable Development in September 2023 to “promote a systemic shift
towards a more inclusive, just, peaceful, resilient and sustainable world”10 will ring hollow unless substantial
progress is made, and seen to be made, in overcoming the scars left by COVID-19 and securing more effective
preparedness.

10

STATE OF THE WORLD’S
PREPAREDNESS IN 2023

Second meeting of the Working Group on Amendments to the International
Health Regulations, WHO, Geneva, Switzerland, 20–24 February 2023.
The amendments to the International Health Regulations form one of
the intergovernmental processes that aim to strengthen the pandemic
preparedness and response architecture.

11

Credit: WHO/Pierre Albouy

4

STATE OF THE WORLD’S PREPAREDNESS IN 2023

The state of global preparedness is not merely the sum of national preparedness, nor is it just a collection of
discrete component elements. As the COVID-19 pandemic has emphatically demonstrated, preparedness, risk
and impact are interlinked, with global, complex interdependencies from local to planetary scale.
Published in May 2023, the GPMB Monitoring Framework for Preparedness provides a robust, independentand evidence-based methodology to measure the global risk of health emergencies and their likely impact,
together with assessments of capabilities for PPPR. The Monitoring Framework is a diagnostic tool, highlighting
where the most serious gaps lie and drawing attention to the most urgent actions to address them.
The Monitoring Framework is being applied for the first time in this 2023 assessment of the state of the world’s
preparedness, and the GPMB has chosen to focus on 30 indicators that are most pertinent to the criticalissues of leadership and accountability, equity, and coherence. These indicators relate to monitoring andaccountability, financing, global governance, R&D and access to medical countermeasures, inclusivity andcommunity empowerment, adoption of One Health approaches, and multisectoral coordination.
For each area, the Board identified experts to provide a preliminary assessment of the indicators. Evidence,
data and analyses provided by the experts were consolidated into a technical assessment report, giving theBoard a more evidence-based analysis of progress, gaps and challenges related to these priorities to support
the development of its report. These expert assessments have been published in the document ‘Compilation ofexpert assessments’.11 The GPMB’s assessment of the state of capacity and the trend in relation to each of the
30 indicators is provided in the Appendix to this report. Key elements of this assessment are summarized below.

Summary of findings
Of the capacities assessed in this report, none are adequate, and many remain insufficient or absent.
The GPMB’s analysis finds that the weakest areas of PPPR relate to:• Financing (global common goods financing, effectiveness and alignment, financing of WHO and otherinstitutions, global surge financing)•Global R&D coordination•

Global management of misinformation and disinformation• The participation of all low- and middle-income countries and all relevant actors in prevention,
preparedness and response.
Sixteen out of thirty indicators tracked this year are improving, showing some progress made following
COVID-19. Indicators for global information platforms, community engagement, an international regulatory
instrument, independent monitoring and regional laboratory capacity show that partial capacities are inplace, albeit not all. However, there are declines in capacity in global R&D coordination, the global impactof misinformation, community engagement, participation of low- and middle-income countries, mostfinancing indicators, independent monitoring and involvement of relevant actors. Important investments
made during COVID-19 are being lost in these areas.
In addition, while independent monitoring has been assessed as having a degree of capacity in place, the
GPMB is concerned with its lack of inclusion in key international instruments including the Political Declarationfrom the United Nations General Assembly High-Level Meeting on Pandemic Prevention, Preparedness
and Response, the draft WHO Pandemic Agreement, and in the proposed amendments to the IHR (2005).
12

Assessing the status of 30 indicators from the GPMB Monitoring
Framework
Figure 2: Heatmap

MULTISECTORALCOORDINATION
R&D AND ACCESS TO
MEDICAL COUNTERMEASURES
Global R&D
coordination
R&D capacity-building

Involvement ofrelevant actors
Trade coordination

ADOPTION OF ONEHEALTH APPROACHES

Coordination during emergencies

Coherence

Regional manufacturing
capacity

National One Healthpreparedness

National R&D
innovation

Regional laboratory
capacity
Global mechanism for early warningand One Health surveillance

Global mechanism tomanage misinformation

Coherence

Universal periodic
review

Global impact of
misinformation

EquityMONITORING AND
ACCOUNTABILITY

Global information platform

Independent monitoring

INCLUSIVITY AND
COMMUNITY EMPOWERMENTInternational regulatory
instrument
Strategic plan
GLOBAL
GOVERNANCE

Community engagement

Leadership andaccountability

Low- & middle-income
country inclusion

Global leadershipplatform

Involvement of civil society
and private sector
Impact on women, youth
and vulnerable groups

National
financingFunding socioeconomic
response
Global surge
financing

Predictability of
global resources
Global common
goods financing

Financing of
WHO and otherinstitutions

Effectivenessof preparedness
spending

FINANCING

Capacity scoring

Trend scoring

Excellent/Yes = 3

Improving = +1

Good/Partial = 2

Unchanged = 0

Insufficient/Incomplete = 1

Declining = -1

Poor/No = 0

13

4.1	Monitoring and accountability↓↑

B.1.4.5 (a) Independent monitoring
B.1.4.5 (b) Universal periodic review

There are a range of mechanisms to support monitoring and accountability for PPPR but they do not provide acomplete picture of multisectoral preparedness. Their focus is on systems and capacities, rather than leadership,
effectiveness, efficiency, or equity, and are mostly based on self-assessment with limited independent
monitoring. Experience suggests that monitoring efforts are most effective in enhancing accountability andimplementation when they draw on the distinctive strengths of self-assessment, peer review, and independent
evidence-based monitoring.
As the COVID-19 pandemic demonstrated, existing monitoring mechanisms did not accurately predict national
preparedness. While they provide some diagnostics and benchmarking, they are not powered to drive change,
having insufficient technical and financial support for implementation of findings and few built-in incentives
for action. In addition, there are no mechanisms to address non-compliance with the International HealthRegulations (IHR) adopted in 2005.
The Intergovernmental Negotiating Body (INB) and Working Group on Amendments to the IHR (2005) arecurrently reviewing proposals to include monitoring and compliance mechanisms, however, independent
monitoring was not included in the draft Negotiating Text of the WHO Pandemic Agreement12, nor in the
proposed amendments to the IHR (2005). The GPMB is disappointed at the lack of a reference to independent
monitoring in the Political Declaration of the High-level Meeting on Pandemic Prevention, Preparedness andResponse.13 Unless reforms of the central instruments governing PPPR include specific reference to independent
monitoring, its essential contribution to the governance of preparedness will never be fully realised.
The WHO Universal Health and Preparedness Review14 offers a broader scope of review and a more supportive
process, which aims to engage political actors to facilitate uptake of recommendations. There is however aneed to improve the rigour and independence of the process through the inclusion of civil society, and of all
countries, as well as through independent expert review.

4.2 Financing

↑
↓
↓
↓
–
↑
–

B.1.4.4 (a) Predictability of resources for global health emergency preparedness and response
B.1.3.1 Global financing of global public/common goods
B.1.3.2 Effectiveness and alignment of spending for preparedness
B.1.3.3 Financing of WHO and other key institutions involved in preparedness and response
B.1.3.4 Global surge financing for response
B.1.3.5 (a) Funding immediate economic and socioeconomic response
B.3.3.1 National assessment of financing for preparedness and response

14

GPMB 2023 REPORT ON THE STATE OF THE WORLD’S PREPAREDNESSGlobal financing for the COVID-19 response was at an unprecedented scale, but at the same time revealed amismatch between needs and timely availability. As a result, the effectiveness of funding could not be maximized
and some funds were left unspent. The lack of a clear and anticipated framework for funding also led to someperverse results. In some cases, countries were reluctant to avail themselves of some funding opportunities
because in a complex and rapidly changing funding environment, they saw the possibility of accessing otherfunds on more favourable terms, such as grants instead of loans; even where the grants were insufficient, lesscomprehensive and less timely.
Funding made available during COVID-19 was extensive and varied. In the early response, the WHO Contingency
Fund for Emergencies (CFE) disbursed US $129 million within a month of the declaration of the PHEIC, andthe United Nations’ Central Emergency Response Fund (CERF) disbursed US $225 million by March.15 By theend of April 2020, the World Bank Group had mobilized US $3 billion in a new fast-track facility16 and theInternational Monetary Fund (IMF) US $15 billion for response. Over the course of the pandemic from 2020 to2022, multilateral development banks made a total of US $200 billion available to countries from pre-arranged
and new financing, ACT-A mobilized an unprecedented US $24 billion principally for vaccines, and the G20
provided US $13 billion in debt relief.17
COVID-19 funding was ad hoc and has not necessarily been translated into a coherent surge financing
approach that could be rapidly triggered in the event of a health emergency. Existing dedicated surge financing
mechanisms are underfunded and are not replenished in a sustainable manner. In a global pandemic, dayzero needs are estimated to be of the order of US $500 million, but the WHO Contingency Fund for Emergencies
currently has US $20 million available out of its target of US $100 million18, and the United Nations’ Central
Emergency Response Fund is only halfway to its target US $1 billion.19 A survey conducted for the G20
Joint Finance-Health Task Force indicated that only 40% of G20 countries had domestic contingency funds
that could be deployed in a health emergency (Figure 3 below).20
As the financial response to the COVID-19 pandemic shows, response funding is of a much greater magnitude
than funding for preparedness. Despite the conclusion that more effective preparedness would avert at least
some of these needs, the spending ‘hangover’ in the wake of the COVID-19 response has seen preparedness
funding fall short of the identified needs. The funding gap for preparedness at country level is approximately
US $6 billion per year.21 The Pandemic Fund has initially adopted a relatively narrow set of priorities for funding
preparedness but was nevertheless 23 times over subscribed in its first round22, showing that there is a large poolof identified yet unmet needs in countries. One Health capacities have received additional funding, but remain

Figure 3: There are important gaps in surge financing for PPPR
US $100m

US $20m

20%

of WHO CFE funded

US $1bn
US $478.1m

50%

40%

of UN CERF fundedof countries have domestic contingency funds
that could be deployed in a health emergency

15

Figure 4: Several countries are spending more on debt interest payments than health

Source: UN Global Crisis Response Group. A world of debt: A growing burden to global prosperity, 2023. https://unctad.org/publication/world-of-debt

disproportionately underfunded, despite their potential impact on outbreak prevention. There are important
gaps in financing global public goods, including R&D and access to medical countermeasure.
As a direct consequence of the COVID-19 pandemic combined with wider economic and geopolitical challenges,
countries’ budgetary space is shrinking. Many countries continue to be burdened by debt servicing requirements
which compound their lack of fiscal space to address pandemic and other health needs. The number of
low-and middle-income countries spending more on debt servicing than on heath rose from 33 in 2010 to
54 in 201923, with more than 3.3 billion people living in countries that spend more on interest payments thanthey do on health or education (Figure 4 above).24 Shrinking fiscal space and new crises have also meant that
Overseas Development Assistance (ODA) funding has ‘rebalanced’ away from pandemic priorities. This has
been evident in the shortfall in financing ACT-A’s transition plan, in meeting CEPI’s replenishment goals andthe initial funding commitments to the Pandemic Fund of only US $1.9 billion.
Beyond the scale of financing, there are also fundamental structural issues that reduce the efficiency of funding.
A tracking exercise identified more than 1,000 donors and over one million transactions since 2014, within afunding environment that lacks overall coordination.25 The timely availability of funding is not matched to need.
For example, inadequate pre-financing of countermeasures at the outset of the COVID-19 pandemic limited
the ability of funders to set conditions for equitable access at the outset of countermeasure development. Somecountermeasures, in particular vaccines, received far more funding than others, such as diagnostics, and thelack of a priorities-driven funding coordination mechanism meant that some measures, such as securingoxygen supply chains, were delayed.

16

4.3 Global governance↑–↑

B.1.4.1 (a) Global platform to support leadership
B.1.4.1 (b) Strategic plan
B.1.4.2 International regulatory instrument

Global governance of PPPR is evolving with key developments in the international negotiation of a WHO
Pandemic Agreement, review and revision of the existing International Health Regulations, debate in the World
Trade Organization (WTO) TRIPS context to ensure that intellectual property rights do not impede equitable
access to medical countermeasures, and evolution of access and benefit-sharing frameworks in relation to
genetic resources and the extension of these frameworks to cover digital sequencing data.
There is a high level of fragmentation in the international governance and regulation of PPPR. Several legal
frameworks apply to PPPR including the International Health Regulations (2005), the Pandemic Influenza
Preparedness Framework, the TRIPS Agreement and the Nagoya Protocol, with little capacity for each ofthese frameworks to operate in concert with the others. The lack of a coherent multisectoral approach cancontribute to ‘forum shopping’ by governments and other actors, and a lack of coordination between relevant
stakeholders. Some international agreements relevant to PPPR, such as those addressing environment,
intellectual property, and trade, have objectives or approaches that are not supportive of better preparedness,for example, inequitable access led WTO Member States to adopt a waiver to the TRIPS Agreement in relation
to COVID-19 vaccines. Important gaps also remain around certain key areas such as equity, R&D and accessto medical countermeasures, access and benefit-sharing (beyond pandemic influenza), and One Health.
Reform of global governance for PPPR has focused on the development of a broad and effective international
agreement that would set out expectations of States and other actors in preventing and responding to pandemics
and other health emergencies, complementing but going beyond the obligations established by the International
Health Regulations. The WHO Pandemic Agreement holds out the promise that States will collectively addressthese challenges and take on binding obligations to better prevent health emergencies, better prepare for theireventuality, and cooperate more effectively not only between themselves but also across sectors. Progress on
the negotiations has been slow and while there are many areas of agreement, countries and other stakeholders
appear to be far apart on several key issues, such as measures to mandate equitable access to vaccines andother medical countermeasures, access and benefit-sharing, integration of One Health approaches, balancing
States’ sovereign interests in protecting their own security with global security and the collective interests of all
countries, and accountability. The concerns expressed by the WHO Director-General in October 202326 at theslow speed of progress with the WHO Pandemic Agreement negotiations are shared by the GPMB.
The Political Declaration on PPPR adopted by the United Nations General Assembly made commitments tomultisectoral preparedness but fell short of establishing concrete goals, deferring much of that discussion to
the WHO Pandemic Agreement process.27
WHO has been significantly empowered over the course of the COVID-19 response as Member States haverecognized the need for its leading technical authority in health emergency response, with a greater degreeof its funding available flexibly to be deployed according to need.
PPPR requires multisectoral action and involves a wide range of actors. There is significant progress in WHO’s
work and engagement with non-health sectors, and Member States themselves are more broadly engaging at
the national level, especially in the context of the WHO Pandemic Agreement negotiations. In addition, beyond
the context of negotiating a new pandemic agreement, there are important gaps in multisectoral engagement
17Non-exhaustive list of international regulatory frameworks applying to PPPR
SectorInternational regulatory framework

Elements covered

HealthInternational Health Regulations (2005)

Prevention, detection and response to healthemergencies, including PPPR core capacities,
information sharing and PHEIC Declaration

HealthPandemic Influenza Preparedness Framework(non-legally binding)Access to medical countermeasures, PPPR corecapacities

One Health

WOAH Standards and surveillance framework(non-legally binding)Outbreak detection in animals

One Health

FAO/WHO Codex Alimentarius Commission(non-legally binding)Food contamination

One Health2022 One Health Joint Plan of Action (non-legallybinding)

Quadripartite collaboration between
One Health organizations

Environment

Nagoya Protocol/Convention on Biological
Diversity

Pathogen sharing and access to benefits derived
from their use

Environment

Multilateral Environmental Agreements (MEA)

Addressing determinants of health emergencies

Intellectual Property

TRIPS Agreements

Access to technologies and medical
countermeasures

Global financial
systemIMF Articles of Agreement; bilateral investment
treaties

Financing of PPPR

Trade

GATT agreement and other trade agreements

Trade restrictions

Distaster risk
reduction

Sendai Framework (non-legally binding)Pandemic prevention

Human rights

Right to healthAccess to healthcare

Source: based on analysis from Gian Luca Burci, Graduate Institute of International and Development Studies

in the organization’s governance. There are also limitations to civil society and private sector engagement,
inherent in a state-based multilateral organization, and in WHO’s capacity to coordinate a whole-of-UN,
multisectoral response to health emergencies.

4.4	Research and development, and access to medical
countermeasures

↓
↑
↑
↑
↑

B.1.1.2.1 Global R&D coordination and priority setting
B.1.1.2.4 R&D capacity-building
B.1.1.2.7 (a) Coordination during health emergencies
B.2.1.2.2 Regional manufacturing capacity
B.3.1.2.1 Assessment of national R&D innovation, development, and access to medical countermeasures
18

There is no effective global system for the coordination of pandemic-related R&D and a market-driven system isunable to deliver equitable outcomes or respond to globally prioritized needs. The WHO-supported global R&D
Blueprint sets global priorities and was convened in timely fashion at the beginning of the COVID-19 pandemic(although not thereafter), but it has limited leverage in directing research priorities or investment – only 3% of the
61,000 products in the development pipeline target R&D Blueprint pathogens.28
COVID-19 required the creation of a new coordination apparatus – ACT-A, which lasted only through the heightof the pandemic and began winding down in October 2022. While ACT-A played an important role during the
pandemic, its governance structure was informal and lacked full participation of low- and middle-income
countries and regional bodies as well civil society and the private sector.
While global spending on R&D is at record highs, amounting to almost US $1.7 trillion, it is highly concentrated withjust 10 countries accounting for 80% of this spending.29 Recent health emergencies have shown that mobilizationof R&D funding in a crisis is uncoordinated and siloed, with philanthropic funders reluctant to give up autonomy
in how they set their own priorities and government research funding largely directed towards narrow definitionsof national self-interest in R&D investments for health emergencies. Funders are largely concentrated in highincome countries and governance of R&D initiatives is not inclusive of low- and middle-income countries.
Several promising technology transfer programmes increased low- and middle-income country access to tools
and medicines during COVID-19, but as yet have not been widely applied. Similarly, networks and collaborations tobuild R&D capacity in low- and middle-income country settings proved valuable during the COVID-19 pandemic
but remain small scale. Biomedical research collaborations remain overwhelmingly concentrated in high-income
countries, and in only a small minority of cases do collaborations extend to lower-income country partners.
The COVID-19 pandemic was proof-of-concept that medical countermeasures can be developed faster withlarge public investments; joint planning across the clinical development, regulation and manufacturing capacity
continuum; and by leveraging innovative platforms. Time to effective product has been reduced to levels thatwere unthinkable pre-COVID-19, for example, in the 2022-2023 Sudan Ebolavirus outbreak a partnership led by
the Serum Institute of India with Oxford University and CEPI brought a vaccine candidate to trial within 79 days

Figure 5: Vaccine development timelines have significantly decreased as a result of COVID-19
Vaccine development timeline – Pre-COVID-19
Clinical development:
Discovery
research:
2-5 years

Pre-clinical:
2 years

Phase I
(Safety):
1-2 years

Phase II
(Efficacy):
2-3 years

Phase III
(Effectiveness):
2-4 years

Regulatory
review andapproval:
2-4 years

Manufacturing
and delivery (starts
during phase II):
3-6 years

Total: 10 years
COVID-19 accelerated vaccine development timeline
Clinical development:

Discovery
research:
A few months

Pre-clinical:
A few months
or skipped
altogether

Phase I
(Safety):
3 months

Phase III
(Effectiveness):
Combined withphase II

Phase II
(Efficacy):
8 months

Regulatory
review andapproval:
3 months

Manufacturing
and delivery (starts
during phase II):
1-2 years

Total: 1-2 years
Source: Wellcome. How have Covid-19 vaccines been made quickly and safely?, 2021. https://wellcome.org/news/quick-safe-covid-vaccine-development

19

Figure 6: Map of current and planned vaccine manufacturing on the African continent, including
ownership structure and value chain capabilities

Source: Clinton Access Health Initiative. The African vaccine manufacturing ecosystem: supply landscape and expansion plans, Dec 2022.
https://www.clintonhealthaccess.org/wp-content/uploads/2022/12/White-Paper-African-Vaccine-Manufacturing-Ecosystem.pdf52of the outbreak.30 However, the experience of COVID-19 showed that when a pandemic causes acute demandfor countermeasures worldwide, high-income countries use their dominance in R&D funding to secure priority
access, and hoard medical countermeasures, leaving the pandemic to spread unchecked throughout the globe.
Global pandemic vaccine manufacturing capacity has increased significantly in recent years, due in large partto the COVID-19 pandemic. However, manufacturing capacity is not uniformly distributed across regions – it isconcentrated in Southeast Asia, Europe, and North America. Africa and the Middle East have relatively low vaccine
manufacturing capacity regionally. Latin America is the region second most dependent, after Africa, on vaccine
imports with initiatives underway to boost regional manufacturing capacity.31
Significant regional initiatives have been launched to increase R&D capability including in Africa, the ASEAN
region32 and Latin America.33 However, there is some fragility in these initiatives – there is already evidence thatinterest is waning as the crisis in COVID-19 vaccine supply has faded from view.

4.5 Inclusivity and community empowerment

↓
↓
↑
↓
↓
↑
–

B.1.2.2 (a) Global mechanism to manage misinformation
B.1.2.2 (b) Global spread and impact of misinformation during health emergencies
B.1.2.2 (c) Global platform to disseminate information and build knowledge
B.3.2.1 Assessment of communities and people at the national level
B.1.4.7 (a) Inclusion of low- and middle-income countries
B.1.4.7 (b) Involvement of civil society, private sector and community representatives
B.1.2.1 (a) Impact of health emergencies on women, youth, vulnerable and marginalized groups
20

The importance of engaging communities in preparedness and in pandemic response has been widely
recognized by countries. When countries assess their own performance, for example, using the IHR State
Party Self-Assessment Annual Report (SPAR) tool, the majority consider that mechanisms are in place toengage communities and that they perform well. The average score for risk communication and community
engagement in the SPAR was 69 out of 100 in 2022.34 However, external assessment of country performance isless optimistic, suggesting that countries may overestimate their performance in this area.
Community engagement is intimately linked to the issue of trust. There are few monitoring measures which
capture the dynamics of trust-building, and track which strategies are most effective. The monitoring of community
engagement is often limited to the dimension of communication, rather than extending to assess meaningful
engagement in planning and decision-making processes, and accountability of leaders to their communities.
In the wake of COVID-19, several instruments have been created which assess different aspects of community
engagement, including artificial intelligence (AI) listening tools, citizen scorecards, engagement of community
health workers and community health centres, and confidence in vaccines. These tools and approaches areboosting efforts to monitor community engagement, but many are still being piloted and involve only a minority
of countries. Many are focused more on pandemic response than preparedness and have not been sustained
after the initial crisis response phase ended.
Increasingly, community monitoring of programmatic effectiveness is being mainstreamed, for example, into
World Bank Group health and nutrition investments35, and country programmes supported by the Global Fundto fight AIDS, TB and Malaria.36 However, community monitoring remains rare in the context of PPPR. Crucially,
what are lacking are community-driven measures which would enable consistent standards for community
engagement to be set and to be compared across countries, and community-owned global and regional
mechanisms that would monitor effectiveness in community engagement.

GenderThere is no overarching global strategy to mitigate the gender impacts of pandemics. Gender is considered
under the Joint External Evaluation Framework and in the Universal Health and Preparedness Review
mechanism. However, there is potential for a more structured and systematic consideration of gender impacts
through the WHO Pandemic Agreement. The Negotiating Text of the WHO Pandemic Agreement contains
some consideration of the need to advance gender equality including the need to promote the equal andmeaningful participation of women and address gender disparities in the health workforce. In the proposed
amendments to the IHR (2005), there is relatively little consideration of gender, with the exception of references
to equal representation on the basis of gender and of gender in relation to workforce capacities. However, somemembers of the Review Committee regarding amendments to the IHR (2005) did see a potential role for greater
inclusion within the proposed amendments to help address “the unequal experiences of the international
spread of disease due to gender, race, locality, age, disability, sexuality, indigeneity and other vulnerabilities”.37

Vulnerable groups
There is also little consideration in the context of PPPR of systematic measures to ensure the protection of persons
in vulnerable situations, including addressing the differential impact on youth, or on ethnic minorities, indigenous
populations or displaced populations. Although the COVID-19 pandemic provided a wealth of data on thedisproportionate impact on groups which are less wealthy and socially marginalized, mitigation strategies
have been piecemeal and not placed within an overall framework of equitable preparedness and response.

Misinformation and disinformation
While the COVID-19 pandemic drew attention to the corrosive effects of mistrust on collective action, burgeoning
misinformation and disinformation have been growing concerns over the past decade. A 2022 study found that
20–30% of the YouTube videos about emerging infectious diseases contain inaccurate or misleading information.38
21

In more and more countries, there is a trust gap between citizens, governments and the private sector, in
multiple directions. While trust in science and scientists has generally been found to be high across the globe39,
misinformation is undermining this trust, with pockets of the population in many settings strongly distrustful.
There is currently no single global mechanism established to deal with health-related misinformation anddisinformation. There are a growing number of initiatives at global and at regional levels to identify and track
misinformation and disinformation, but they remain uncoordinated, limiting their capacity to intervene. WHO
has established several initiatives to support infodemic management, include the Early AI-supported Responsewith Social Listening (EARS) platform to monitor misinformation.40 Regional initiatives include the Africa
Infodemic Response Alliance network and the European Union’s strategy to tackle online misinformation anddisinformation, and globally the United Nations Development Programme (UNDP), UNESCO, the UN Human
Rights Office (OHCHR) and the International Federation of Red Cross and Red Crescent Societies (IFRC) havedeveloped platforms to identify and seek to counter misinformation and disinformation.
Governments have started to legislate and take measures to manage misinformation, and social media
companies have implemented a range of policies and tools, including specific policies on COVID-19-related
misinformation during the pandemic.41 While these measures have had a positive impact, they do not have thereach or scale to counter the deterioration in the information environment. Digital and social media platforms
have provided the technologies to accelerate misinformation, and a more unified, proactive approach to
reducing the harms of misinformation needs to be taken by both regulators and corporate governance bodies.
Solidarity-based data governance which strengthens collective control and ownership of data is a corollary
to solidarity in global health.

Inclusion and engagement
There is currently no mechanism to track the participation of low- and middle-income countries in governance,
nor of the involvement of civil society and the private sectors, and therefore there is little information to assess
the quality of their engagement.
Progress was made in the COVID-19 context to improve representation of civil society in the governance of PPPR
but this progress is fragile. The establishment of WHO’s new civil society commission is a positive development.42 A
key gap are requirements to ensure governance is inclusive of all genders. At every level, local, national, regionaland global, insufficient attention is paid to the composition of decision-making bodies.
Low- and middle-income country participation in PPPR governance has improved through the Intergovernmental
Negotiating Body and the IHR (2005) amendment processes. Effective measures to create entry points for theprivate sector to join preparedness efforts as trusted actors have been stymied by ineffective mechanisms forengagement. The only systematic involvement of the private sector in the governance of PPPR is the inclusion of
the pharmaceutical industry in the Pandemic Influenza Preparedness Framework.

4.6 Adoption of One Health approaches

↑
↑
↑
↑

B.1.1.1.2 (a) Global mechanism for early warning and One Health surveillance
B.2.1.1.1 (a) Regional laboratory capacity
B.3.1.1.1 Assessment of national One Health and health systems preparednesss
B.1.4.8 Coherence22

In the wake of COVID-19 there was some progress in reinforcing the capacities for One Health-focused
prevention and preparedness, but capacities are still short of what is needed. In the most recent IHR SPAR
annual report, 70% of countries report some One Health activities are in place43, but most of these are initialsteps rather than a mature integration of a One Health approach. Many One Health activities have been
focused on a particular human disease, such as influenza; neglected zoonoses, such as rabies; or emerging
One Health priorities, such as antimicrobial resistance. A broader perspective would consider animal healthin a more genuinely integrated way alongside human health as fundamental capacities for PPPR. Only when
this fully integrated approach is taken will One Health activities have the scope and capacity to assess andrespond to the needs of prevention and early warning across a broad range of diseases.
Global initiatives for early warning and One Health surveillance have been strengthened during COVID-19.
However, the pandemic highlighted that traditional surveillance systems alone are not sufficient to provide
public health and policy decision-makers, at all levels, with access to timely and robust pandemic intelligenceneeded to make decisions. Greater efforts are needed to facilitate multisectoral integration of intelligencein decision-making to strengthen national capacities to detect emerging events, communicate information
quickly, understand local vulnerabilities and the scenarios that might unfold, initiate responses rapidly, andcontinue to inform actions throughout an emergency cycle. While laboratory capacities have been reinforced
at regional level in many regions, fully flexible laboratory capacity that can respond to a range of novel threats
is inadequate. In some regions, laboratory capacities are principally in response to specific diseases or aspectsof laboratory capacity, rather than a full set of generic capacities that can be adapted across a range of threats.
Integration of One Health into policy-making, governance instruments and programming has been challenging,with some disagreement about the extent to which the WHO Pandemic Agreement should address One Health,and challenges in ensuring representation of animal and environmental health interests in negotiation fora for
PPPR. However, the draft Negotiating Text for the WHO Pandemic Agreement44 includes concrete proposals
to support countries in implementing a One Health approach, demonstrating that progress has been madeon this front. In addition, the Quadripartite – the UN Food and Agriculture Organization (FAO), WHO, World
Organisation for Animal Health (WOAH) and UN Environment Programme (UNEP) – has adopted a One
Health Joint Plan of Action (2022-2026),45 which includes Action track 2: Reducing the risks from epidemics andpandemics, and commits the Quadripartite to implementation, monitoring and evaluation of the plan throughwide engagement with stakeholders.

Figure 7: National Influenza Centres and WHO Collaborating Centres for Epidemic and Pandemic
Preparedness and Response

Source: World Health Organization, Dec. 2022

23

4.7 Multisectoral coordination↑↓

B.1.1.4.1 (a) Trade coordination
B.1.1.4.2 Involvement of relevant actors

Beyond the ad hoc and time-limited coordination mechanisms created during recent health emergencies,
some elements of global multisectoral coordination around PPPR exist, for example, the Inter-agency Standing
Committee. Other platforms are under consideration, including through the WHO Pandemic Agreement and theUnited Nations Secretary-General’s proposal for an Emergency Platform.46 However, gaps and weaknesses incoordination remain, including weak multisectoral and multistakeholder coordination and the lack of effective
mechanisms to consider interactions and trade-offs between public health and socioeconomic dimensions ofpandemics, such as the impact on education and employment.
The level of involvement of different actors in preparedness is inconsistent. Beyond the WHO Frameworkof Engagement for Non-State Actors (FENSA)47 there is no overall framework which mandates the basis onwhich civil society and private sector actors are involved in preparedness and able to coordinate efforts withgovernments, at national, regional and global levels. Current governance discussions have focused on new
structures and mechanisms, rather than first establishing greater clarity on the coordination and oversightfunctions needed.
One of the key failures of the early response to COVID-19 was the adoption of export bans on critical medical
supplies and trade barriers by several WTO Member States, leading to restrictions on access. These werecompounded by disruptions to global supply chains due to local lockdowns (affecting production and shipmentof a broad range of goods), travel restrictions and border closures. Without better guidance, countries struggled
to assess trade-offs between health and socioeconomic impacts. While WTO and the Organization for Economic
and Co-operation and Development (OECD) provided support during the pandemic, this remains an important
gap where greater coordination is needed between countries, but also between the health and trade sectors.
Existing instruments such as the Trade Facilitation Agreement (TFA) could provide greater coordination, butthere is insufficient funding to support its implementation by low- and middle-income countries.

24

STATE OF PREPAREDNESS: CONCLUSIONS
While there are signs of improvement in some aspects of global preparedness, and significant global andregional initiatives are under development to enhance collective action, the world lacks a commonly agreed
framework for PPPR that is comprehensive in scope, based on shared goals and targets, and able to facilitate
planning, implementation, monitoring, and resource mobilization.
Overall, global preparedness for PPPR remains inadequate. There are key weaknesses or declining capacities
in independent monitoring, most of the financing indicators, global R&D coordination, management of
misinformation, community engagement, participation of low- and middle-income countries, and involvementof relevant actors. Where there are signals of improvement, they are weak and in urgent need of reinforcement.
The COVID-19 pandemic resulted in a clearer picture of where the most critical points of system failure arelocated and what can be done about them. Many national governments, international organizations, civilsociety, private sector and research actors have developed tools, programmes and initiatives directed towards
better and more sustainable PPPR. But more of these initiatives are at the planning than the implementation
stage. Until and unless they are brought to fruition, global vulnerability to a new or resurgent pandemic threat
remains extremely high.
Grounded in the expert assessments provided to it, the GPMB has drawn the following conclusions in relation
to equity, leadership and accountability, and coherence.

Leadership and accountability
1Monitoring and accountability has been insufficiently resourced and institutionalized. In particular,
there is a need for independent monitoring to complement self-assessment and peer review, tocreate layered and improvement-oriented systems that reinforce accountability.

2

Systemic deficiencies in the global financing of PPPR were revealed over the past three years anddespite major initiatives including the creation of the Pandemic Fund, the level of available funding is not
yet close to meeting identified needs. The failure to align different elements of global financing for PPPR
make it inefficient, and continuing reliance on Official Development Assistance leaves it unsustainable.

3

Negotiations of a WHO Pandemic Agreement are underway, but progress has been slow. Significant
differences remain between different interest groups and a geopolitical context that lacks trust
makes it challenging to reach consensus. Strong opposition from the pharmaceutical industry to
proposed measures to encourage equitable access to countermeasures is also concerning. Other
international obligations and governance in non-health sectors that have an impact on PPPR, suchas trade facilitation, intellectual property, pathogen-sharing, and environmental measures, remain
poorly aligned.

Equity4

The gross global inequities in timely access to COVID-19 vaccines has demonstrated the needfor sustained and distributed R&D innovation, able to deliver its benefits fairly based on need.
The inequity in access resulted from the concentration of R&D capacity in a few - mainly wealthy countries. Without R&D capacity closer to hand to all countries, countries remain vulnerable to being
locked out of supplies of medical countermeasures in the event of a widespread health emergency.

25

5

In many settings, the COVID-19 pandemic resulted in enhanced community engagement, itself a key
determinant of response success. However, many of these positive initiatives are in danger of falling into
disuse now that the urgency of the crisis has faded. COVID-19 has had hugely different outcomes withincountries across gender, age, race and ethnicity, especially for vulnerable groups. Yet, there is no
consistent global effort to tackle these inequities. The increasingly fragmented information environment
as well as misinformation and disinformation is undermining trust between citizens, governments andthe private sector but efforts to tackle this problem do not have the required structure, reach or scale.

Coherence
6

A One Health approach has not been integrated effectively into preparedness. However, the newly
released draft WHO Pandemic Agreement proposes several approaches to better integrate One
Health and shows promise.

7

The failure of coordination which characterized the COVID-19 response remains a critical gap, withweak multilateral and multisectoral coordination, situations where access to support and financeis fragmented, where some countries are central to decision-making but others feel marginalized,
and weak and inconsistent mechanisms for including civil society and the private sector.

Initiatives developed in the wake of the COVID-19 pandemic raise the hope that the global preparedness
landscape is on the threshold of transformative change, but too often in the past that hope has been dashedas momentum is lost post-crisis. Global, regional and national leaders need to keep the hope of transformativechange alive by seizing the moment to fully institutionalize an effective system of preparedness for pandemics
that works in the collective interests of all.

26

A special note about trust-building for better preparedness
Pandemics are the paradigm for security through the pursuit of mutual interests. States attentively
guard their sovereignty, but it is a mistake to imagine that their sovereignty is best safeguarded only
through the lens of self-interest. Mistrust between States is a geopolitical reality, which will not disappear
through well intentioned calls for change, but must be addressed in ways that encourage cooperation
and advance mutual accountability.
The lack of global solidarity shown when COVID-19 vaccines were most in demand profoundly affected
global trust, and exceptional efforts will be needed to turn it around. Accountability and transparency
boost trust, from open science to community engagement, to inclusive multilateral processes. Just as
inequity erodes trust, taking meaningful steps towards equity builds trust. Trust-building should be
elevated to an explicit goal of multilateral institutions.
Independent monitoring serves as a reinforcer of trust. It adds to the confidence and veracity of dataand creates a platform for accountability by tracking whether commitments made are kept and where
additional effort is required.
The fundamental imbalances in global financing of preparedness also feed mistrust between countries.
When countries are forced to spend more on debt servicing than they have available for health oreducation, it is little wonder that citizens lose faith in the fairness of the global system. Countries in needcannot trust those with resources to help put financing on a sustainable basis.48
Regional institutions and processes are often in a better position than global ones to build trust, as they
are closer to the needs and concerns of both national governments and the citizenry of their regions.
The participation of governments from all regional and income levels in the governance of instruments
like the Pandemic Fund are important confidence-building measures. When equity can be advanced
by ensuring that every region has at minimum skilled workforces, technical know-how and vaccine,diagnostics and therapeutics manufacturing capabilities, they will build trust as a concrete measureof self-reliance.
There is a complex relationship between inequity, economic uncertainty and misinformation, which
feed a vicious cycle of deepening mistrust.49,50 The trust-building measures to counter it are parallel at
the level of individuals and of nations – transparency, inclusion and engagement.
When governance bodies also include civil society, trust and accountability is further enhanced. Building
a web of trust will require concerted good-faith efforts which jointly mobilize government, civil society
and the private sector, across geopolitical divides.

27

MOVING AHEAD:
RECOMMENDATIONS FOR ACTION

Laboratory testing during COVID-19, Egypt, March 2020.
A WHO expert team on a COVID-19 technical support mission to Egypt inMarch 2020 found significant work in laboratory testing, early detection,
isolation, contact tracing and referral of patients.

5	MOVING AHEAD: RECOMMENDATIONSFOR ACTION
We live in a world of poly crises and cascading risks, made worse by a negative spiral of geopolitical divisionand multi-layered mistrust. Exhausted by these multiple demands, countries are scaling back their ambition
for what can be achieved by acting together. But the risk of tinkering with a system that has fundamental flaws
is that it gives the illusion of progress while the fatal flaws are left untouched.
Over the past four years, the GPMB has made a series of recommendations to improve PPPR. These
recommendations remain as relevant today as when they were made. The GPMB reaffirms its past calls toaction and encourages countries, international organizations and actors to strengthen PPPR across all its
dimensions.
Noting with concern that the assessment of the state of the world’s preparedness in 2023 has revealed thepersistence of key gaps and shown areas where global preparedness is deteriorating, the GPMB makes fourrecommendations.

Recommendation 1: Strengthen monitoring and accountability at all levels by improving
national monitoring of pandemic prevention, preparedness and response, investing in
better data and evidence collection, and strengthening global multisectoral independent
monitoring.
Strengthening monitoring and accountability through a step-by-step approach across all actors at the local,
national, regional and global levels will enhance PPPR as countries, institutions and communities are better
able to assess risks and track their capacities to respond. A combination of self-assessment, peer review, andindependent monitoring is needed. Self-assessment allows countries and actors to assess their own capacity
based on their specific context, needs and resources; peer reviews encourage the sharing of best practices
and create mutual accountability; and independent monitoring provides the most objective and accurate
picture of successes, challenges and gaps, and supports more effective investments. Robust monitoring andaccountability must be adequately resourced and supported through greater investment in building betterdata and evidence collection capacity.

Improving monitoring of national pandemic prevention, preparedness and response
Mandating monitoring in international regulatory instruments will help countries track their progress in meeting
their obligations under international instruments, uncover challenges and gaps, and identify areas where theyneed further action and support. It would facilitate prioritization and targeting of investment. Monitoring should
not be about criticism, blame and fault-finding, but ensuring that countries have the best data and information
to support evidence-based decision-making, and are empowered to protect themselves.

29

The GPMB reaffirms its previous calls for the inclusion of monitoring in the governance of PPPR and recommends
that Member States ensure the WHO Pandemic Agreement includes both review and compliance mechanisms
with the following characteristics:•

A universal periodic peer-review mechanism should include country self-assessment with technicaland, where necessary, resource support from WHO and other international organizations, and with
contributions from national civil society groups; a peer-review mechanism led by State Parties; andindependent expert review. The universal periodic peer-review process will need to ensure thatcountries have the support in place to implement, and track the implementation of, recommendations.

•

A conference of parties with the mandate to assess compliance with the WHO Pandemic Agreement’s
provisions. The Conference of Parties should be supported by independent expert monitoring andcivil society engagement and should provide support to State Parties in meeting their commitments.

The GPMB also supports current proposals to amend the IHR (2005) to improve compliance through theestablishment of a Conference of Parties or a formal review process by the World Health Assembly. This should
be supplemented by an independent assessment process.

Investing in global, regional and national data collection capacities
The accuracy, and usefulness, of monitoring depends on the quality of the information and evidence available.
There are major blind spots in our understanding of PPPR because insufficient investments have been made inbuilding global, regional and national data collection capacities. As a priority, countries, international bodies
and funders must invest in these capacities, building on existing data collection systems. A better understandingis needed of PPPR capacities globally, with key knowledge gaps that should be filled in relation to:•

One Health surveillance•

R&D capacity and pipelines including regional/national manufacturing capacity, national regulatory
and clinical capacities, access to medical countermeasures•

Global, regional and national financing and investments in PPPR•

Impact of misinformation on PPPR and broader public health•Impact of pandemics and health emergencies on women, youth, displaced populations and vulnerable
groups•Inclusion of women, low- and middle-income countries', civil society and the private sector in PPPR
governance processes•

Community engagement and social accountability.

Strengthening multisectoral independent monitoring
A strong multisectoral independent monitoring mechanism is needed to support national monitoring.
Independent monitoring can reinforce self-assessment and peer review, and help provide a more objective,
transparent, impartial and evidence- and science-based expert assessment of PPPR. Beyond assessing
data and information, independent monitoring can propose solutions and make recommendations tostrengthen PPPR.
Existing monitoring mechanisms such as the Intergovernmental Panel on Climate Change (IPCC) offer examplesof good practice. Effective independent monitoring should comprise high-level independent leaders andexperts. To be credible, balanced, reliable, and comprehensive it must be inclusive and informed by experts30

from all regions and subregions and across all relevant sectors and stakeholders. A complete picture of thestate of the world’s preparedness requires assessment of the impacts of health emergencies, their drivers andamplifiers, gaps and weaknesses in our collective ability to anticipate and respond to health emergencies,
and the extent to which national obligations under international law – including the IHR (2005) and the WHO
Pandemic Agreement – are met.
The GPMB will soon reach the end of its first mandate. The need for the GPMB – or a similar multisectoral
independent monitoring mechanism – is as important today as it was when the Global Health Crises Task
Force called for it in 2017 and when the WHO Director General and the World Bank Group President established
it in 2018. The GPMB therefore requests its co-Conveners, WHO and the World Bank Group, to carry out an
independent review of the work of the GPMB to identify gaps and areas of improvement so that it can evolve
into a more robust, multisectoral, independent monitoring mechanism. Potential reforms could include the
GPMB being formally recognized as a source of independent monitoring for the WHO Pandemic Agreement,
expanding the scope of its work to the full continuum of PPPR, and enhancing its multisectoral nature by
expanding the GPMB co-Conveners to include other relevant international organizations, for example, FAO,
IMF, UNEP, UNICEF, the World Intellectual Property Organization (WIPO), WOAH, and WTO, or to derive its
mandate from the UN Secretary-General.

Actions under Recommendation 1
The GPMB calls on:

1

Member States to ensure the WHO Pandemic Agreement includes both a universal periodic peerreview mechanism for PPPR and a Conference of Parties with the mandate of reviewing compliancewith its measures.

2

All countries to invest in building their national capacity for data collection and analysis on PPPR, in
collaboration with regional bodies.

3International organizations and other actors such as the G7, G20, CEPI, GAVI and the Global Fund,with support from funders, to invest in building data collection and analyses to support a better
understanding of PPPR capacities globally.

4

WHO and the World Bank Group to carry out an independent review of the work of the GPMB to
identify gaps and areas of improvement and consider expanding the GPMB co-Conveners to include
other relevant international organizations, for example, FAO, IMF, UNEP, UNICEF, WIPO, WOAH, and
WTO, or to derive its mandate from the UN Secretary-General.

Recommendation 2: Reform the global financing system for PPPR by fully financing thePandemic Fund and reviewing its funding model, and finding new ways of financing
pandemic prevention, preparedness and response.
Improving the global system for financing PPPR requires addressing urgent funding gaps and aligning it aroundnational priorities and needs, but also identifying new ways to bolster national and international financing.
The GPMB has repeatedly stated that development assistance (ODA) is not an adequate or sufficient sourceof financing and has called for a new financing approach, grounded in burden-sharing, to supplement
development-assistance-based funding. Strengthening global financing requires increasing available
31international financing through ODA and non-ODA sources; expanding the fiscal space for domestic resource
mobilization in those countries where it is lacking; mainstreaming PPPR in international financing instruments;aligning grant, loan and debt relief modalities; and ensuring predictability and timeliness across long-term
prevention and preparedness capacity-building as well as immediate response and surge financing needs.
The adage “no one is safe until all are safe” remains true after the pandemic. PPPR is a global good that requires
ensuring that all countries are better equipped to detect and respond to pandemics. Similarly to climate change
prevention and adaptation, financing for PPPR must go beyond the more traditional donor models of ODA.

National and global financing of prevention and preparedness
Financing for PPPR should be anchored by domestic investment. International financing will complement
domestic investment by providing additional resources and by improving the ability of countries to accessfinancing. New sources of sustainable financing need to be found, and the structural issues which limit thecapacity of low- and middle-income countries to invest in PPPR addressed.
In order to ground financing discussions, definitions of the scope of PPPR need to be agreed, and financing
flows better tracked. The GPMB calls on the World Bank Group, WHO and the G20, as part of the work of
the G20 Health and Finance Task Force, to press ahead to achieve a transparent global consensus on PPPR
financing needs and flows.

Fully finance the Pandemic Fund and review options for additional funding sources
Donors should ensure that the Pandemic Fund is sustainably and adequately funded to meet the US $10
billion a year gap identified by the G20 High-Level Independent Panel on Financing the Global Commons for
Pandemic Preparedness and Response. While the Pandemic Fund is not currently powered to fully meet thefinancing needs of PPPR, it is the largest dedicated international mechanism to fund PPPR, and should be
sufficiently resourced. The GPMB encourages a broad range of donors to contribute to the Fund, including
philanthropists, foundations and the private sector.
However, the GPMB has repeatedly stated that PPPR should not be primarily funded through a replenishment,
donor model, especially one relying largely on ODA. The GPMB believes that the Pandemic Fund should evolve
towards a more sustainable, collective financing mechanism, with improved inclusivity of governance. Itsrole should be developed in the broader context of national financing needs, with predictable and sustained
funding, avoiding the drawbacks of dependence on ODA which is often on a project basis or subject tovariability as donor priorities change. The Pandemic Fund should conduct an assessment of potential new
financial resources to improve its future financing. Non-ODA options to be explored could include a collective
contribution mechanism, a public-private mechanism and the use of IMF special drawing rights.
The GPMB welcomes the alignment of the Pandemic Fund’s financing with National Action Plans for Health
Security and calls on the Pandemic Fund to consider a more bottom-up approach to setting financing priorities,
based on countries’ identified needs, and to eliminate earmarked funding.
For its first round of funding, the Pandemic Fund prioritized “strengthening comprehensive disease surveillanceand early warning, laboratory systems, and human resources/public health workforce capacity”. Prioritization
can help avoid overstretching and ensure the Pandemic Fund is able to demonstrate tangible results. However,
future funding should not be limited to these areas. The GPMB also reaffirms its 2021 call for the Pandemic
Fund to provide funding for global and regional common goods.
The Pandemic Fund, the Global Fund, GAVI and other International Financing Institutions providing funding
for PPPR should ensure that the resources they provide are coordinated and aligned with countries’ priorities
and needs. Countries should be using their National Action Plans for Health Security as a basis for funding
proposal requests.
32

Enable greater national investments and bolster international financing through newmodalities and sources of financing
Beyond the Pandemic Fund, the global financing system should prioritize funding PPPR as a fundamental
dimension of advancing wellbeing and supporting economic stability. Conditions must be in place to increase
domestic resource mobilization and identify new modalities and sources of financing.
As proposed in the Bridgetown Initiative, the IMF, the World Bank Group, the G20, as well as public and private
creditors, should support debt restructuring to improve debt sustainability, freeing funds for countries to invest
in their own PPPR. The GPMB also endorses the Initiative’s call for ‘Natural Disaster and Pandemic Clauses’ in all
debt instruments to automatically suspend debt service for two years when WHO declares a pandemic or PHEIC.
To bolster international financing, the IMF, the World Bank Group and other multilateral and public developmentbanks should invest in PPPR, including by providing additional concessional financing for national investment in
PPPR and supporting global public goods. The IMF’s Resilience and Sustainability Trust (RST), which channels
IMF Special Drawing Rights (SDR), should support PPPR projects. During the COVID-19 pandemic, the IMF
allocated 650 billion SDR in 2021 to its members to boost liquidity and reserve; 31.2 billion SDR (US$ 41.1 billion)
is currently available through the RST. While the RST was created to support climate resilience and pandemic
preparedness in low- and middle-income countries, no PPPR project has been funded.
Reforming the global financing system may eventually require more fundamentally transforming thegovernance and functioning of international financial institutions. Making them ‘more representative, equitable
and inclusive’51 could better enable them to play a core role in financing global public goods and ensureinternational financing better meets the needs of countries.

Surge financing for pandemic response
It will be crucial to identify rapidly deployable sources of financing well in advance of another pandemic or
health emergency. Considering the scale of surge financing needed, relying on existing response funds will
not provide sufficient resources and new approaches must be identified.
The GPMB calls on all countries to develop domestic contingency funds to respond to health emergencies.
These funds should be integrated into broader emergency financing.
The WHO Contingency Fund should be increased to meet the US $500 million day-zero needs and sustainably
funded, including through non-ODA sources. In addition, the GPMB calls on multilateral development banks
globally and regionally, including the IMF and the World Bank Group, together with the G7, G20 and others, toimplement strategies to boost international surge financing, including support for R&D as well as procurementand delivery of medical countermeasures early on during a health emergency. These strategies would likely
involve multiple new and existing sources; therefore, the GPMB calls on financing actors to ensure international
surge financing is well coordinated and rapidly accessible to countries at the time of a health emergency.
WHO plays a key role in the prevention of and early response to health emergencies, and therefore its surge
capacity must be ensured through adequate financing.

Actions under Recommendation 2
The GPMB calls on:

1

The World Bank Group, WHO and the G20, as part of the work of the G20 Joint Finance and Health
Task Force, to conduct an assessment of PPPR financing needs and flows.

33

2

Donors to sustainably and adequately fund the Pandemic Fund to meet the US $10 billion a year
gap identified by the G20 High-Level Independent Panel on Financing the Global Commons for
Pandemic Preparedness and Response.

3

The Pandemic Fund to conduct an assessment of potential new financial resources outside of ODA
and to develop a more bottom-up approach to setting financing priorities, based on countries’
identified needs and to eliminate earmarked funding. The GPMB also reaffirms its 2021 call for the
Pandemic Fund to provide funding for global and regional common goods.

4

The Pandemic Fund, the Global Fund, GAVI and other International Financing Institutions thatprovide funding for PPPR to ensure that the resources they provide are coordinated and alignedwith countries’ priorities and needs.

5

The IMF, the World Bank Group, the G20, as well as public and private creditors, to support debt
restructuring to improve debt sustainability.

6

The IMF, the World Bank Group and other public and multilateral development banks to increase
their investment in PPPR and provide additional concessional financing for national investments in
PPPR. The IMF’s Resilience and Sustainability Trust (RST) should provide support for PPPR projects.

7

All countries to develop domestic contingency funds to respond to health emergencies. These funds
should be integrated into broader emergency financing.

8

WHO Member States to increase funding for the WHO Contingency Fund to meet the US $500 million
day-zero needs and ensure it is sustainably funded, including through non-ODA sources. They should
also ensure adequate financing for WHO’s surge capacity.

9

Multilateral development banks globally and regionally, including the IMF and the World Bank Group,
together with the G7, G20 and others, to implement strategies to boost international surge financing.

Recommendation 3: Establish baseline regional capabilities to drive more equitable
and robust R&D and supply chains.
Neither R&D nor supply chains can be equitable and robust if they are concentrated in a small number ofregions and countries. Within every global region, there should exist at least: baseline manufacturing capacity
in product-agnostic vaccines, therapeutics and diagnostics, oxygen and other key medical countermeasures;
generic early detection and surveillance systems and laboratories; capacity to track and shape pandemicrelevant social and economic trends; and agile stock management systems across pandemic response needs.
These regional capacities should be component elements of a global approach that promotes strategic
coherence and coordination. Regional capacities should play a catalytic role in ensuring that national capacitybuilding is sustained and adapted to national circumstances. Long-term investment in building more equitable
R&D capabilities should begin now, building on the growing efforts of many middle-income countries. Moreeffective surge financing at the global and national levels will also be key to supporting the development andprocurement of medical countermeasures. Regional institutions should play a key stewardship role in ensuring
these regional capacities are developed.
The GPMB calls on countries and regional institutions to build sustainable regional capacity for surveillance,
R&D, manufacturing, regulatory processes and deployment of medical countermeasures by creating strong
regional ecosystems for R&D. Sustaining these ecosystems will require building regional markets for vaccinesand other medical countermeasures, developing regional pooling or stockpiling mechanisms, regulatory
coordination across countries, and open information sharing. Strengthening routine vaccine capacity between
34

pandemic periods can improve sustainability. In addition, creating a more sustainable R&D ecosystem will
require strengthening the capacity and role of low- and middle-income countries, including by improving
financing of R&D, workforce retention and capacity to implement technology transfers.
Investments in animal health R&D should also be prioritized as a way to integrate a One Health approach andprevent pathogen spillover.

Improve global R&D governance and coordination through the WHO Pandemic Agreement
Regional ecosystems will need to be embedded in a global framework for R&D and access to medical
countermeasures to support global prioritization and coordination of R&D, data generation and sharing acrosscountries, capacity-building and technology transfers, and equitable access to medical countermeasures,
especially while regional capacities are being built. Global R&D governance should integrate a One Healthapproach and ensure coordination between human and animal R&D systems where appropriate.
The GPMB reaffirms its 2021 call for an international agreement creating, among others, “mechanisms for
One-Health surveillance and for R&D to ensure rapid data, sample and benefits sharing and equitable accessto countermeasures and essential medical goods”. The GPMB calls on Member States to adopt strong rules
to address global R&D in the WHO Pandemic Agreement and to implement these rules through a global
R&D roadmap that will include a focus on strengthening regional ecosystems. The WHO should support thedevelopment of this roadmap by publishing the updated list of R&D Blueprint priority pathogens.
Countries must also commit to ensuring that intellectual property rights do not impede access to life-saving
medical countermeasures and technologies for PPPR.

Ensure equity through upstream commitments
To ensure investments in R&D can lead to greater equitable access to medical countermeasures, equity shouldbe implemented upstream in the R&D phase. The public sector as well as philanthropic organizations, as key
sources of financing for R&D in the context of PPPR, can leverage financing to ensure this is implemented. The
GPMB calls on funders (governments and philanthropic organizations) to ensure terms for equitable accessto technologies, countermeasures, and data and information are included in funding agreements.
The GPMB also calls on the private sector, especially countermeasures manufacturers, to support greater equitable
access to medical countermeasures, including through technology transfers and support for regional capacitybuilding, private-public collaborations, as well as support for more equitable terms of access, including fair pricing.

Actions under Recommendation 3
The GPMB calls on:

1

Countries and regional institutions to build sustainable regional capacity for R&D, manufacturing,
regulatory processes and deployment of medical countermeasures by creating strong regional
ecosystems for R&D.

2

Member States to adopt strong rules to address global R&D in the WHO Pandemic Agreement and to
implement these rules through a global R&D roadmap that will include a focus on strengthening regional
ecosystems. Countries should also find appropriate mechanisms to ensure that intellectual property rights
do not impede access to life-saving medical countermeasures and technologies for PPPR.

3

WHO to support R&D coordination by publishing the updated list of R&D Blueprint priority pathogens.
35

4Funders (governments and philanthropic organizations) to ensure terms for equitable access totechnologies, countermeasures, and data and information are included in funding agreements.

5

The private sector, especially countermeasures, manufacturers, to support greater equitable accessto medical countermeasures.

Recommendation 4: Develop a new approach to multisectoral, multistakeholder
engagement for pandemic prevention, preparedness and response.
Strengthening multisectoral preparedness through engagement of sectors outside of health as well as civilsociety and the private sector is crucial. COVID-19 demonstrated that responding to health emergencies requires
the involvement of multiple sectors beyond health.
A new multisectoral, multistakeholder approach is needed to bring together all stakeholders and sectors
involved in PPPR, and support a more integrated, coherent response to pandemics and health emergencies.
This new approach should be focused on building a more inclusive and broad movement to support PPPR;
creating a forum to discuss policy design and implementation; strengthening citizen-led PPPR and improvingsocial accountability; and promote coordination, information exchange and harmonization between stakeholder
groups. It should provide information and support the activities of relevant governance bodies in the respective
sectors, such as the WHA, to ensure their work is well informed of the needs and functioning of these sectors.
This approach should aim to create full participation from all regions, incorporate civil society voices throughrepresentative structures, provide a forum for private sector engagement across economic sectors, and be
grounded in One Health, multisectoral approaches.
The GPMB calls on WHO, in collaboration with key partners including WOAH, FAO and UNEP, World Bank Group,
WTO and WIPO, to work together to develop an approach to improving multisectoral, multistakeholder PPPR at
all levels. Existing approaches that can be drawn on include the Sendai Framework’s Global Platform for Disaster
Risk Reduction and its Stakeholder Engagement Mechanism, the AMR Multi-Stakeholder Partnership Platform
and the Multi-stakeholder Forum on Science, Technology and Innovation for the Sustainable Development Goals.
The GPMB recommends a structured coordination rather than a regulatory approach. Therefore, this process
does not need to await the conclusion of intergovernmental negotiations on a WHO Pandemic Agreement – itcan commence immediately. Establishing this approach in parallel to the finalization and implementation of
the WHO Pandemic Agreement would assist in understanding how multisectoral engagement can underpin
multilateral accountability and governance. Once the WHO Pandemic Agreement enters into force, thisapproach can play a key role in supporting implementation of the Agreement and IHR (2005).
To support greater engagement of civil society and communities, the GPMB also encourages civil society
organizations, citizens and communities to build a PPPR advocacy movement, aligned with other sectors suchas universal health coverage and climate change.

Actions under Recommendation 4
The GPMB calls on:

1

WHO, in collaboration with the Quadripartite for One Health (FAO, UNEP WOAH) and other key
partners, including the World Bank Group, WTO, and WIPO, to work together to develop a structured
approach to improving multisectoral, multistakeholder PPPR at all levels.
36

2
CONCLUSIONSAND NEXT STEPS

Medications inspection, Iran, April 2023. WHO staff in Iran inspect ashipment of calcium gluconate, used to treat conditions caused by low
calcium, acquired through international financial support.

37

6

CONCLUSIONS AND NEXT STEPSIn order to give effect to the recommendations above, the full range of institutions implicated in PPPR need tomake specific and time-bound commitments. Every month that this action is delayed will further expose theworld to pandemic risks. The achievements which were hard won in the unprecedented scale of the responseto the COVID-19 pandemic will rapidly fade unless action is taken now to reinforce global PPPR.

The GPMB therefore calls for the following actions to be taken over the next year:→

The INB must complete negotiation of a WHO Pandemic Agreement for adoption by the World Health
Assembly in May 2024.
The draft WHO Pandemic Agreement should include a universal periodic peer-review mechanism anda mechanism for reviewing compliance, as well as the inclusion of independent monitoring to support
these mechanisms. It should also include strong measures to promote R&D coordination and ensure
equitable access to medical countermeasures as well as support data capacity-building.
The INB and the Working Group on amendments to the International Health Regulations shouldcommission a simulation exercise to test the effectiveness of these instruments and ensure coherence,
before the negotiations are finalized.

→

The international community must urgently adopt strategies to boost international surge financing
and enable greater national investments and bolster international financing through new modalities
and sources of financing.
At their 2024 Spring meetings, the World Bank Group and the IMF should consider how they can further
strengthen support for PPPR, including through the IMF’s Resilience and Sustainability Trust (RST).
UN Member States should consider proposals to reform the international financing system for PPPR
as part of broader discussions during the 2024 UN Forum on Financing for Development in April 2024.
The 2024 Finance in Common Summit should advance proposals for reinforcing the role of Public
Development Banks (PDBs) in supporting PPPR.
G20 countries at the G20 Summit in Brazil in July 2024 should consider strategies to continue efforts to
support debt sustainability and to boost international surge financing, including for early R&D.
WHO Member States should review the target capitalization of the WHO Contingency Fund for
Emergencies and increase it to US $500 million at the 77th World Health Assembly (WHA77) in May 2024.

→

Relevant regional organizations, including the African Union and the European Union, should conduct
an exercise to map their regional R&D capacities by mid-2024.

→

Building on the Quadripartite plan of action, the Quadripartite with relevant partners should initiate
discussions to develop an approach to improving multisectoral, multistakeholder PPPR at their next
meeting.

→

WHO and the World Bank Group, should conduct an independent review of the work of the GPMB
and its future role as the independent monitoring mechanism for PPPR in early 2024.

38

Nurse Ramatu registers participants at a mobile COVID-19 vaccination
clinic in the remote farming community of Rofunta, Bombali District,
Sierra Leone, December 2022. Credit: WHO/Michael Duff
39

GPMB PURPOSE AND MEMBERSHIPThe GPMB is an independent monitoring and accountability body to ensure preparedness for global healthcrises, co-convened by the World Health Organization and the World Bank Group. The Board provides an
independent and comprehensive appraisal for leaders, key policy-makers and the world on system-wide
progress towards increased preparedness and response capacity for disease outbreaks and other emergencies
with health consequences. The Board monitors and reports on the state of global preparedness across all
sectors and stakeholders, including the UN system, government, non-governmental organizations, and theprivate sector.

Co-Chairs

Ms Kolinda Grabar-Kitarović
Former President of Croatia

Ms Joy Phumaphi
Former Minister of Healthof Botswana

Members

Dr Palitha Abeykoon
Senior Advisor to the Ministry of
Health of Sri Lanka and a former
WHO Special Envoy for COVID-19
Preparedness and Response

Dr Ibrahim Abubakar
Dean of the University College
London Faculty of Population
Health Sciences and former
Head of Tuberculosis at Public
Health EnglandMs Bente Angell-Hansen
Norwegian former diplomat
and former President of the
EFTA Surveillance Authority

Dr Maha El Rabbat
Former Egyptian Minister of Healthand Population; former WHO Special
Envoy for COVID-19 Preparedness
and Response; Professor of Public
Health, Cairo University; Member,
Recovery Working Group of the AU
COVID-19 Commission

Professor Victor J. Dzau
President of the United States
National Academy of Medicine
and Vice-Chair of the US
National Research Council

Dr Chris Elias
President of the Global
Development Program at
the Bill & Melinda Gates
Foundation and former
President and CEO of PATH

40

Members

Dr Zijian Feng
Secretary-General andExecutive Vice President of theChinese Preventive Medicine
Association

Hon. Henrietta Fore
Former Executive Directorof UNICEF; Former USAID
Administrator and CEO &Chairman, Holsman
International

Ms Bience Gawanas
Namibian lawyer and former
Under-Secretary-General andSpecial Advisor on Africa to the
UN Secretary-General

Dr Jayati Ghosh
Indian development economist
and Professor of Economics at
the University of Massachusetts
AmherstProfessor Naoko Ishii
Former Deputy Vice Minister ofFinance of Japan and Professor
and Executive Vice President at
the University of Tokyo

Professor Ilona Kickbusch
Founder and Chair of the Global
Health Centre at the Graduate
Institute of International andDevelopment Studies in Geneva

Sir Mark Lowcock
Former Head of the UN
Office for the Coordinationof Humanitarian Affairs andformer Permanent Secretaryof the UK Department forInternational Development

Ms Susana Malcorra
Former Foreign Minister ofArgentina, former Chef deCabinet to UN SecretaryGeneral Ban Ki-moon, former
Chief Operating Officer of theWorld Food Programme

Dr Matthew Stone
Veterinary epidemiologist andformer Deputy Director-General– International Standards
and Science at the World
Organisation for Animal Health

41

ABBREVIATIONS
ACT-A		

Access to COVID-19 Tools (ACT) Accelerator

AFRO		

World Health Organization Regional Office for Africa

AI		

Artificial intelligence

AIDS		

Acquired Immune Deficiency Syndrome

AIRA		

Africa Infodemic Response Alliance

AMR		

Antimicrobial resistance

ASEAN		

Association of Southeast Asian Nations

CBD

Convention on Biological Diversity

CDC		

Centers for Disease Control and Prevention

CEPI		

Coalition for Epidemic Preparedness Innovations

CERF		

Central Emergency Response Fund

CFE		Contingency Fund for Emergencies

COP		

Conference of Parties

COVAX		

COVID-19 Vaccines Global Access

C-TAP		

COVID-19 Technology Access Pool

DVCMN		Developing Countries Vaccine Manufacturing Network

ECRIN		

European Clinical Research Infrastructure Network

EMA		

European Medicines Agency

EU		European Union

EUL		

Emergency Use Listing ProcedureEURO		

World Health Organization Eastern Mediterranean Regional Office

FAO		

United Nations Food and Agricultural Organization

FENSA		WHO Framework of Engagement for Non-State Actors

FIND		

Global non-profit that works to accelerate equitable access to reliable diagnosis

G7		

Group of Seven

G20		

Group of Twenty

GAVI		

Global Alliance for Vaccines and Immunisation

GFATM

Global Fund to Fight AIDS, Tuberculosis and Malaria

GISAID

Global Initiative on Sharing All Influenza Data

GISRS		

Global Influenza Surveillance and Response System

GLASS		

World Health Organization Global Antimicrobial Resistance and Use Surveillance System

GLEWS		Joint FAO–OIE–WHO Global Early Warning System for health threats and emerging risks at thehuman–animal–ecosystems interface
GOARN

World Health Organization Global Outbreak And Response Network

GPMB		

Global Preparedness Monitoring Board

IFRC		

International Federation of Red Cross and Red Crescent Societies

IHR		

International Health Regulations

IMF

International Monetary Fund

42

INB		

Intergovernmental Negotiating Body

IPCC		

Intergovernmental Panel on Climate Change

IPSN 		

International Pathogen Surveillance Network

JEE

Joint External Evaluation

LIC

Low-income country

LMIC		

Low- or middle-income country

MERS

Middle East respiratory syndrome coronavirus

Mpox

Monkeypox

MPP

Medicines Patent PoolmRNA		

Messenger ribonucleic acid

ODA

Official Development AssistanceOECD

Organization for Economic Cooperation and Development

OHCHR

United Nations Human Rights Office

PAHO

Pan American Health Organization (Inter-American System and World Health Organization)

PEPFAR

President’s Emergency Plan for AIDS Relief

PHEIC		

Public Health Emergency of International Concern

PIP		

Pandemic Influenza Preparedness Framework

PPPR		

Pandemic prevention, preparedness and response

R&D

Research and development

RST		

Resilience and Sustainability Trust

SCHEPPR

Standing Committee on Health Emergency Prevention, Preparedness and Response

SDG		

Sustainable Development Goal

SEARO

World Health Organization South-East Asia Regional Office

SPAR

State Party Self-Assessment Annual Reporting

TB		

Tuberculosis

TFA		

Trade Facilitation Agreement

TRIPS

Trade-Related Aspects of Intellectual Property Rights

UHPR

Universal Health and Preparedness Review

UN		

United Nations

UNDP

United Nations Development Programme

UNEP

United Nations Environment Programme

UNESCO

United Nations Educational, Scientific and Cultural Organization

UNGA

United Nations General Assembly

UNICEF

United Nations Children’s Fund

WB		World Bank Group

WHA 		

World Health Assembly

WHE		

World Health Organization Health Emergencies Programme

WHO		World Health Organization

WIPO		

World Intellectual Property Organization

WOAH

World Organisation for Animal Health

WPRO

World Health Organization Western Pacific Regional Office

WTO

World Trade Organization
43

ACKNOWLEDGEMENTS
We extend our deep appreciation and thanks to the Director-General of the World HealthOrganization and to the President, World Bank Group for having co-convened the Global
Preparedness Monitoring Board (GPMB).
The GPMB expresses its sincerest gratitude to the following for their contribution to thetechnical assessments:
Amal Saif Sulaiman Al-Maani, Strategic Technical and Advisory Group on Infectious Hazards (STAG-IH);
Daniel Bausch, STAG-IH; Lucille Blumberg, STAG-IH; Gian Luca Burci, Graduate Institute of International andDevelopment Studies; Daria Danilenko, STAG-IH; Eve Dubé, STAG-IH; Sarah England, Independent Consultant;
Delia Enria, STAG-IH; Ngozi Erondu, The O’Neill-Lancet Commission on Racism, Structural Discrimination and
Global Health; Joseph François, World Trade Institute; George Fu Gao, STAG-IH; Johan Giesecke, STAG-IH;
David Hayman, One Health High-Level Expert Panel (OHHLEP); David Heymann, STAG-IH; Daniel Jernigan,
STAG-IH; Rebecca Katz, Becky Knowles, International Pandemic Preparedness Secretariat (IPPS);
Georgetown University; Marion Koopmans, One Health High-Level Expert Panel; Clifford Lane, STAG-IH;
Heidi Larson, London School of Hygiene & Tropical Medicine; Julie Leask, University of Sydney; Yee-Sin Leo,
STAG-IH; Jakir H. B. Masud, STAG-IH; Jodie McVernon, STAG-IH; Ziad Memish, STAG-IH; Suerie Moon,
Graduate Institute of International and Development Studies; Justice Nonvignon, STAG-IH; Folasade Ogunsola,
STAG-IH; Myoung-don Oh, STAG-IH; Hitoshi Oshitani, STAG-IH; Malik Peiris, STAG-IH; Gerson Penna,
STAG-IH; Heulwen Philpott, IPPS; Helen Rees, STAG-IH; John-Arne Røttingen, IPPS Science and Technology
Expert Group; Majdi Sabahelzain, Ahfad University for Women; Rana Safdar, STAG-IH; Amadou Alpha Sall,
STAG-IH; Adam Kamradt-Scott, Harvard University; Mariangela Simao, IPPS Science and Technology Expert
Group; Renu Swarup, IPPS Science and Technology Expert Group; Kumnuan Ungchusak, STAG-IH; Niteen
Wairagkar, IPPS Science and Technology Expert Group; Claire Wardle, STAG-IH; Clare Wenham, London
School of Economics and Political Science Lothar H. Wieler, STAG-IH.

The GPMB would like to thank the following individuals for contributing their expertise to thedevelopment of this report:
Ombretta Baggio, IFRC; Charlotte Baker, IPPS; Priya Basu, Secretariat of the Pandemic Fund; Chris Carter,
United Kingdom Foreign, Commonwealth & Development Office; Lucy Cassels, New Zealand Ministry of Health;
Helen Clark, former Prime Minister of New Zealand and former Co-Chair, Independent Panel on Pandemic
Preparedness and Response; Elisabeth Deus, Auswärtiges Amt; Rania Elessawi, UNICEF; Jeremy Farrar, WHO;
Chikwe Ihekweazu, WHO; Hyunhee Jung, WHO; Ricardo Baptista Leite, UNITE; Sandra Machiri, WHO; Jaouad
Mahjour, WHO; Laurent Muschel, HERA project; Serina Ng, G20 Joint Finance & Health Task Force Secretariat;
Ngashi Ngongo, Africa CDC; Aurélia Nguyen, GAVI; Anders Nordström, Swedish Ministry of Foreign Affairs;
Ranna Eardley-Patel, CEPI; Scott Pendergast, WHO; Nahoko Shindo, WHO; Barbara Stocking, Chair, former
chair of the Ebola Interim Assessment Panel and chair of the Panel for a Global Public Health Convention;
Theresa Tam, Canada, Chief Public Health Officer; Stephanie Williams, Australia Department of Foreign Affairs
and Trade; Abigail Buchanan Wright, WHO.

Finally, the Board is grateful for the financial support provided to the GPMB Secretariat fromthe Government of Germany, the Government of Norway and the World Health Organization.

44

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44

Ibid., page 21.

45

Ibid., page 10.

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Ibid., page 10.

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47

Global Preparedness Monitoring Board Secretariat
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gpmbsecretariat@who.int | www.gpmb.org@TheGPMB@global-preparedness-monitoring-board