A GLOBAL DEAL
FOR OURPANDEMIC AGEREPORT OF THE
G20 HIGH LEVELINDEPENDENTPANEL

A GLOBAL DEAL
FOR OURPANDEMIC AGE
Report of the G20 High Level Independent Panel on
Financing the Global Commons for
Pandemic Preparedness and Response
June 2021

www.pandemic-financing.org

A Global Deal for Our Pandemic Age:
Foreword

The High Level Independent Panel was asked by
the G20 in January 2021 to propose how financecan be organized, systematically and sustainably, toreduce the world’s vulnerability to future pandemics1.
Our report sets out critical and actionable solutions
and investments to meet the challenge of an age of
pandemics, and to avoid a repeat of the catastrophic
damage that COVID-19 has brought. The Panelarrived at its recommendations after intensive
deliberations and consultations with a wide rangeof stakeholders and experts around the globe
over a period of four months. We urge that our
proposals be discussed, developed further, andimplemented as a matter of urgency.
Scaling up pandemic preparedness cannot wait
until COVID-19 is over. The threat of future
pandemics is already with us. The world faces
the clear and present danger of more frequent andmore lethal infectious disease outbreaks. The current
pandemic was not a black swan event. Indeed, it
may ultimately be seen as a dress rehearsal for the
next pandemic, which could come at any time, in thenext decade or even in the next year, and could beeven more profoundly damaging to human security.
The world does not lack the capacity to limit
pandemic risks and to respond much more
effectively than it has responded to COVID-19.
We have the ideas, the scientific and technologicalresources, the corporate and civil society capabilities,
and the finances needed.
Our collective task must be to better mobilize anddeploy these resources to sharply reduce the risk
of future pandemics, and the human and economic
damage they bring. This will require whole-ofgovernment and whole-of society responsibilities,
not only those of health authorities and medical
scientists. It will mean thinking internationally, notjust domestically. It must also involve bolstering
multilateralism, not only bilateral initiatives.
Most fundamentally, investing collectively
to prevent infectious disease outbreaks, and11

to ensure that large swathes of the world’s
population are not left ill-equipped to respondwhen a pandemic strikes, is in the mutual interestsof all nations, not only a humanitarian imperativein its own right.
In short, we need a global deal for our pandemic
age. We must strengthen global governance andmobilize greater and sustained investments inglobal public goods, which have been dangerously
underfunded. Both are critical to building resilienceagainst future pandemics.
It requires establishing a global governance andfinancing mechanism, fitted to the scale andcomplexity of the challenge, besides bolstering
the existing individual institutions, including the
WHO as the lead organization.
The economic case for the investments we propose
is compelling. They will materially reduce the risk ofevents whose costs to government budgets alone are
300 times as large as the total additional spending
per year that we propose, and 700 times the annual
additional international investments. The full damageof another major pandemic, with its toll on lives andlivelihoods, will be vastly larger.
In a historically unprecedented way, security forpeople around the world now depends on global
cooperation. Acting and investing collectively forpandemic security, together with climate change,
represents the primary international challenge of ourtimes. Failure to establish the basis for international
cooperation will make it almost impossible toaddress these existential challenges.
In closing, the Panel wishes to record how its thinking
was enriched by others. As we are comprised mainlyof economic and financial experts, we benefited
significantly from extensive consultations withthe global health community, including the majorinternational organizations, the medical science
community, the private sector, and philanthropic andcivil society organizations with deep engagementsin the field. The Global Preparedness Monitoring

The membership of the Panel, Project Team and Administrative Secretariat of the G20 High Level Independent Panel (HLIP) on Financing the Global Commonsfor Pandemic Preparedness and Response is at Annex A. The Panel’s terms of reference are at Annex B.

FOREWORD

Board, in particular, provided the Panel with acomprehensive assessment of requirements forpandemic prevention, preparedness and response.
We also drew on the insights of the top management
and staff of the International Financial Institutions
and leading economic and financial professionals2.
The Panel’s thinking is broadly aligned with that ofthe Independent Panel for Pandemic Preparedness
and Response (IPPPR) which published its report in
May 2021, and with whose members we had very
informative discussions. We also gained insightsfrom interactions with the Pandemic Preparedness
Partnership, the Pan-European Commission on
Health and Sustainable Development, and theLancet COVID-19 Commission.

*

Co-Chairs#

Project Directors

2

A non-exhaustive list of persons consulted is at Annex C.

The Panel’s work would not have been made possible
without the expert knowledge and analysis of our
Project Team, constituted by Bruegel and the Center
for Global Development, and the timely and efficient
coordination by the Administrative Secretariat drawn
from the US National Academy of Medicine and theWellcome Trust.
Finally, we extend our appreciation to the G20 underits Italian Presidency for leadership in convening thisimportant review, and are committed to supporting
further discussion of our proposals. We harbor hopethat the grim lessons from this crisis will catalyze
the collective political will and ambition needed toprevent such a deadly and costly pandemic fromhappening again.

2

Contents
A GLOBAL DEAL FOR OUR PANDEMIC AGE: FOREWORD

1

HIGH LEVEL SUMMARY5KEY PROPOSALS AND ROADMAP

12A. OVERVIEW

18

The Challenge

19

Plugging Four Major Global Gaps

22

Financing Pandemic Prevention, Preparedness and Response: the Basic Approach

25

The Scale of Investments Required28

B. PLUGGING FOUR MAJOR GLOBAL GAPS

31(1) Globally networked surveillance and research: to prevent and detect emerging
infectious diseases

32

(2) R
 esilient national systems: to strengthen a critical foundation for global pandemic
preparedness and response34(3) Supply of medical countermeasures and tools: to radically shorten the responsetime to a pandemic and deliver equitable global access

36(4) Global governance: to ensure the system is tightly coordinated, properly funded
and with clear accountability for outcomes41		 Establish a Global Health Threats Board

42

CONTENTS

C. FINANCING PRIORITIES45The Immediate Task: Funding ACT-A and COVAX

46

Financing Future Security from Pandemics

47

(1) A
 dopt a systemic approach to ensure enhanced and predictable global financing
for pandemic PPR

50

(2) E
 stablish a Global Health Threats Fund

51(3) Develop resilient domestic finances for prevention and preparedness

53(4) Strengthen financing for the WHO and One Health, and put it on morepredictable footing

54

(5) M
 ake financing of global public goods part of the core mandate of World Bankand other MDBs

55

(6) E
 nable fast-tracked surge financing by the IFIs in response to a pandemic

57(7) Ensure complementarity between multilateral and targeted bilateral funding

59(8) Leverage the capabilities and resources of the private and philanthropic sectors

59(9) Develop insurance solutions for adverse compensation events associated withuse of medical countermeasures

61

D. CONCLUSION

63

ANNEXESA. G
 20 High Level Independent Panel: Members, Project Team and
Administrative Secretariat

65

B. G
 20 High Level Independent Panel Terms of Reference

67

C. List of Institutions and Persons Consulted

68

D. Major Infectious Disease Outbreaks in the Past Two Decades

72

E. Increasing Frequency of Wildlife Zoonotic and Influenza Spillover Events

73

F. COVID-19 African Vaccine Acquisition Task Team74

G. Key Capacities and Functions of Preparedness and Response75

H. Estimated Financing Needs for Global Public Goods for Pandemic Prevention
and Preparedness

80

I. The International Finance Facility for Education (IFFEd) Model and Pandemic
PPR Financing

86

HIGH LEVEL SUMMARYHigh Level Summary
We are in an age of pandemics. COVID-19 has painfully reminded us of what SARS, Ebola,
MERS and H1N1 had made clear, and which scientists have repeatedly warned of: without greatly
strengthened proactive strategies, global health threats will emerge more often, spread more
rapidly, take more lives, disrupt more livelihoods, and impact the world more greatly than before.
Together with climate change, countering the existential threat of deadly and costly
pandemics must be the human security issue of our times. There is every likelihood thatthe next pandemic will come within a decade — arising from a novel influenza strain, anothercoronavirus, or one of several other dangerous pathogens. Its impact on human health and theglobal economy could be even more profound than that of COVID-19.
The world is nowhere near the end of the COVID-19 pandemic. Without urgent and concerted
actions and significant additional funding to accelerate global vaccination coverage, the emergenceof more variants of the virus is likely and will continue to pose a risk to every country. The solutions
for vaccinating the majority of the world’s population are available and can be implemented
within the next 12 months. More decisive political commitments and timely follow-throughwill resolve this disastrous global crisis.
The world is also far from equipped to prevent or stop the next pandemic. Lessons fromCOVID-19, on how the world failed to prevent the pandemic, why it has been prolonged at suchcatastrophic cost, and how we can overcome the crisis if we now respond more forcefully, provide
important building blocks for the future. We must use this moment to take the bold steps needed
to avoid the next pandemic, and not allow exhaustion from current efforts to divert attention
from the very real risks ahead.

Plugging Four Major Gaps
Making the world safer requires stepped-up and sustained national, regional and global actions
and coordination, leveraging fully the private sector, to prevent outbreaks as well as to respondmuch faster, more equitably and more effectively when a pandemic emerges. We must plug
four major gaps in pandemic prevention, preparedness and response:• Globally networked surveillance and research: to prevent and detect emerging infectious diseases• Resilient national systems: to strengthen a critical foundation for global pandemic preparedness
and response• Supply of medical countermeasures and tools: to radically shorten the response time to apandemic and deliver equitable global access• Global governance: to ensure the system is tightly coordinated, properly funded and with clear
accountability for outcomes5

HIGH LEVEL SUMMARY

Investing in Global Public Goods: To Save Immense Costs
We can only avoid future pandemics if we invest substantially more than we have been
willing to spend in the past, and which the world is now paying for many times over indealing with COVID-19’s damage.
Countries must step up domestic investments in the core capacities needed to prevent andcontain future pandemics, in accordance with the International Health Regulations. Governments
will in many cases have to embark on reforms to mobilize and sustain additional domestic resources,
so as to build up these pandemic-related capacities and strengthen public health systems more
broadly, while at the same time enabling their economies to return to durable growth. Low- andmiddle-income countries will need to add about 1% of GDP to public spending on health overthe next five years.
However, domestic actions alone will not prevent the next pandemic. Governments mustcollectively commit to increasing international financing for pandemic prevention andpreparedness by at least US$75 billion over the next five years, or US$15 billion each year,with sustained investments in subsequent years.
The Panel assesses this to be the absolute minimum in new international investments
required in the global public goods that are at the core of effective pandemic prevention
and preparedness. The estimate excludes other investments that will contribute to resilienceagainst future pandemics while benefiting countries in normal times. These complementaryinterventions — such as containing antimicrobial resistance, which alone will cost about US$9
billion annually, and building stronger and more inclusive national health and delivery systems— provide continuous value. Furthermore, the estimated minimum international investments are
based on conservative assumptions on the scale of vaccine manufacturing capacity required inadvance of a pandemic. Larger public investments to enable enhanced manufacturing capacity
will indeed yield much higher returns.
The minimum additional US$15 billion per year in international financing for pandemic preparedness
is still a significant increase. It is a critical reset to a dangerously underfunded system.
These investments are a matter of financial responsibility, besides being a scientific andmoral imperative. They will materially reduce the risk of events whose costs to government
budgets alone are 700 times as large as the additional international investments per year that we
propose, and 300 times as large as the total additional investments if we also take into accountthe domestic spending necessary. The full damage of another major pandemic, with its toll on
lives and livelihoods, will be vastly larger.
Crucially, this additional international funding must add to, and not substitute for, existingsupport to advance global public health and development goals. It would be short-sighted
to scale up efforts for pandemic prevention and preparedness by reallocating multilateral orbilateral Official Development Assistance (ODA) resources from other development priorities,
particularly given the likely lasting negative impacts of the current pandemic on economic andhuman development in low- and lower-middle-income countries. The threat of pandemics to
our collective security warrants a new and more sustainable global financing approach, beyond
traditional aid, to invest in global public goods from which all nations benefit.
6

HIGH LEVEL SUMMARY

Strengthening Global Governance of Health and FinanceHowever, money alone will not deliver a safer world without stronger governance. The
current global health architecture is not fit-for-purpose to prevent a major pandemic, nor to
respond with speed and force when a pandemic threat emerges. As the Global Preparedness
Monitoring Board highlights, the system is fragmented and complex, and lacks accountability
and oversight of financing of pandemic preparedness. We must address this by establishing agovernance mechanism that integrates the key players in the global health security and financing
ecosystem, with the World Health Organization (WHO) at the center.
To plug this gap, we propose establishing a new Global Health Threats Board (Board).
The proposal builds loosely on the model of the Financial Stability Board, established by theG20 in the aftermath of the 2008 Global Financial Crisis and which has operated successfully
as a collective to contain risks to the global financial system.
This new governance mechanism will bring together the worlds of health and finance.
The Board should include Health and Finance Ministers from a G20+ group of countries
and heads of major regional organizations, with leadership and membership that ensurescredibility and inclusivity. It should have a permanent, independent Secretariat, drawing on
the resources of the WHO and other multilateral organizations.
This new Board will complement the Heads of State/Heads of Government-level Global
Health Threats Council that has been proposed by the Independent Panel for Pandemic
Preparedness and Response (IPPPR), to be established by the UN General Assembly. The Panelsupports the establishment of this top-level political leadership council, to mobilize the strong
collective commitment required for global health security. The Board, on the other hand, will aim
more specifically to match tightly networked global health governance with financing, which areboth critical enablers to reduce pandemic risks. It should take reference from the initiatives andwork of the proposed Global Health Threats Council, to ensure a complementarity of functions.
The Board would provide systemic financial oversight aimed at enabling proper and timely
resourcing of capacities to detect, prevent and rapidly respond to another pandemic, andto ensure the most effective use of funds. It must join up the efforts of international bodies,with clearly delineated responsibilities that match their comparative strengths, and ensure thatthe system fully engages and leverages the capabilities of the private sector and non-state
actors. The Board must also track global risks and outcomes, and ensure every country plays
its part to enhance global health security.

7

HIGH LEVEL SUMMARYThe Key Strategic Moves
A transformed system, with stronger global financial governance, will require both
greater resources for existing institutions, with enhanced mandates where necessary,and a new multilateral funding mechanism that will plug the major gaps in global public
goods needed to reduce pandemic risks.
We must make four strategic moves.
First, nations must commit to a new base of multilateral funding for global health security
based on pre-agreed and equitable contribution shares by advanced and developing
countries. This will ensure more reliable and continuous financing, so the world can act
proactively to avert future pandemics, and not merely respond at great cost each time a new
pandemic strikes.
This must include a fundamentally new way of financing a reformed and strengthened
WHO, so that it receives both enhanced and more predictable resources. The Panel joins
the call by the IPPPR for assessed contributions to be increased from one-quarter to two-thirdsof the budget for the WHO’s base program, which will effectively mean an addition of about
US$1 billion per year in such contributions.
Second, global public goods must be made part of the core mandate of the International
Financial Institutions (IFIs) — namely the World Bank and other multilateral developmentbanks (MDBs), and the International Monetary Fund (IMF). They should draw first on their
existing financial resources, but shareholders must support timely and appropriately sized
replenishments of their concessional windows and capital replenishments over time to ensurethat the greater focus on global public goods is not at the expense of poverty reduction andshared prosperity.
The IFIs are a potent but vastly under-utilized tool in the world’s fight against pandemics andclimate change. The MDBs should partner with countries to incentivize and increase investmentsin pandemic preparedness and accelerate closing of critical health security gaps. This will
require enhancing the grant element of their funding through dedicated concessional windows
for pandemic preparedness. In this, they should partner with the grant-based global healthintermediaries including Gavi and the Global Fund to Fight AIDS, Tuberculosis and Malaria,
to leverage each other’s funding for investments that will strengthen health system resilience.
The IFIs should also provide swift, scaled-up access to funds in response to a pandemic, withrelaxed rules on country borrowing and automatic access for pre-qualified countries. This should
entail new or strengthened pandemic windows in the IMF and MDBs, and the authorization for
MDBs to access additional market funding at the onset of a pandemic to finance a scaled-up
response. To ensure that these official funds are used to counter the impact of the pandemic,
the IMF, working with the relevant stakeholders, should propose a framework of pre-establishedrules for relief on debt servicing that involves the participation of all creditors in restructurings
instituted in future pandemics.

8

HIGH LEVEL SUMMARY

Third, a Global Health Threats Fund mobilizing US$10 billion per year should be established,
and funded by nations based on pre-agreed contributions. This new Fund, at two-thirdsof the minimum of US$15 billion in additional international resources required, brings threenecessary features into the financing of global health security. First, together with an enhanced
multilateral component of funding for the WHO, it would provide a stronger and morepredictable layer of financing. Second, it would enable effective and agile deploymentof funds across international and regional institutions and networks, to plug gaps swiftly andmeet evolving priorities in pandemic prevention and preparedness. Third, it would also serve
to catalyze investments by governments and the private and philanthropic sectors into thebroader global health system, for example through matching grants and co-investments. The
Fund’s functions should be defined to ensure that it complements rather than substitutes forfinancing of the MDBs’ concessional windows and the existing global health organizations.
The new Fund should support the following major global actions:• B uilding a transformed global network for surveillance of infectious disease threats.
This will require a major scale-up of the network, combining pre-existing and new nodes ofexpertise at the global, regional and country levels, with the WHO at the center.
• Providing stronger grant financing to complement MDBs’ and the global health intermediaries’
support for country- and regional-level investments in global public goods.
• Ensuring enhanced and reliable funding to enable public-private partnerships for globalscale supply of medical countermeasures, so we can preclude severe shortages anywhere
and avoid prolonging a pandemic everywhere. This added layer of funding will support apermanent network to drive end-to-end global supply, which builds on the lessons learned
from the ACT-Accelerator coalition.
• Supporting research and breakthrough innovations that can achieve transformationalchange in efforts to prevent and contain future pandemics, complementing existing R&D
funding mechanisms like the Coalition for Epidemic Preparedness Innovations (CEPI).
The Fund will be structured as a Financial Intermediary Fund (FIF) at the World Bank, which
will perform the treasury functions, similar to how it hosts other international arrangements
like the Global Environment Facility. Governance of the Fund will be independent of the World
Bank, under an Investment Board, which could also be constituted as a committee of the Global
Health Threats Board, which will determine the priorities and gaps to be addressed by the Fund.
Fourth, multilateral efforts should leverage and tighten coordination with bilateral ODA,
and with the private and philanthropic sectors. Better coordination within country and regional
platforms will have greater impact in reducing pandemic risks, and enable better integration withongoing efforts to tackle endemic diseases and develop other critical healthcare capabilities. It
will be important to ensure that ODA flows mobilized for pandemic preparedness add to anddo not divert resources from other priority development needs.

9

HIGH LEVEL SUMMARY

There is significant scope for governments and the MDBs to mobilize private sector
resources for pandemic preparedness and response, especially in developing global-scalecapacity for critically-needed supplies, from testing kits and vaccines to oxygen cylinders andconcentrators, as well as the whole delivery infrastructure needed within countries. The public
sector should also grow partnerships with philanthropic foundations to substantially expand
research on infectious disease threats and breakthrough countermeasures. This could include
efforts to de-risk early-stage R&D and other high-risk investments, in order to attract private
institutional investors.
Significant progress is within reach in the next five years. Strong and sustained politicalcommitment, a recognition of the mutual interests of nations in health security, and long-term
financing will be essential.
The collective investments we propose, with equitable contributions by all nations, areaffordable. They are also miniscule compared to the US$10 trillion that governments havealready incurred in the COVID-19 crisis.
We must invest without delay. It will be a huge error to economize over the short term
and wait once again until it is too late to prevent a pandemic from overwhelming us. The
next pandemic may indeed be worse.

10

Establish a Global Health Threats Boardfor systemic ﬁnancial oversight, toensure enhanced and reliable global
ﬁnancing for pandemic PPR andeffective use of funds

Establish a
Global Health Threats Fund

Develop insurance
solutions for adverse
compensation
events associatedwith use of medical
countermeasures

Develop resilient
domestic ﬁnances
for prevention andpreparedness

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11

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PANDEMIC AGE

KEY PROPOSALS AND ROADMAPKey Proposals and Roadmap
Proposal

Key Action Items

Main Actors

Timeline

1. E s t ablish a Global HealthThreats Board for systemic
financial oversight, to ensure
enhanced and predictableglobal financing for pandemic
PPR and effective use of funds.

i.

G20

Q4 2021*Develop a charter for the Board
including detailed mandate,composition and governance.

ii. Establish the Board with apermanent, independent
Secretariat.
iii. Identify early priorities forfunding by the Global HealthThreats Fund (see item 2 below).

A minimum of US$15 billion peryear in new international financing
is required for effective pandemic
prevention and preparedness.
Establish an independent scientificadvisory panel to provide systemwide analysis of emerging healththreats and advice based on thebest available science.

iv. The scientific advisory panel
can be formed by transforming
the Global Preparedness
Monitoring Board (GPMB) totake on this function.

GPMB

Q2 2022

Establish a Health Security
Assessment Program (HSAP),
to provide in-depth assessmentsof countries' pandemic prevention
and preparedness capabilities andinvestments.

v.

The HSAP should be coordinatedby the WHO and the World
Bank, with the outcomes ofthis assessment reflected in
IMF Article IV reports.

WHO,
World Bank, IMF

Q4 2022

2. Establish a Global HealthThreats Fund. This would be a
dedicated fund mobilizing US$10
billion per year, based on preagreed contributions, to support
investments in global public
goods for pandemic PPR. This new
multilateral funding mechanism
will enable effective and agile
deployment across existing
institutions and networks, andhelp catalyze financing for thebroader global health system.
It would serve to support a few
major global actions:i.

Establish a Global Health Threats
Fund structured as a Financial
Intermediary Fund (FIF) at theWorld Bank, with governanceindependent of the World Bank.

G20

Q4 2021**ii. Kickstart the Fund with directcontributions by G20 andother governments, ideallyin amounts equivalent to anassessed contribution scheme,
as well as philanthropic andcorporate contributions.

For (i), toinitiate early
discussions with
the World Bankon establishing
the FIF.

This is aligned with the timeline for the establishment of the IPPPR’s Global Health Threats Council and its International Pandemic Financing Facility.

12

KEY PROPOSALS AND ROADMAP

Proposal

Key Action Items

Main Actors

Timelinei.

National
governments,
with support
from WHO, IFIs
and OECD

Medium Terma. Building a transformed global
network for surveillance of
infectious disease threats.
b. Providing stronger grant
financing to complement
MDBs’ and the global healthintermediaries’ support for
country- and regional-level
investments in global public
goods.
c. Ensuring enhanced andreliable funding to enablepublic-private partnerships
f o r r a p i d d e ve l o p m e n t ,manufacturing and deliveryof medical countermeasures
on a global scale.
d. Supporting research andbreakthrough innovations
that can achieve transformationalchange in efforts to preventand contain future pandemics,
complementing existing R&D
funding mechanisms like CEPI.
3. Develop resilient domestic
finances for prevention andpreparedness. Governments
working with international
institutions must embark on
a major agenda of reforms tomobilize domestic resources
on a sustained basis so as toenable investments in the key
capacities required to avoid
future outbreaks and strengthen
national health systems, while
enabling their economies toreturn to durable growth. Lowand middle-income countries willneed to add about 1% of GDP to
public spending on health overthe next five years.

Scale up national capabilities
for surveillance, detection,and containment of any new
outbreaks.

ii. N a t i o n a l g o v e r n m e n t s
and International Financial
Institutions (IFIs) to jointly
develop a plan for more
resilient tax revenues.
iii. Define and track budgetary
expenditures on outbreakprevention and preparedness.
iv. Develop and implement
costed national action plansfor health security, withFinance and Health Ministries
as full partners in this effort,
including human resources
development, performancebased budget policies andmatching fund schemes.
v. Ensure necessary external
f i n a n c i a l a s s i s t a n ce tocomplement nationaldomestic financing.

13

To undertake
learning around
COVID-19, andupgrade National
Action Plans for
Health Security(NAPHS) by
2022, with clear
implementation
timelines over the
medium term.

KEY PROPOSALS AND ROADMAP

Proposal

Key Action Items

Main Actors

Timeline

4. Strengthen financing for the
WHO and One Health, andput it on more predictablefooting. Greater and morepredictable funding is necessary
for the WHO to perform its
critical functions and ensurethat there are no gaps in thesurveillance-to-action loop, andto strengthen the integrated
One Health approach.

i.

WHO
Sustainable
Financing
Working Group,
World Health
Assembly

Q2 2022

World Bank andother MDBs

2022

Enhance the share of multilateralfunding for the WHO throughin c rea s e d a s s e s s m e ntbased contributions — witha s s e s s m e n t- b a s e d c o r econtributions from Member
States increased to two-thirdsof the budget for the WHO baseprogram, and an organized
replenishment process for theremainder of the budget.

ii. Support WHO, OIE, FAO and
UNEP in their integrated One
Health approach.
5. Make financing of global
public goods par t of thecore mandate of World Bankand other MDBs. The MDBs
should incentivize investmentsin pandemic prevention andpreparedness at the country
and regional levels, with grants
and greater concessionality thatcomplement existing resultsbased and programmatic lending.
They should draw first on their
existing financial resources.
However, shareholders must
support timely and appropriately
sized replenishments of theirconcessional windows and capital
replenishments over time toensure that the greater focus
on global public goods is not at
the expense of poverty reduction
and shared prosperity.

i.

Revise MDBs’ mandates where
necessary to move boldly insupport of the global commons.

ii. World Bank to set IBRD lending
and performance targets forpandemic prevention andpreparedness.
iii. World Bank to establish a
dedicated pandemic prevention
and preparedness window inan expanded IDA, as part of a
successful IDA20 replenishment
and leading to a more permanentmechanism, with funding relying
more heavily on new grant
contributions from IDA donors.

Most of theseoutcomes can beachieved by 2022.
For items which
may require moretime, e.g. (vii), a
clear roadmap
should be
developed in thenext year.

iv. World Bank to develop a strategy
for its lending and technicalassistance to increase the grantelement and concessionality infinancing linked to pandemic
prevention and preparedness,
including through results-based
and programmatic lending.
v. IDA support for pandemic
prevention and preparedness
should seek to incentivize
domestic investments throughma tc hin g g r a nt s to L I C
governments.
vi. Each RDB to set out its strategy
for suppor ting pandemic
preparedness and reduce risks
in member countries, including
through the establishment ofdedicated lending windows ortargets.
14

KEY PROPOSALS AND ROADMAP

Proposal

Key Action Items

Main Actors

Timeline

IMF, World Bankand other MDBs

Next 12 months

vii. MDBs to explore greater
leveraging of their shareholder
capital, with G20 tocommission an independent
review of scope for doing so
as well as the requirements
for new capital. MDBs to also
consider more innovative
financing mechanisms.
6. Enable fast-tracked surge
financing from the IFIs in
response to a pandemic. The
MDBs and IMF should institutepandemic response windows thatare automatically triggered toprovide swift, scaled-up access tofunds; they should also streamline
their operational requirements
and relax country borrowing
limit s during a pandemic.
Appropriately designed debt
service relief by other creditors
will be an important complement
to surge lending from the IFIs in
responding to future pandemics.

i.

Wo r l d Ba n k to s u p p o r t
countries to participate inpooled global procurement
mechanisms for entering into
advance purchase contracts inthe early phase of a pandemic.

ii. World Bank to scale up its
capacity to help countries
establish a safety net surge
response, with a strategy totarget supporting 50 countries
within five years.
iii. Access to MDB crisis response
windows to be simplified andmade more automatic.
iv. MDBs to relax single borrowerand country lending limits
during a pandemic.
v. MDBs enabled to automaticallytap financial markets for
additional funds in a pandemic,
with these loans guaranteed bycountries and repaid over time.
vi. IMF to establish a pandemic
response window (in its rapid
financing facilities) that would
provide rapid, automatic and atscale financing to all members
in good standing.
vii. Rules and access limits forcountry borrowing from regular
IMF facilities to be relaxed
automatically in a pandemic.
viii. The IMF, working with relevant
stakeholders, to design a debt
service relief framework for
future pandemics.

15

Most of themechanisms
proposed can be
developed within
12 months.

KEY PROPOSALS AND ROADMAP

Proposal

Key Action Items

Main Actors

Timeline

7. E n s u r e c o m p l e m e n t a r i t y
bet ween mult ilatera l a ndtargeted bilateral funding.
Multilateral ef for t s should
leverage and tighten coordination
with ODA and other bilateralfunding streams, which continue
to play an important role. Better
coordination within country andregional platforms will generate
greater impact in pandemic PPR,
and better integration with othercritical development needs.

i.

Multilateral efforts to leverageand tighten coordination withdiscretionary bilateral funding,including through country
platforms.

National
governments,
multilateraland bilateraldevelopment
partners, private
sector andphilanthropies

2022

8. Leverage the capabilities andresources of the private andphilanthropic sectors. Thereis significant scope to catalyze
private sector participation inpandemic PPR.

i.

Scaling up end-to-end global
supply chain for medical
countermeasures and othercritical supplies will require a
new, permanent governancestructure for the network postCOVID-19, including roles andresponsibilities for different
organizations, that builds
on the lessons learned fromthe ACT-A coalition of healthpartners.

Global HealthThreats Board
working with
ACT-A coalitionof partners

Medium Term

This must, foremost, involve
installing adequate capacity for
manufacturing and supply of
medical countermeasures andother critical supplies throughpublic-private partnerships. (Seealso Item 2 above.)
Further, a much bolder shift ingovernment and MDB strategies isneeded to mobilize and augment
private finance for infrastructure,so as to optimize official balance
sheets for investments in bothglobal public goods and economic
development.
We must also build strengthened
and continuous public sector
partnerships with philanthropic
foundations to meet the needsof an expanded research agenda
for pandemic PPR.
9. Develop insurance solutions
for adverse compensation
events associated with useof medical countermeasures.
These schemes can be pooledinternationally, as COVAX has
done for vaccines procured under
its platform.

ii. The IFC and the private sector
arms of other MDBs to scale
up tools to catalyze private
sector investments in capacity
for medical supplies.

MDBsiii. B r o a d e n t h e b a s e o fphilanthropic foundations thatare engaged in supporting
national health resilience andpandemic PPR.

National
governments
andinternationalorganizations

i.

MDBs

The World Bank and other MDBs
should work with countries andprivate insurers to enable risk
financing solutions to better
protec t LIC governmentsfrom the liability of adverse
compensation events.

This must be an
ongoing effort,
with a clear
step-up incoordination
within country andregional platforms
in 2022.

Next 6 months
This task is relevantto the current
pandemic, andshould be worked
on urgently
for vaccines
procured bycountries outsideof the COVAX
framework.
16This report is structured in three parts. Section A comprises
an Overview, summarizing the basic thinking behind thereport, the four major global gaps in pandemic prevention,
preparedness and response that must be addressed, and thePanel’s key financing proposals. Sections B and C elaborateon these major gaps and our financing proposals respectively.

Mamunur Rashid/Shutterstock.com

A. OVERVIEWThe Challenge
Plugging
Four Major Global Gaps
Financing Pandemic
Prevention,
Preparedness
and Response: theBasic Approach
The Scale ofInvestments Required

Pi m

en /

Shu t

ter s tock.com

OVERVIEW

A. Overview
The Challenge
1.

COVID-19 is the biggest setback to lives and livelihoods globally since the Second World War.
a. A reported 4 million3 lives have already been lost. Estimates of the full death toll are much higher. Vastly
more among those who have survived face grave long-term health impairments.
b. The number of people living in extreme poverty is projected to reach about 740 million by end-2021, a quartermore than the pre-COVID-19 trajectory4 and the first significant increase in two decades. Progress on the
Sustainable Development Goals has been set back many years. The most vulnerable in every population
have suffered disproportionately.
c. Governments’ fiscal costs are large and growing: an estimated US$10 trillion5 up to March 2021. The global
economy contracted more sharply in 2020 than it has in the last seven decades, and the IMF has projectedcumulative losses by 2025 of US$22 trillion6.
d. Welfare losses globally will be substantially larger and more lasting. They include the consequences of theloss of a year or more of education for a significant proportion of the world’s young, the scarring due toheightened unemployment and under-employment in many economies, and the effects of ‘long-COVID’
on both earnings and the quality of lives.

2.	
Vaccinating a majority of the population in all countries, and ensuring adequate supply of other medical
countermeasures, must be the most urgent goal of the international community today.
a. As of June 2021, the ACT-Accelerator still had a large gap in funding to meet its targets to provide vaccines
to cover 20% of the world’s population by end-2021, and the needed diagnostics tests, treatments andother critical supplies7.
b. There is significant scope for supply shortages and mismatches to be addressed. We must also extend global
support to countries that cannot afford procurements, and tackle delivery bottlenecks. A recent IMF study
proposes ways to vaccinate at least 60% of the population in all countries by mid-2022 and ensure adequate
supply of diagnostics, therapeutics and personal protective equipment (PPE), at an additional cost of US$50
billion — comprising US$35 billion in donor grants and US$15 billion from national sources or concessional loans8.
c. Achieving this immediate goal is essential to reduce the risk of new variants and avoid further escalationof the pandemic. The financing solutions exist, and require the urgent attention of the world’s leaders.
3.

We must also plan for the eventuality of an endemic COVID-199, with a long tail of costs for all nations.
a. Even with the major push for global vaccination, it will be a long time before the world achieves the immunity
needed to stop the virus from spreading. New and possibly more transmissible variants may continue toemerge in the meantime, while protection among those already vaccinated may also wane.

3

https://ourworldindata.org/covid-deaths

4

https://blogs.worldbank.org/opendata/updated-estimates-impact-covid-19-global-poverty-looking-back-2020-and-outlook-2021

5

Comprising additional spending and foregone revenue; this does not include another US$6 trillion in government loans, guarantees, and capital injections.
(IMF Apr 2021 Fiscal Monitor)

6

https://blogs.imf.org/2021/01/26/a-race-between-vaccines-and-the-virus-as-recoveries-diverge/

7

For a detailed description of how the COVAX initiative has fallen short, see for example https://www.thelancet.com/journals/lancet/article/PIIS01406736(21)01367-2/fulltext dated 19 June 2021.

8

https://www.imf.org/en/Publications/Staff-Discussion-Notes/Issues/2021/05/19/A-Proposal-to-End-the-COVID-19-Pandemic-460263

9https://www.nature.com/articles/d41586-021-00396-2

19

OVERVIEW

b. An endemic COVID-19 will blur the lines between responding to the current pandemic and preparing fora future new pandemic.
4.

Even as we fight this pandemic, we must face the reality of a world at risk of more frequent pandemics.
a. The last two decades have seen major global outbreaks of infectious diseases every four to five years,
including SARS, H1N1, MERS and COVID-19. (See Annex D.) This is besides the ongoing HIV/AIDS pandemic
and Ebola, which has seen 29 regional epidemics over the last five decades.
b. There has been an acceleration of zoonotic spillovers over the last three decades. (See Annex E.)
They account for about three quarters of new and emerging infectious diseases.
c. Scientists attribute the increased frequency of infectious disease outbreaks to population growth and increased
human encroachment on the natural environment; the loss of the world’s biodiversity; the growth of thewildlife trade; increasing urbanization, crowded living conditions and increased mobility; and the broader
consequences of a warming environment on the life cycle of pathogens and the geographical spread ofinsect-borne diseases.
d. These assessments also point to the prospect of more frequent and increasingly virulent epidemics andpandemics in future. The Global Preparedness Monitoring Board (GPMB) has warned of the risk of a major
pandemic arising from a deadly strain of influenza. Given also other dangerous pathogens that are alreadyknown and continuing coronavirus transmissions to human populations, the next major pandemic canhappen anytime. It could come in 20 years, in 10 years, or next year.

Figure 1: Global Examples of Emerging and Re-emerging Diseases by the Global Preparedness Monitoring Board

Source: Global Preparedness Monitoring Board’s 2019 Annual Report on Global Preparedness for Health Emergencies,
A World At Risk

20

OVERVIEW

Epidemic-prone diseases such as
influenza, Severe Acute Respiratory
Sy n d r o m e (SA R S ), M i d d l e E a s t
Respiratory Syndrome (MERS), Ebola,
Zika, plague, Yellow Fever and others,
are harbingers of a new era of highimpac t, potentially fast-spreading
outbreaks that are more frequently
detected and increasingly difficult tomanage … High-impact respiratory
pathogens, such as an especially deadly
strain of influenza, pose particular global
risks in the modern age. The pathogens
are spread via respiratory droplets; they
can infect a large number of people very
quickly and with today’s transportation
infrastructure, move rapidly acrossmultiple geographies.”—
GLOBAL PREPAREDNESSMONITORING BOARD,
2019 Annual Report on Global Preparedness for Health
Emergencies: A World At Risk

COVID-19 is neither the first nor the last healthemergency we will face. My fellow scientists estimatethat we will face a pandemic or health emergency atleast once every five years from here on. There is achance that this is the optimistic scenario. The reality
could be far worse.”—
SALLY DAVIES,
Former Chief Medical Officer of England, Master of Trinity College,
Cambridge, 26 September 2020

Without preventative strategies, pandemics will
emerge more often, spread more rapidly, kill more
people, and affect the global economy with moredevastating impact than ever before.”—
INTERGOVERNMENTAL SCIENCE-POLICYPLATFORM ON BIODIVERSITY ANDECOSYSTEM SERVICES (IPBES),
Workshop Report on Biodiversity and Pandemics, 29 October 2020

5.	Preventing future pandemics, together with action on climate change, has to be a central obligation ofnational and global governance.
a. Both require urgent political commitment, clear recognition of the benefits that all nations share,stronger national and global actions, and larger collective financing.
b. They are both a race against time.
i. Avoiding the next major pandemic is the race of the decade — and a race measured in days and weeks
when an outbreak does emerge.
6.

It is within our means to avoid repeating the large-scale collective failures that led to the damaging pandemicof the last 18 months. The world has the scientific, technological and financial resources to sharply reduce
the risk of a pandemic, and the massive human, social, and economic costs it brings.

7.

We must better mobilize and organize these resources, public and private, and ensure that the world isbetter equipped — individually and collectively — to detect, prevent and counter another major outbreak.
a. We must also ensure the system has the capacity to reach vulnerable populations both globally andwithin countries.

8.	The world faces other catastrophic risks, besides repeated pandemics and climate change which are clearlyon the horizon. A key lesson of COVID-19 should be to plan for catastrophic risks generally. Recommendations
on how to do so are outside the scope of this report, and other groups could be convened to examine this.
However, since addressing global catastrophic risks has intrinsic global public good characteristics, some of
the lessons from this report will apply to them.
21

OVERVIEW

Plugging Four Major Global Gaps
9.	Great progress in pandemic prevention, preparedness and response (PPR) is within reach in the next five years.
It requires bold and sustained national, regional and global investments and actions in normal times, aswell as capacity to respond with speed and force in the event of an emerging pandemic threat.
10.	The investments we propose aim at plugging four major gaps in pandemic PPR. They are set out below, andelaborated in Section B of the report:(1) Globally networked surveillance and research: toprevent and detect emerging infectious diseases
i. We can substantially reduce the risk of pathogens spilling over into human populations and causing
disease outbreaks.
ii. We need stronger, internationally coordinated efforts to prevent spillovers at their source — especiallyby reducing the loss of natural habitats, controlling wildlife trade, and addressing livestock production
near to wildlife. Strengthening One Health approaches is critical to this effort.
iii. A massive scale-up of global surveillance and alert systems is needed to detect cross-species
spillovers, send an early warning to the world, enable swift public health responses and accelerate
development of medical countermeasures.10
1. We must urgently build a global genomic and epidemiological surveillance program, combining
pre-existing and new nodes of expertise at the global, regional, and country levels, with the WHOat the center.
2. This will also require enhancing foundational public-health surveillance capabilities11 at the nationaland regional levels, including in partnership with regional CDCs and regulatory bodies. Such efforts
bring domestic benefits all the time but are also critical in identifying and stopping emerging
outbreaks with cross-border potential.
iv. Surveillance at scale has to be integrated with a substantially expanded program of researchon known and emerging infectious diseases. This should include an agenda to fully characterize
prototype pathogens that are capable of becoming infectious diseases in human populations, creating
the building blocks for early development of medical countermeasures that are cross-protective
against a range of pathogens.

(2) Resilient national systems: to strengthen a criticalfoundation for global pandemic preparedness
and response
i. Resilient national health systems — from healthcare capacity to trained human resources and frameworks
for policy decisions in crisis — remain the foundation for stopping an emerging outbreak. National
surveillance and preparedness is the bedrock of effective global surveillance and information-sharing.

	https://pubmed.ncbi.nlm.nih.gov/33712471/

1011

For instance, every country must be able to report deaths and disease in a complete, accurate and timely manner.

22

OVERVIEW

ii. We need significant improvements and whole-of-government health security plans to enable countries
to comply with the WHO’s International Health Regulations (IHR). Public health strategies must also be
developed to identify those who need care and treatment in a pandemic, and provide a comprehensive
and effective response. Countries’ capacity to respond using non-pharmaceutical interventions, such as
lockdowns, quarantines and social restrictions, also requires adequate welfare safety nets.
iii. The International Financial Institutions (IFIs) — the IMF, World Bank and Regional Development
Banks — must step up their support for Low-Income Countries (LICs) and Lower-Middle Income
Countries (LMICs) to make the needed investments in preparedness, and be ready to swiftly scale up
assistance when a pandemic is triggered.
iv. Investments in pandemic preparedness should be integrated with the ongoing efforts andinfrastructure to tackle endemic infectious diseases. Existing global health institutions like the Global
Fund to Fight AIDS, Tuberculosis and Malaria (hereafter referred to as the “Global Fund”) and Gavi
should be given a more explicit mandate and increased funding to invest in system-level preparedness.
v. International implementing organizations like UNICEF also play a key role in strengthening
domestic systems for agile, last-mile delivery of essential supplies. This applies not just to vaccines
but lifesaving therapeutics and oxygen cylinders and concentrators.

(3) Supply of medical countermeasures and tools:
to radically shorten the response time to apandemic and deliver equitable global access
i. As COVID-19 illustrates: the human and economic costs of a pandemic are driven by the length of time
it takes to equip the world with the diagnostic tools, vaccines, therapeutics and PPE to deal with it.
ii. The global scientific community responded with unprecedented speed to sequence the new virus anddevelop a portfolio of effective vaccines within a year. We have been far less successful in boosting
global supply, ensuring the equitable global distribution of these vaccines and strengthening thecapacity of delivery systems to go from vaccines to fully vaccinated people.
iii. To prevent the major damage caused by highly transmissible and severe diseases, we must develop thecapacity to reach the majority of the world’s population within a radically shorter timeline — including
a 100-day target for the development of vaccines, therapeutics and high quality rapid diagnostics.
iv. We also need substantially larger, ever-warm capacity for manufacturing and delivery of critical medical
supplies, and modular technologies that allow rapid scale-up of capacity, to meet the surge in demandin a pandemic. This scaled-up capacity is critical to reducing the short-term trade-offs that nations face
between meeting domestic and global needs. We also need greater geographical diversification ofsuch facilities to ensure resilience of supply chains in a crisis and equitable global access. The facilities
should be used as much as possible in inter-pandemic years to address ongoing infectious disease needs.
v. A global network of public-private-philanthropic partnerships must be established to assure suchcapacity and the delivery mechanisms to reach the world rapidly in a pandemic.
vi. Both national and global pooling of public sector investments in these partnerships are necessary toensuring global access to medical countermeasures in a pandemic. Building on the lessons learned
from the ACT-Accelerator initiative that was launched in the current pandemic, a permanent end-toend supply ecosystem needs to be created. The lack of proactive public investment for manufacturing
and procurement before the pandemic has greatly hampered the response to COVID-19.

23

OVERVIEW(4) Global governance: to ensure the system istightly coordinated, properly funded and withclear accountability for outcomesi. The current global health architecture is not fit-for-purpose to prevent a major pandemic, nor to respondwith speed and force when a pandemic threat emerges. As the Global Preparedness Monitoring Board
highlights, the system is fragmented and complex, and lacks accountability and oversight of financing
of preparedness. We must address this by establishing a governance mechanism that integrates all
the key players in the global health security ecosystem, with the WHO at the center.
ii. The solution rests not in creating new institutions, but in introducing a new mechanism of global
governance and establishing a tightly networked system of responsibility and accountability
among existing institutions:
1. A reformed and strengthened WHO12; its One Health partners in FAO, OIE and UNEP; the World
Bank, the Regional Development Banks (RDBs) and the IMF; the WTO; the specialized global healthbodies like Global Fund, CEPI, Gavi, FIND, and Unitaid; and international organizations like UNICEF
that address health and humanitarian interventions and delivery mechanisms.
2. The regional bodies should be integrated in this architecture. The current pandemic has demonstrated
the strengths of regional ownership, e.g. the major initiatives taken by the African Union and
Africa Centres for Disease Control and Prevention (Africa CDC).
iii. It must also fully leverage the capabilities of the private sector and the non-state actors.
1. The private sector plays a key and growing role in health service delivery as well as in transport,
logistics, communications, data, and other capacities for preparedness and response.
2. Local-level and non-state actors including NGOs and the global scientific community play importantroles in detecting emerging threats, strengthening preparedness, and helping communities copewith public health measures in the event of outbreaks. The network of international institutions
should continue to have the flexibility to fund these sub-national and non-state actors.
iv. A new global governance mechanism is needed to match tightly networked global health governance withfinancing. We propose a new Global Health Threats Board, to provide systemic oversight in enablingproper and timely resourcing of capacities, and to ensure the most effective use of funds. It should join
up the efforts of international bodies, with clearly delineated responsibilities that match their comparative
strengths, and ensure the system fully leverages the capabilities of the private sector and non-state actors.
11.	In plugging these four major gaps, we must recognize above all that international support for pandemic PPR isfundamentally not about aid, but about investment in global public goods from which all nations benefit.
a. Every nation rich and poor benefits when every other nation is equipped and resourced to prevent andrespond quickly to disease outbreaks.
i. The longer that a part of the world remains without immunity, the greater the scope for new variants of concern
to emerge, challenging even previously immunized populations. We have already seen new variants of the
SARS-CoV-2 pathogen emerging with higher transmissibility and reducing the efficacy of existing vaccines.

12

As recommended by the IPPPR in its Main Report: “WHO is and should be the lead health organization in the international system, but it cannot do everything…
WHO should focus on providing strategic direction and analysis, and formulating norms, standards and technical advice to ensure that countries have resilient
health systems that are prepared with the required response capacities for health emergencies. In the case of emergencies WHO has an important operationalrole to play providing technical advice and support.” It adds in its Institutional Review of the WHO that “WHO´s mandate should be focused on activities
where it provides true added value, where it makes the most use of its core competencies, and where there is less overlap with the mandate of other actors
in the busy and crowded global health space.”

24

OVERVIEW

ii. Ensuring widespread global access to tests, vaccines, treatments, and other medical countermeasuresis hence both a humanitarian imperative and a scientific and economic necessity everywhere.
b. We distinguish between two levels of global public goods, with different implications for financing
and accountability.
i. There are ‘pure’ global public goods such as surveillance and R&D, which require both internationaland country-level capacities, but where the benefits are mainly not internalized by countries. In thecase of LICs and LMICs in particular, these should be largely financed by collective mechanisms.
ii. There are other investments that have a clearer benefit for individual countries or regions, such as strengthened
national capacities to stop the spread of infectious diseases, but which nonetheless have positive externalities
for the global community. Governments have to mobilize domestic resources to develop and maintain thesecapacities, complemented by external financing support to ensure a strong alignment of incentives.

Financing Pandemic Prevention, Preparedness
and Response: the Basic Approach12.	The broad principles that underpin financing for pandemic PPR flow from its global public good nature.
Prevention and preparedness require predictable and sustained funding. Financing of response in a pandemic
must be rapid, available to all countries that need it and delivered without complicated, business-as-usual
requirements. All funding flows must show clear accountability for outcomes.
a. Pandemic PPR should be anchored in enhanced, reliable and timely multilateral funding, complemented
by bilateral funding streams and philanthropic contributions.
i. A predictable system of pre-agreed contributions and callable capital is needed for reliable funding innormal times, and for the swift scale-up of financing needed in a pandemic. Both have been badly lacking.
1. The current experience with ACT-A shows how the absence of a system of pre-agreed commitments
leads to considerable underfunding when it is needed.
2. Without pre-agreed rules of funding, we risk a waiting game in which governments and institutions
delay investments because they expect these to be covered by others at some point in the future.
ii. We echo the call by the Independent Panel for Pandemic Preparedness and Response (IPPPR) for the
WHO to be more reliably funded for its critical roles — with assessment-based core contributions
from Member States increased to two-thirds of the budget for the WHO base program, and an organized
replenishment process for the remainder of the budget.
iii. Our recommendations also call for stronger multilateral funding of pandemic PPR through other bodies,including a larger role for the IFIs.
iv. Targeted bilateral funding provides an important complement, and a catalyst for action. ODA
should have a component to help LICs prepare to mitigate the cost of future pandemics, for example
through investments in human capital and resilient health systems.
v. But an international system that rests heavily on discretion is open to free-riding, and complicatesprocesses for ensuring accountability. Such investments must therefore only be complementary toenhanced multilateral funding.

25

OVERVIEW

b. Empower the IFIs to more boldly support the global commonsi. The IFIs, despite record lending, are not structured to address global threats forcefully. They should beclearly mandated to support country- and regional-level investments in global public goods, which haveboth local and global benefits. They must adjust their business models to meet this sharpened mandate.
ii. The IFIs are uniquely placed to do so: by their ability to mobilize international resources; leverage
capital or guarantees; incentivize countries to invest in global public goods and other enabling spending;and catalyze private investments.
iii. Their activities should be more boldly oriented towards supporting countries and regions in meetingthe largest global challenges of the 21st century, including climate change and pandemics. While incountry development challenges are still pronounced, poorer countries are also most vulnerable tothese challenges to the global commons. Further, both future pandemics and climate change can only
be managed if developing countries have the capacities to be fully engaged in the process.
1. The Bretton Woods institutions have historically had country-focused business models. They werealso established at a time when capital markets were much less developed.
2. The World Bank and RDBs should move decisively to help countries invest in global public goods
to reduce pandemic risks — including through the strengthening of health systems and core publichealth capacities that are critical to effective pandemic prevention, preparedness and response.
a. To achieve this, they will need a stronger mandate and deep technical capacities in pandemic
preparedness, along with more fit-for-purpose instruments that can combine loans with grantbuy-downs and other incentives to fund countries and regional initiatives more effectively.
3. They should do so without it being at the expense of their current goals on poverty reduction,
shared prosperity, and financial stability. This will require new resources.
4. There is also significant scope to optimize the use of their balance sheets so as to augment
resources for both global public goods and economic development. The MDBs should workwith countries to move more decisively to leverage private finance. The mechanisms for doing so
include appropriately designed risk guarantees, as well as the expanded use of blended finance tocatalyze private investments, especially for infrastructure with clear economic returns.
5. The IMF, World Bank and the other MDBs should also play major roles in helping countries respond to
pandemics, including by providing pandemic response windows that are triggered automatically, forexample, upon the WHO’s declaration of a Public Health Emergency of International Concern (PHEIC).
c. Provide stronger incentives for LICs and LMICs themselves to invest in global public goods in pandemic
PPR, especially through expanded grant support and matching funding for domestic investment,
accompanied by accountability for outcomes
i. Failure to prioritize and budget for pandemic prevention and preparedness has been an issue forcountries at all income levels13.
ii. LICs and LMICs in particular face more binding budget constraints to make investments that havepositive global externalities. National investments are stymied by uncertainties about the scale of domestic
benefits, as well as the hard trade-offs between spending on preparedness for a future event of uncertain
timing versus other pressing health and development priorities, given limited resources. The COVID-19
recession has worsened long-standing fiscal constraints on already insufficient public spending on health.

13

While existing international benchmarks, including the Joint External Evaluations (JEEs) and Global Health Security Index (GHS Index), have not been very
useful predictors of individual country performance in the current pandemic, we have to take seriously the broad-based international preparedness gaps
they highlight: the average country 2019 GHS Index score was 40 out of a possible 100.

26

OVERVIEW

iii. Countries have hence historically been reluctant to use their limited borrowing envelopes from the
MDBs for this purpose.
iv. Grants can be used strategically to incentivize investments in global public goods through co-investments
by national governments, as has been done via Global Fund and Gavi.
v. Contributions by bilateral development partners for pandemic preparedness have also been small, andshould be increased. These resources should not be taken from resources for poverty alleviation or aid
budgets more generally, as discussed below.
vi. Governance and institutional capacities also need strengthening. We need a more robust global
mechanism to assess countries’ plans and data on pandemic prevention and preparedness, provide
technical assistance, encourage countries towards closing any identified gaps, and tie financing toperformance on preparedness indicators.
d. Maximize complementarities between different funding streams in global health, including private
and philanthropic investments
i. New funding for pandemic PPR must add to rather than substitute for existing streams of funding.
1. It would be short-sighted to bolster our efforts for pandemic prevention and preparedness byreallocating resources from other critical development priorities in poverty alleviation, human capitaldevelopment, climate, and other priorities.
ii. Today’s different streams of funding must be tightly coordinated.
1. Internationally, we must tackle the threat from multiple pathogens more effectively and support
multiple PPR interventions — instead of a disjointed landscape organized around specific diseases
and interventions.
2. Regional and country platforms should bring together multilateral and bilateral partners, as well as
philanthropic and private investors, coordinated by national authorities, to ensure a sustained andcoherent effort to build up national preparedness.
iii. We need a different construct for public partnerships with the private and philanthropic sectors:
with continuous engagement, not only once a pandemic strikes.
1. Besides the core requirement to enter into such partnerships to scale up end-to-end supply chainsfor medical countermeasures, the private sector must also be mobilized to boost supply of othercritical medical supplies.
2. Pandemic PPR plans must also consider all health providers, and the ways in which people can most
readily access care. In most LICs and LMICs, private sector providers are important sources of careand have to be mobilized and properly regulated in support of public policy objectives, even as
governments working with external partners seek to build up more resilient national healthcare
systems over the longer term.
iv. The major philanthropic foundations have been playing a critical role in supporting investmentswith high risk and/or low commercial incentives. However, the major scale-up of research on infectious
diseases and countermeasures needed will have to involve stronger partnerships between the public
and philanthropic sectors, nationally and globally.
1. These include early-stage investments, e.g. the search for vaccines that can provide broad protection
against a range of pathogens; and interventions that can address the rising threat of drug resistance.

27

OVERVIEW

2. Governments should develop strong partnerships with philanthropies to enable research forinterventions where commercial interest is low, including many ongoing regional epidemics for which
global demand is weak.
e. Improved policy-making and regulatory processes are critical complements to enhanced financingof global health security
i. The experience of the last 18 months has shown the importance of international and national leadership,collaboration, and policy-making in determining the effectiveness of responses to the pandemic.
ii. Internationally: we must create incentives for countries to keep supply chains open — especially forcritical medical supplies, and their components and raw materials. WTO has a key role in monitoringand surveillance of member countries’ trade practices, to ensure export restrictions and trade facilitation
issues are quickly tackled.
iii. Domestically: even financially-equipped countries have not always pursued the policies needed tocontain the damage brought by the pandemic.
1. As highlighted by the IPPPR, too many governments took a wait-and-see approach, while international
agencies were slow to act, constrained by their limited mandates, capacities and silos.
2. Getting policies right based on science and evidence, and taking actions early and mobilizing
capabilities and resources on a whole-of-country basis, can suppress the spread of a pandemic
and buy precious time for medical countermeasures to be developed and procured.
iv. Governance, communication and behavioral science tools have also been important in shaping social
adherence to public health measures, and minimizing distrust of science and medical professionals.
v. Rigorous, quantitative research on the causal impact and efficacy of various non-pharmaceuticalinterventions, building on countries’ varied responses to COVID-19, is also necessary to guidepolicy responses.

The Scale of Investments Required13.	
We can only avoid future pandemics if we invest substantially more resources than we have been willing tospend in the past, and which the world is now paying many times over in dealing with COVID-19’s damage.
14. Greater domestic investments by national authorities in the key capacities are needed to prevent and containfuture pandemics. These investments, specifically for pandemic prevention and preparedness, must be partof broader national efforts for healthcare and public health system strengthening. Together, these efforts
would require low- and middle-income countries to add about 1% of GDP to public spending on healthover the next five years.
15.	
However, domestic actions alone will not prevent the next pandemic. We must collectively commit to
expanding international financing by US$75 billion over the next five years — or US$15 billion eachyear. This will comprise funding for both global-level functions and the support needed for LICs and LMICs
to invest in the country-level global public goods needed for pandemic PPR.
16.	The scale of investments required reflects the need to catch up from a long period of underfunding. Investing
upfront in the next five years is critical to lowering the growing risks of pandemics.

28

OVERVIEW

17.	
The Panel believes that US$15 billion per year is the absolute minimum in the new international
investments required in global public goods that are at the core of effective pandemic prevention andpreparedness. This estimate excludes the cost of other complementary investments that will contribute toresilience against future pandemics, while providing benefits to countries in normal times.
a. It excludes the costs of containing antimicrobial resistance (AMR), which is a growing threat to healthsecurity nationally and globally. AMR may worsen the impact of future epidemics and pandemics by rendering
ineffective the treatment of such infections and associated co-infections, as evidenced in previous influenza
pandemics14. Countering AMR is estimated to cost US$9 billion annually15. Since AMR containment measures
have benefits well beyond pandemic PPR and operate through ongoing programs for more rational use of
antimicrobials in health and agriculture, we have not included these costs in our estimates.
b. The estimated costs would also be much higher if they included upstream environmental investments forprevention and a more extensive scope for One Health including upgrading of veterinary services; basic andpre-clinical research; and the broader strengthening of healthcare systems and delivery infrastructure
beyond that directly related to pandemic PPR. These actions provide continuous benefits to countries, andhave therefore been excluded from our strict estimates of costs specific to pandemic PPR.
c. Further, the estimated minimum investments required are based on conservative assumptions on the scaleof at-ready manufacturing capacity required for medical countermeasures16.
18.	We set out in Section C of the report several key financing proposals to help close the major gaps in pandemic PPR:
(1) Adopt a systemic approach to ensure enhanced and predictable global financing for pandemic PPR. The
Global Health Threats Board should provide financial oversight to ensure adequate funding across the systemand effective use of funds. Two-thirds of the total additional international financing needed, i.e. US$10 billion
per year, should be pooled in a new, multilateral funding mechanism (Proposal 2 below), with the remaining
US$5 billion going directly towards strengthening funding to WHO and other existing institutions.
(2) Establish a Global Health Threats Fund. This would be a dedicated fund amounting to US$10 billion per year,
based on pre-agreed contributions, to support and catalyze investments in global public goods for pandemic
PPR. The new multilateral mechanism will enable effective and agile deployment across institutions and networks.
(3) Develop resilient domestic finances for prevention and preparedness. Governments working with international
institutions must embark on a major agenda of reforms to mobilize domestic resources on a sustained basis so
as to enable investments in the key capacities required to avoid future outbreaks and to strengthen national
health systems, while enabling their economies to return to durable growth. Low- and middle-income countries
will need to add about 1% of GDP to public spending on health over the next five years.
(4) Strengthen financing for the WHO and One Health, and put it on more predictable footing. Greaterand more predictable funding is necessary for the WHO to perform its critical functions and ensure that there
are no gaps in the surveillance-to-action loop, and to strengthen the integrated One Health approach.

14

See, for example, ReAct network’s briefing note circulated ahead of the 74th World Health Assembly: https://www.reactgroup.org/wp-content/uploads/2021/05/
ReAct-Briefing-Pandemic-Preparedness-and-Antibiotic-Resistance.pdf

15

https://documents1.worldbank.org/curated/en/323311493396993758/pdf/final-report.pdf

16

Our costings for incentivizing supply capacity for all medical countermeasures are about half of the costs estimated for vaccines alone by the Accelerating HealthTechnologies (AHT) group (comprising economists and statisticians, including G20 HLIP member Michael Kremer). The AHT group estimates that investments inneeded production capacity and supply chain inputs for vaccines alone require US$60 billion in public funding to enable the capacity to be installed over a periodof years, and about US$2 billion per year thereafter to maintain this capacity. Their estimates take into account that most vaccine candidates fail, and in order torepurpose capacity in parallel with clinical trials, any vaccine capacity would need to be split between many candidates. There is therefore a need for significantly
larger vaccine capacity. However, the added investments generate far greater benefits in future and far higher returns than a small scale of investments would.

29

OVERVIEW(5) Make financing of global public goods part of the core mandate of World Bank and other MDBs. The
MDBs should incentivize investments in pandemic prevention and preparedness at the country and regional
levels, with grants and greater concessionality that complement existing results-based and programmatic
lending. They should draw first on their existing financial resources. However, shareholders must support
timely and appropriately sized replenishments of their concessional windows and capital replenishments
over time to ensure that the greater focus on global public goods is not at the expense of poverty reduction
and shared prosperity.
(6) Enable fast-tracked surge financing by the IFIs in response to a pandemic. The MDBs and IMF should
institute pandemic response windows that are automatically triggered to provide swift, scaled-up accessto funds, with relaxed rules on country borrowing and automatic access for pre-qualified countries.
Appropriately designed debt service relief by other creditors will be an important complement to surge
lending from the IFIs in responding to future pandemics.
(7) Ensure complementarity between multilateral and targeted bilateral funding. Multilateral efforts should
leverage and tighten coordination with ODA and other bilateral funding streams, which continue to play
an important role. Better coordination within country and regional platforms will generate greater impact
in pandemic PPR, and better integration with other critical development needs.
(8) Leverage the capabilities and resources of the private and philanthropic sectors. There is significant
scope to catalyze private sector participation in pandemic PPR. This must foremost involve installing
adequate capacity for manufacturing and supply of medical countermeasures and other critical supplies
through public-private partnerships. (See also Item 2 above.) Further, a much bolder shift in government
and MDB strategies is needed to mobilize and augment private finance for infrastructure, so as to optimize
official balance sheets for investments in both global public goods and economic development. We mustalso build strengthened and continuous public sector partnerships with philanthropic foundations to meetthe needs of an expanded research agenda for pandemic PPR.
(9) Develop insurance solutions for adverse compensation events associated with use of medical
countermeasures. The MDBs should work with countries and private insurers to enable risk financing
solutions to better protect LIC governments from the liability of adverse compensation events, particularlyin the form of no-fault compensation schemes or an explicit compensation fund with pre-determined
compensation awards. These schemes can be pooled internationally, including amongst G20 governments,
and could be put in place in the inter-pandemic period, supported by international financing.
19.	The reforms and investments we proposed are critical to future global security. With contributions apportioned
equitably, they are affordable to all nations. They are also miniscule compared to the enormous costs theworld will incur if we fail once again to invest ahead of the next pandemic.
a. They provide immense social returns, both nationally and globally.
b. They will materially reduce the risk of events whose costs to government budgets alone are 700 times aslarge as the additional international investments per year that we propose, and 300 times as large as thetotal additional investments if we also take into account the domestic spending necessary.
c. The next major pandemic may come at any time. Even if it occurs only 10 or 20 years from now, thecosts to governments will still be 10 to 25 times the cumulative additional investments in prevention andpreparedness over the years until then, in present value terms17.
d. The full damage of another major pandemic, with its toll on lives and livelihoods, will be vastly larger. Basedon estimates by Metabiota, there will be 4 million expected deaths in the next decade from the threepathogen groups — pandemic influenza, epidemic coronaviruses and viral hemorrhagic fever — which isroughly equivalent to the losses to date in today’s pandemic.
17

Even if we assume the investments in prevention and preparedness only reduce the probability of a pandemic by 50%, and reduce the cost of any resulting
pandemic by 50% — hence saving 75% of the costs of a COVID-19-scale pandemic — the cost savings to government budgets are 8 to 18 times the cumulative
additional investments over the next 10 to 20 years, in present value terms.

30

B. PLUGGINGFOUR MAJOR
GLOBAL GAPS
Globally networked surveillance
and research: to prevent and detect
emerging infectious diseases
Resilient national systems: tostrengthen a critical foundation for
global pandemic preparedness andresponse
Supply of medical countermeasuresand tools: to radically shorten the
response time to a pandemic anddeliver equitable global access
Global governance: to ensure thesystem is tightly coordinated,properly funded and with clear
accountability for outcomes stablish a
E
Global Health Threats BoardPLUGGING FOUR MAJOR GLOBAL GAPS

B. Plugging Four Major Global Gaps
20. The investments that the G20 HLIP proposes will enable the world to plug the four major gaps in pandemic PPR:
a. Globally networked surveillance and research: to prevent and detect emerging infectious diseases
b. Resilient national systems: to strengthen a critical foundation for global pandemic preparedness
and response
c. Supply of medical countermeasures and tools: to radically shorten the response time to a pandemic
and deliver equitable global accessd. Global governance: to ensure the system is tightly coordinated, properly funded and with clear
accountability for outcomes(1) Globally networked surveillance and research:
to prevent and detect emerging infectious diseases
21. Without significant investments in an early warning system, we will not be able to prevent and address
future outbreaks quickly enough.
a. We must step up our investments in One Health.
i. WHO, OIE, FAO and UNEP must be supported to drive the development of standards for the prevention
and control of health risks at the human-animal-ecosystems interface, with the WHO providing active
support to the immediate response to emerging outbreaks once identified.
b. We must prioritize installing a global genomic and epidemiological surveillance program within thenext five years to prevent and detect cross-species spillovers and to rapidly share data:i. Comprising a tightly coordinated network of authorities and experts, with the WHO at the center. There
should also be representation especially of countries and regions at higher risk of cross-species spillovers.
ii. With just-in-time sharing of data on new pathogens.
iii. Enabling rapid genome sequencing.
iv. This is a critical capacity for detecting emerging outbreaks, allowing for rapid tailoring of public healthinterventions based on the attributes of a pathogen and its transmission, and the early development
of diagnostic kits, vaccines and therapeutics where viable.
1. A good but underfunded precedent to build on is the WHO's Global Influenza Surveillance andResponse System.

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PLUGGING FOUR MAJOR GLOBAL GAPS

v. The G7 has recently endorsed a broadly similar proposal for an enhanced international pathogen
surveillance network18 which will be docked into the WHO, and supported by partners from national
public health agencies, governments and research organizations to ensure the utility of the network all
the time.
c. As proposed by CEPI experts, the development of countermeasures would also be sped up through a
global prototype pathogen agenda — that addresses the problems of vaccinology and develops vaccines
against representatives of the roughly 25 viral families known to cause disease in humans. The number ofprototype vaccines required to substantially reduce future risk has not been determined but, even if large(~100), is clearly finite.
d. We must build up the requisite in-country and regional capacities for effective surveillance. International
financing and technical assistance are needed to help build this up especially for LICs and LMICs.
i. Investment is required in specialized labs and staffing, advanced molecular diagnostic capabilities, anddigitalization and data integration.
ii. These capacities for detecting new outbreaks have to be built on systems that are able to provide
continuous and cost-effective utility19. This can leverage the work of the Global Fund and other global
health bodies which have been developing such systems in many countries.
iii. We must also build up effective capabilities for the broader disease surveillance pyramid that should
include timely reporting of the number of deaths and the domestic circumstances in an outbreak inall countries; the strengthening of conventional diagnostics and community health worker reporting;population-based CRVS (Civil Registration and Vital Statistics) or sample registration systems so thatthe impact of outbreaks can be measured; and data surveillance infrastructures to aggregate data andextract recommendations for swift action.
iv. Technical assistance can also help in regulation of wildlife trade as well as private, informal and unregulateddrug-sellers, pharmacies, and providers.
v. National public health institutes, regional centers for disease control, and international agencies
like WHO, FAO and OIE require greater funding support to develop and maintain this key capacity.
1. Urgent work is needed to define and coordinate the partnership ‘hubs’ and ‘spokes’, put key infrastructure
and training in place, and define the necessary policies, principles, and an underlying ethical framework
essential for global cooperation within the network.
2. There is also a need for a globally networked group of pandemic responders who can be embedded
in national and regional public health institutes.
e. A deeper understanding of zoonotic infections and disease origins is absolutely critical to successfully
prevent future outbreaks.
i. We know that we must urgently enhance our ability to track, report and immediately respond to disease
outbreaks at local, national and international levels.
ii. It will require minimizing possible spillovers from animals and humans, through internationally coordinatedefforts to reduce the loss of natural habitats, regulate the wildlife trade and take down illegal trade,
and address livestock production near to wildlife. Strengthening One Health approaches is criticalto this effort.

18

https://s3.documentcloud.org/documents/20860689/carbis-bay-g7-summit-communique-430kb-25-pages-1.pdf

19There are already well-functioning surveillance systems for HIV, tuberculosis, malaria and influenza, and can be augmented by including other pneumonia,
meningitis, typhoid, cholera, STIs, drug resistant pathogens and clusters of defined clinical syndromes, as well as tracking the interplay between human andanimal pathogens.

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PLUGGING FOUR MAJOR GLOBAL GAPS

1. Few policies today seek to minimize human-animal interactions linked to environmental degradation,
close live wildlife markets, reduce wildlife consumption, or ban commercial trade of high-risk wildlife —and rarely do these topics come up in mainstream health policy discussions.
2. Interventions to arrest environmental degradation not only help to reduce the risk of spillover, they also
help to reduce greenhouse gas emissions, conserve biodiversity and provide natural climate solutions.
iii. Policies governing gain-of-function virological research should be reviewed with accountability forsafeguards and responsibility clearly placed on sponsors and funders20.

(2) R esilient national systems: to strengthena critical foundation for global pandemic
preparedness and response
22. Every country must play its part, share information, and be accountable for strengthening pandemic PPR.
Doing so has benefits both domestically and for the rest of the world.
a. Countries that are in the tropics or have significant interfaces between human and wildlife habitats are more
vulnerable to pathogens jumping into human populations, and becoming the source of a future outbreak.
b. But highly urbanized countries and those which are most closely integrated within their regions and globally,
run the risk of amplifying the spread if they are unable to keep pandemics under control.
23. It is not possible to neatly separate efforts to counter new diseases with epidemic potential fromcontinuing efforts to contain existing infectious diseases. They require many similar investments ininfrastructure, healthcare workforce and technical specialists, and technologies and information systems.
24. It is therefore critical to have robust, whole-of-government health security plans that are regularly andtransparently stress-tested, and assessed for compliance with the IHR and adherence to best practices. The
IMF should incorporate assessments of health security status into regular monitoring of countries’ broader
economic resilience (see below).
25. National authorities have the primary ownership and responsibility.
a. However, the strong element of global public goods in national-level pandemic PPR, the scale ofpast underinvestment, and today’s gaps in capabilities require significantly enhanced funding andtechnical support for LICs and LMICs.
i. Stronger funding support should be provided by the MDBs, working together with the WHO, the One
Health partners, other global health intermediaries and regional healthcare organizations, as well aswith bilateral partners and philanthropies.
ii. A significant share of the additional financing will have to be in the form of grants. Grants are
required for investments in global public goods, and to incentivize countries to borrow from the MDBs
(by making their non-concessional loans more IDA-like). Grants should also be used to incentivize
governments to allocate their own budgetary resources to complement external support from theirdevelopment partners.

20

The few laboratory biosecurity incidents that have been documented include a 2007 incident at Pirbright laboratories in the United Kingdom that caused afoot-and-mouth outbreak. The laboratory was a Defra category four, similar to those that deal with smallpox and Ebola, and was investigated thoroughly tofind that the virus likely leaked from drainage pipework. The incident had wide-reaching international trade repercussions.

34

PLUGGING FOUR MAJOR GLOBAL GAPS

b. Development partners must coordinate better with each other, and with national authorities.
i. The use of country and regional platforms can leverage the strengths of each development partner; andii. Allow countries room to decide on the most effective use of PPR funds, but with tracking and reporting
to ensure effectiveness of spending and progress towards preparedness standards.
c. Key global health intermediaries like Global Fund, Gavi and UNICEF should work with countries toimprove the value proposition for private sector co-investments in dual-use capacities21 that cansignificantly contribute to health outcomes during the inter-pandemic years, including by making a forcefulcontribution towards the control of endemic diseases.
d. International organizations also play a key role in strengthening domestic delivery systems. Massive
effort has to go into developing in-country systems for agile, last-mile delivery of essential supplies, which
are critical in a pandemic but also have continuous utility in normal times. This applies not just to vaccines
but lifesaving therapeutics and oxygen cylinders and concentrators.
26. We also need credible benchmarks for tracking each country’s progress and identifying gaps in preparedness. The
Panel recommends establishing a new Health Security equivalent of the Financial Sector Assessment Program(FSAP), that will provide in-depth assessments of countries’ pandemic prevention and preparedness capabilities
and investments, building on lessons learned from the IHR State Party Self-Assessment Annual Reporting (SPAR),
Global Health Security Agenda and the associated Joint External Evaluation (JEE) peer review process.
a. The Health Security Assessment Program (HSAP) should be led and coordinated by the WHO andthe World Bank, with its findings put out in the public domain. It should factor in findings from the JEE
and other voluntary assessments under the IHR.
b. This would include the aforementioned stress tests to assess preparedness and resiliency in multiple
scenarios, including highly mutable viruses and non-viral health risks.
i. Administered nationally, stress tests should be supervised by regional and/or global authorities applying
the same criteria and methods to all geographies.
ii. Stress tests should include quantitative and qualitative assessments to enable authorities to take into
consideration all factors when allocating resources, aligned with agreed incentives.
c. The outcomes of this regular assessment of pandemic preparedness should be reflected in IMF Article
IV reports, so as to ensure attention by Finance Ministers and national leadership. This is similar to
how climate has recently been integrated into the Article IV surveillance.

21

These could include multi-disease surveillance, lab networks, febrile illness detection, supply chain and delivery infrastructure for medical countermeasures,personnel deployment systems, and emergency operations centers.

35

PLUGGING FOUR MAJOR GLOBAL GAPS

(3) Supply of medical countermeasures and tools:
to radically shorten the response time to apandemic and deliver equitable global access
27. Speed, scale and equitable rollout of medical countermeasures are critical in a pandemic.
28. Experts point to the prospect of a future major outbreak involving pathogens as transmissible as or even moretransmissible than SARS-CoV-2. Given the devastating impact of such a pandemic, a year is too long to waitfor vaccines. We must collectively commit to achieving a 100-day goal for the development, production
and deployment of effective countermeasures.
29. Further, each of the medical countermeasures and other essential medical supplies needed in the current
pandemic, including diagnostic tests, PPE and ventilators, and the components and raw materials required
for their production, have been in severe shortage, in many cases even one year into the pandemic. The
consequence has been a much wider spread of the virus, and much greater human and economic costs.
30. With regard to vaccines, governments and international organizations should co-invest with the private
sector to strengthen the supply chain during the inter-pandemic years. Estimates by the Accelerating HealthTechnologies (AHT) group22 find that having sufficient at-ready capacity for multiple vaccine candidates
generates very high economic returns. This is because the payoffs to having large quantities of vaccine available
rapidly are enormous, most early-stage vaccine candidates fail, and it historically has taken many months torepurpose capacity from one vaccine candidate to another. However, utilizing new, low-cost modular manufacturing
technologies that can interchangeably manufacture products across multiple platforms could reduce the needfor ‘duplicative’ capacity in the future, so procurement systems should be open to such proposals.
a. During COVID-19, vaccine capacity installation and production was constrained by shortages of production
capacity that could be repurposed, trained staff, and inputs. This led to costly delays in vaccination. A shortageof vaccines and inputs also increased incentives for countries to restrict exports and ‘hoard’ vaccine doses.
b. To mitigate this problem for future pandemics, governments and international organizations should create
standby production capacity for both finished vaccines and inputs in the vaccine supply chain. Such capacity
includes having adequately trained staff, quality checks and procedures in place to ensure that facilities
are ready to produce quickly when needed. Companies could submit proposals for providing this capacity
which should be judged on both cost and other dimensions.
c. As much as possible of this capacity should be kept occupied producing other products during nonpandemic times, which would have the benefit of keeping capacity warm, as it is difficult to rapidly ‘engage’
manufacturing capacity that is left idle. It might also significantly reduce costs.
d. The aim should be to enable vaccine capacity to be ready for each of several vaccine candidates to be
produced at scale so that mass vaccination could begin globally as soon as clinical trials prove successful,and for this to be possible even if only one of the candidates was successful.

22

A group of economists and statisticians, including G20 HLIP member Michael Kremer, working on the problem of how to accelerate widespread access tovaccines and other health products to address COVID-19.

36

PLUGGING FOUR MAJOR GLOBAL GAPSe. Companies have limited incentives to make investments that will be needed only during pandemic
periods. Some capacity investment may have valuable dual uses in the inter-pandemic years, but having
sufficient at-ready capacity for multiple vaccine candidates is socially valuable even if much of it cannot
be used during non-pandemic years. Ethical, social and political considerations may prevent companies
from charging very high prices during a pandemic which would allow them to recoup costs. Therefore,
governments and international organizations will need to be prepared to cover a large portion of the costsof this capacity. To the extent that capacity can be used for other purposes, this will bring down costs andhelp ensure pandemic readiness.
f. Contracting can be undertaken through a standard procurement process, in which governments andinternational organizations solicit bids from companies.
g. These bids should be judged on several dimensions. These include but are not limited to price, quantity,
dual-use possibilities, speed to repurpose during a pandemic, geographical location, and reliability.
i. For example, a bid which could use capacity to produce other valuable products in peace-time at low
cost would be more attractive, both because the dual-use is valuable and because using capacity might
ensure that it could be repurposed quickly and reliably during a pandemic. However, capacity which
requires high and constant demand to stay ‘warm’, may be less attractive if that demand does not matchsocial needs.
ii. For certain more standardized inputs, stockpiles can be created. Once stockpiles are sufficient, thesupplies can be sold and replenished, where ongoing production enables verification of capabilities forachieving contracted capabilities.
31. When a pandemic hits, governments and international organizations should sign contracts to repurpose
sufficient manufacturing capacity for each of many vaccine candidates, ahead of final regulatory approvals
for the successful candidates.
a. Sufficient capacity is needed to ensure rapid and equitable global access, including by the LICs and LMICs,
which is critical to containing a pandemic everywhere. This will require global support. In order to fundthese contracts, a pool of flexibly deployable ‘at-risk’ funds will be needed.
b. Both national and multilateral investments should be welcomed.
c. It is efficient to structure contracts to reimburse companies for most of the cost of capacity repurposing,with an option to buy product from that capacity at a pre-agreed price.
32. Governments and international organizations should also make investments to ensure sufficient supply
and delivery of therapeutics, diagnostics, and PPE.
a. The right financing mechanism differs for each product, and should be designed appropriately.
b. For example, while for vaccines and therapeutics it is important to duplicate capacity for several candidates,
this is not necessary for PPE.
c. Some kinds of PPE and medical equipment are useful for a broader set of pathogens than a specific vaccine,meaning it may be possible to maintain stockpiles in advance.

37

PLUGGING FOUR MAJOR GLOBAL GAPS

33. We need to make sure there are sufficient raw materials and intermediate inputs to rapidly provide
critical medical supplies at a global scale in a pandemic and that there is a large enough margin of error toaccommodate multiple negative shocks, such as some supplies proving unusable or only one vaccine candidate
with particular specialized adjuvant requirements proving successful in clinical trials.
a. Doing so will also reduce the short-term trade-offs that nations face between meeting immediate
domestic needs and the global good, which all nations eventually benefit from.
b. Ensuring broader geographical diversification of manufacturing capacity would help develop resiliencein supply chains in a crisis, and avoid the huge trust deficit seen in COVID-19 among countries dependent
on unpredictable global arrangements.
i. This could begin with a broader distribution of fill-and-finish facilities, while building up more advanced
capabilities for biomanufacturing in the longer term.
ii. We will however have to ensure that regional supply chains continue to work as part of a global system:
1. The scale required for manufacturing means that individual regions will find it difficult to comprehensively
cover all the possible platforms needed for responding to a future pandemic.
2. Regional supply chains can still be vulnerable to localized shocks.
iii. The need for greater diversification and resilience of supply chains also extends to PPE and other critical
medical supplies23.
c. The remarkable progress achieved in research, manufacturing and market launch for vaccines has to beextended to diagnostics and therapeutics.
34. We also need a substantially larger network of sustainably-financed, ever-warm manufacturing capacitythat can be repurposed in a pandemic to target specific pathogens.
a. Multi-modal manufacturing capacity (mRNA, protein, and virus-based vaccines and therapeutics) can rapidly
ramp up production of pandemic-specific medical countermeasures when needed.
b. At-risk financing is needed for manufacturing of multiple prototype pathogen vaccine/diagnostic/therapeuticcandidates before outbreaks.
c. Dual-use purposes should be sought for such capacity, which could contribute to controlling endemic
diseases and improving health outcomes during the inter-pandemic years. This can also improve the value
proposition for such investments.
d. Production capacities in different regions would render the system more resilient and contribute to a more
equitable global distribution of scarce supplies24.

23

IPPPR Background Paper 7 — “Access to Essential Supplies.”

24

The recent Franco-German initiative to boost BioNTech vaccine production in South Africa is a positive example in this regard, see https://www.dw.com/en/
vaccine-makers-want-to-help-south-africa-germanys-health-minister/a-57715373

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PLUGGING FOUR MAJOR GLOBAL GAPS

35. This requires both public and private participation and risk sharing25. The private sector cannot on its own
invest in excess (peak-load) capacity ahead of a pandemic, given the uncertainties over the scale and timingof demand, and over which specific vaccines or other medical countermeasures will meet regulatory approval.
a. A combination of push incentives (co-funding of R&D and supply capacity) and pull incentives (assured
procurements) will be needed ahead of a pandemic, as well as to accelerate R&D and manufacturing
capacity expansion at the beginning of an outbreak.
i. It is more cost-efficient for this to be weighted towards push contracts. They provide the greatest
opportunity for securing significant access commitments because of the higher risk involved in the earlystages of developing vaccines and other medical countermeasures.
ii. There should also be government funding to support the development of new manufacturing technologies,
e.g. for mRNA vaccines and therapeutics to be made on biochips. This has the potential of reducing
production costs and human capital requirements, and enabling more ready access to supplies.
b. Contractual clauses must incentivize early deliveries and commit firms to quantity, adequate allocations
to LICs and LMICs, and affordable pricing.
i. Government funding in the current pandemic, as well as prior public sector investments in R&D, played
an outsized role in the funding of vaccine discoveries for COVID-19. However, these were not structured
to fully recognize the public good nature of R&D and such discoveries.
ii. Future government funding for medical research should attach clearer conditions if successful discoveries
are made, e.g. commitments to provide affordable medical countermeasures with cost-plus pricing for
LICs and LMICs, treatment of intellectual property and requirements for technology transfers to thirdparty manufacturers.
iii. There is a critical need for transparency of contracts and in particular, with regard to pricing. The lackof this transparency has militated against developing countries in the current pandemic, with some ofthem ending up paying more than high-income countries for their vaccines.
36. Expanding public-private-philanthropic partnerships: We should ensure that this end-to-end ecosystem
for global supply of medical countermeasures is tightly networked to significantly scale up productionof these supplies26.
a. We have to leverage comparative strengths across a network of ready-to-act, adequately-funded entities
working across different functional areas (from R&D through to manufacturing and procurement)27.
b. ACT-A was an important, ad hoc arrangement during COVID-19, to coordinate efforts to fund and enable
equitable access to diagnostics, vaccines, therapeutics and implementation of these in health systems.
i. Each of the institutions in ACT-A adapted to an evolving situation, and added value through its respective
expertise and networks with the private sector and within countries.
ii. ACT-A’s experience also showed the ability of the international community to assemble a coalition of
the willing in short order during a major crisis.

25

https://science.sciencemag.org/content/371/6534/1107

26

https://pubmed.ncbi.nlm.nih.gov/33711296/

27

This includes the WHO; CEPI; the international procurement agencies (Gavi, Global Fund, FIND, Unitaid and UNICEF); the WBG; national/regional agencies
like BARDA, HERA and the African Vaccine Alliance; national regulators; the private sector and non-state entities.

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PLUGGING FOUR MAJOR GLOBAL GAPS

iii. But it has also shown the drawbacks of waiting for a crisis to occur. The current system — under a loose
coordinating mechanism within ACT-A — lacks upfront financing and is not speedy enough. A year on, it
remains significantly underfunded, which has hampered progress in purchasing and deploying medical
countermeasures to those in need.
iv. Further, as also observed by the IPPPR, ACT-A is seen by countries and civil society as supply-driven
and not inclusive enough, with large donor countries and institutions having an asymmetric influence
on decision-making28, and some parts of the world opting for regional pooling as an alternative.
c. We should learn from the COVID-19 experience and develop a permanent, scaled-up and tightly
networked ecosystem of partners — public, private and philanthropic — to enable the following:i. Accelerating innovation processes and facilitating the development of candidates and platforms to theregulatory end-point
ii. Achieving adequate global scale in manufacturing, including by:
1. Having a full view of global manufacturing capabilities to know which ones can be activated rapidly
at any point
2. Enabling adequate global diversification of facilities to ensure supply resilience in a pandemic, andsupporting technology transfer to countries or regions to build up manufacturing capabilities
3. Implementing a coherent strategy of push and pull contracts to support the business case for theneeded ever-warm global manufacturing capacity, including its use in inter-pandemic periods tomeet continuing needs29
iii. Focusing on last-mile delivery, including investments in critical domestic supply chains in developing
countries for delivering vaccines and other medical suppliesd. Significantly enhanced, continuous and pre-arranged funding is required to enable this end-to-end supply
chain ecosystem and avoid huge gaps in access to medical countermeasures in a pandemic. We proposethat this be financed through a new Global Health Threats Fund (Proposal 2 in Section C), which will
provide enhanced and more predictable funding to complement existing global health intermediaries.
37. We also need regulatory reforms to speed up time from development of these medical countermeasures
to manufacturing.
a. Enable trials to be conducted across pharmaceutical companies and for multi-vaccine platform technologies.
b. Allow products that are developed in one country to be able to rapidly undergo regulatory assessment
internationally.
c. Formalize process for adaptive regulatory reviews in emergency situations.
i. Governments should also consider setting up commissions to be able to make decisions rapidly on novel
study and trial methods — based on both scientific and ethical foundations — in the effort to speed
up availability of medical countermeasures.

28

IPPPR Background Paper 5 — “Access to Vaccines, Therapeutics, and Diagnostics.”

29

For instance, CEPI could support development and technology transfer of a yellow fever mRNA vaccine, which would set up a new manufacturing plant witha potential commercial product in the inter-pandemic period but prepared to manufacture mRNA-based vaccines during a pandemic. UNICEF could support
the tech transfer for key vaccine platforms from manufacturers to entities based in LICs and MICs by supporting the business case, incentivizing regional
supply, supporting prequalification for new manufacturers and awarding them UNICEF offers for pediatric vaccines to ensure a warm manufacturing baseand functional production sites.

40

PLUGGING FOUR MAJOR GLOBAL GAPS

38. Besides enhancing research upstream, integrated with global surveillance, a whole range of downstream
R&D on medical countermeasures will also have social returns significantly higher than commercial value,
and would be undertaken more swiftly with the aid of the public sector. Examples include:a. Efficacy studies (e.g. studies to ascertain the optimal dosing regimen given vaccine shortages, and toevaluate mix-and-match vaccine doses, should take place in parallel with standard clinical trials, so thisinformation is available as soon as possible.)b. Thermo-stable mRNA vaccines
c. Repurposing of generic drugs
i. A Repurposed Generic Development Program (RGDP)30 could be part of this global ecosystem.
ii. Employing public-private partnerships with academic labs, clinical development networks and drug
manufacturers, to identify promising drug repurposing targets, coordinate clinical trials, and contract
for the manufacturing of promising candidates.
d. Earlier release of data from clinical trials, before final regulatory approvals, can also shorten the responsetime for investments in production capacity.
39. Governments and international organizations should also fund rigorous, quantitative evaluations of the causal
impact and efficacy of various non-pharmaceutical interventions (NPIs).
a. These include mask-wearing, ventilation, closure of different institutions (schools, restaurants, public
transport), and reduction in contact between people, indoors and outdoors.
b. This will allow governments to design NPIs appropriately to reduce transmission in a way that is more sustainable
over time, and minimize the economic and social costs of achieving targeted transmission reductions.

(4) Global governance: to ensure the system istightly coordinated, properly funded and withclear accountability for outcomes
40. The current global health architecture is not fit-for-purpose to prevent a major pandemic, nor to respond withspeed and force when a pandemic threat emerges. As the Global Preparedness Monitoring Board highlights,
the system is fragmented and complex, and lacks accountability and oversight of financing of preparedness.
41. We must address this by establishing a governance mechanism that integrates all the key players in the global
health security ecosystem, with the WHO at the center. It should integrate health and finance bodies, withina tightly networked system of responsibility and accountability.
a. Ensuring adequate and sustained investment in normal times, to break the cycle of panic and neglect inpandemic preparedness

30“Generic drug repurposing for COVID-19 and beyond”, Susan Athey et al, 15 July 2020.

41

PLUGGING FOUR MAJOR GLOBAL GAPS

b. Enabling the world to respond with speed and force when a pandemic does strikec. Putting the system on stronger and more reliable financial footing, anchored in rules-based multilateral fundingi. Going beyond funding for specific diseases and interventions towards broader investments in corecapacities needed to prevent and respond to future pandemics
42. Several global mechanisms have been set up in recent years, including the Global Preparedness Monitoring
Board (GPMB)31, Independent Oversight and Advisory Committee (IOAC)32 for the WHO Health Emergencies
Programme and the Global Health Security Agenda (GHSA)33. However, none has the mandate to ensure
the effective coordination of key health and finance institutions needed to achieve the objectives above.

Establish a Global Health Threats Board
43. We propose establishing a new Global Health Threats Board (Board). This will comprise a G20+ group ofcountries and major regional organizations, to provide systemic oversight of finance for pandemic PPR,
and ensure coordination and accountability of the key international health and finance organizations. The
Board should be supported by a permanent, independent Secretariat, drawing on the resources of the
WHO and other multilateral organizations.
44. This new Board will complement the recent proposal by the IPPPR for a Global Health Threats Council, tobe established by the UN General Assembly and mainly comprising Heads of State/Heads of Government34.
The Panel supports the case for top-level political leadership to demonstrate the strong commitments requiredfor global health security.
45. The Board will aim more specifically to match tightly networked global governance with financing, which
are both critical enablers to reduce pandemic risks. It is loosely modeled on the successful experience of the
Financial Stability Board (FSB), which was established by the G20 following the Global Financial Crisis and has
played a key role in strengthening global financial system resilience35. It also has similarities with the Global
Health Board proposed by the Pan-European Commission on Health and Sustainable Development.
46. The Board should make available progress reports to G20 leaders as well as to the UN General Assembly through the
UN Secretary General. These reports should include the allocation and usage of funds by the Global Health Threats
Fund (see below), as well as reliable and transparent reporting of investment outcomes to ensure accountability.

31

The GPMB, which was set up by the WHO and the World Bank in 2018, is a time-bound scientific advisory body, not a policy-making board. It provides an
independent appraisal for policy makers on progress towards preparedness and response capacity.

32

The IOAC was established in 2016 with a specific mandate to provide ongoing oversight by a group of health and humanitarian experts of the effectivenessof WHO’s Health Emergencies Programme.

33

The GHSA, established in 2014 and currently extended till 2024, facilitates target-driven, multi-sectoral coordination and communication among its members.
It currently lacks the necessary higher-level political engagement, financing, and wider country membership required for oversight of pandemic PPR.

34

The UN General Assembly will appoint two Co-Chairs for the Council and the G20 shall be invited to nominate a Co-Chair. The three Co-Chairs will put forward
suggestions for the remaining Council members, for the UN General Assembly to endorse.

35

The FSB’s role has comprised:i

Identifying risks to financial stability and orchestrating appropriate responses amongst financial regulatorsii

Promoting coordination of policy development and exchange of information and best practices among financial stability authorities and standard-setting bodies

iii

Overseeing member jurisdictions’ implementation of agreed commitments, standards, and policy recommendations through implementation monitoring, peer
review and disclosure

42

PLUGGING FOUR MAJOR GLOBAL GAPS

47. Mandate. The Panel recommends that the Board be mandated to provide systemic financial oversight to ensure
proper and timely funding for pandemic PPR across the international system and the most effective useof funds. This will require a few functions:a. Identify the key priorities to be addressed by the proposed Global Health Threats Fund, which would
be established as a Financial Intermediary Fund (FIF) at the World Bank. The most efficient governancearrangement could be for the Board to constitute a committee (‘Investment Board’) to directly oversee
the Global Health Threats Fund. (Proposal 2 in Section C.)
b. Contribute to a tightly coordinated approach among all the relevant international organizations, withjoint and clearly delineated responsibilities, to ensure the most effective use of funds with each institution
doing what it does best in pandemic PPR.
c. Ensure complementarity between multilateral and bilateral funding and initiatives to maximize their
combined impact.
d. Identify gaps for proactive action and funding:i. Review emerging pandemic threats based on scientific assessments and a global health risk map.
ii. Oversee the proposed HSAP, to be instituted and coordinated by the WHO and World Bank.
1. This will provide in-depth assessments of countries’ pandemic prevention and preparedness capabilities
and investments.
2. It would take into account findings from the JEEs and other assessments.
The Board should, in these regards, take reference from the initiatives and work of the proposed
Global Health Threats Council.
e. Ensure that when a pandemic threat emerges, global resources are swiftly mobilized and flexibly deployed
to support the key international institutions, which should readily constitute a global pandemic response force.
48. Composition. The Board should have leadership and membership that ensures credibility, effectivenessand inclusivity.
a. We believe that the G20 is the most effective platform for this new Board, given the sizeable role ofG20 nations collectively in funding pandemic PPR (if relying on established approaches for international
contributions), and in containing global pandemic risks given their size and global interconnectedness.
b. Anchoring the Board in the G20 also ensures the participation and active collaboration of both Health and
Finance Ministers. This will build on the efforts at the G20 to deepen collaboration between health andfinance authorities, with the inaugural joint meeting of Health and Finance Ministers in 2019.
c. However, the composition of the Board would have to be expanded to comprise a broader ‘G20+’ group,
including the major regional organizations and a rotating representation of countries that are more vulnerable
to infectious disease outbreaks with pandemic potential. It should also include other significant non-G20
contributors to the proposed Global Health Threats Fund that is discussed in Section C of this report. The
geometry of the Board should provide for flexibility so as to respond to the major threats of the day.
49. Provisions should be made to ensure that the leadership of the Board does not rotate every year. We recommend
a three-year term to ensure adequate continuity, besides the establishment of the permanent Secretariat.

43

PLUGGING FOUR MAJOR GLOBAL GAPS

50. Advisors. The leadership of key global and regional agencies with major roles in funding and implementing
pandemic preparedness and response programs would serve as Advisors to the Board. Besides the WHO,
which plays the leading role, they should include the leading multilateral agencies as permanent Advisors: theIFIs (World Bank, IMF, and the rotating chair of the Heads of Regional Development Bank meeting) and theWTO. They should also involve either on a permanent or rotating basis, the One Health partners (OIE, FAO
and UNEP); major global health intermediaries (CEPI, Gavi, Global Fund, FIND, UNICEF, WFP, Unitaid, OCHA);
regional Centers for Disease Control and Prevention (e.g. Africa CDC, ECDC); philanthropies with a large rolein funding global health and pandemic preparedness; relevant civil society organizations; and leading private
sector participants.
51. Scientific advisory panel. More effective pandemic PPR requires improved data collection, system-wide
analysis of emerging health threats, and advice based on the best available science. GPMB is working on a
global monitoring framework and developing a dashboard using a risk scoring and preparedness measurement
approach. It will bring together different data sources and synthesize them. We recommend that the GPMB
be transformed to constitute this scientific advisory panel (“Intergovernmental Panel on Epidemic Risks
and Infectious Health Threats”), drawing on the parallel of the Intergovernmental Panel on Climate Change36.
The Panel should be independent, and tap on a large network of scientists to analyze data on risks and thelevel of management of those risks across all geographies. This Panel’s reports would serve as valuable input
to both the Global Health Threats Council proposed by the IPPPR and the Board.
52. The Board must ensure that the world leverages fully the strength of regional ownership.
a. An example in the last year has been the African Union (AU)’s initiative to establish the African Vaccine
Acquisition Task Team (AVATT) to overcome the continent’s lack of access to vaccines. (See Annex F.)
i. The AVATT was launched in August 2020, under the leadership of the AU and Africa CDC, and supportedby the WHO, UN Economic Commission for Africa (UNECA), and UNICEF. It aims to achieve a minimumof 60% immunization of the African population to eliminate COVID-19, augmenting the COVAX initiative.
53. The Board must also ensure that there is continuous learning from responses to pandemics and outbreaks. It
should promote post-crisis reviews of responses, especially at the national level, to generate solid, evidencebased national policies and investment plans for pandemic PPR and enable sharing of best practices
globally. This will help ensure that injections of new resources can be most effectively deployed.

36

See also https://www.nature.com/articles/s41591-021-01374-x

44

C. FINANCINGPRIORITIESThe Immediate Task:
Funding ACT-A and COVAX
Financing Future Security
from Pandemics
 dopt a systemic approachA
to ensure enhanced andpredictable global financing
for pandemic PPR	Establish a
Global Health Threats Fund	Develop resilient domestic
finances for prevention andpreparedness	Strengthen financing for the
WHO and One Health, and put
it on more predictable footing	Make financing of global
public goods part of the coremandate of World Bank andother MDBs
	Enable fast-tracked surge
financing by the IFIs in
response to a pandemic	Ensure complementarity
between multilateral andtargeted bilateral funding	Leverage the capabilities andresources of the private andphilanthropic sectors
	Develop insurance solutions
for adverse compensation
events associated with use of
medical countermeasures

FINANCING PRIORITIESC. Financing Priorities
The Immediate Task: Funding ACT-A and COVAX
54.	The G20 HLIP’s mandate concerns reforms and financing solutions to strengthen preparedness and response
to future pandemics. However, we must first end this pandemic. We need to take bold, concerted actions
to lift the world out of the COVID-19 crisis.
55.	The first priority for the international community is to agree on and implement an action plan to vaccinate
the majority of the world’s vulnerable population before the end of 2022.
a. Achieving this requires closing the gap in vaccine supply, scaling up delivery capacity across countries
to make use of this supply and ensuring that lack of financing is not a binding constraint at any point of
this process.
b. Despite welcome progress on all fronts, the world is not yet on an assured trajectory to achieve an end to
this pandemic by the end of 2022.
c. The most immediate task is to close the urgent financing gaps for ACT-A and its COVAX Facility for 2021
and 2022.
d. The IMF has presented a cogent US$50 billion proposal to vaccinate 40% of populations in all countries by
end-2021 and 60% by mid-2022, and ensure adequate supply of diagnostics, therapeutics and personal
protective equipment (PPE). This will require an urgent combination of grant financing, concessional andnon-concessional loans coming from a variety of stakeholders37.
56.	
There are now a number of promising proposals on how the required funds can be mobilized and deployed toachieve the goal of global immunization against COVID-19. Among them, the following merit urgent consideration:a. Raising additional grant financing is the most appropriate way to support LIC access to vaccinesand other medical countermeasures, as well as global public goods like surveillance and research38.
However, relying on ad hoc bilateral contributions — as we have done for the last year and a half — has stillleft a large gap to be closed. Recent additional commitments from the G7 countries as well as the effortsof Norway and South Africa, Co-Chairs of the ACT-A Facilitation Council, to build support for equitableburden-sharing amongst countries, now need to be accelerated and followed through from commitment
to disbursement.
b. In parallel to efforts to mobilize additional grants, LICs and MICs should be able to acquire vaccinesand other resources by drawing on concessional finance from the International Financial Institutions(IFIs). Borrowing from existing or new IFI facilities should be seen as a second-best alternative to grantfunding; however, rapid access to concessional loans is far better than delaying vaccine purchases andvaccination drives until sufficient grants have been mobilized.
i. Existing vaccine financing windows in the MDBs need to be expanded and streamlined to disburse
funds more expeditiously and through upfront bridge finance, in coordination with ACT-A and the
COVAX Facility.

https://www.imf.org/en/Publications/Staff-Discussion-Notes/Issues/2021/05/19/A-Proposal-to-End-the-COVID-19-Pandemic-460263

37

	Agarwal and Reed (2021) suggest that besides an upfront grant of US$4b to the COVAX AMC, there are two additional options to address the funding gapthat rely on the existing institutional framework:

38a.	Reducing donors’ upfront commitment by relying on the International Finance Facility for Immunisation (IFFIm) to issue Vaccine Bonds against a long-term
donor commitment.
b. Relying on in-kind donations to equalize the distribution of vaccine pre-purchases across countries.

46

FINANCING PRIORITIES

ii. The IMF should urgently consider introducing a time-bound vaccine financing window that would
provide quick access to funds to help LICs and MICs to close remaining COVID-19 vaccine financing
gaps, including through COVAX.
iii. Donor grants could be used to help reduce the cost of this borrowing and to repay the associatedprincipal when it comes due.
c. In addition, IDA could provide an additional US$10 billion in grant support during IDA19, based on
immediate reserve capacity. The grant could be used for vaccine procurement and rollout through COVAX
and other regional procurement arrangements for 2021 and 2022. It is important to design this support in a
way that facilitates COVAX and other aggregated mechanisms to enter into advance purchase agreements
as needed.
d. The proposed allocation of SDRs provides a one-off instrument to help meet urgent financing needs in
response to this pandemic. In addition to the direct allocation that LMICs will receive as their proportional
share of the total US$650 billion, a portion of the SDRs of countries not in need could be reallocated tomeet urgent needs of LMICs while preserving the unique character of the SDR as an international
reserve asset.
i. This could be done through providing additional general liquidity and balance of payments support, forexample through rechanneling $25 to $35 billion SDRs under the Poverty Reduction and Growth Trust.
ii. The ‘excess SDRs’ could also be directed more specifically to support accelerated vaccination, forexample by funding a newly created, time-bound vaccine window to provide concessional lending forthis use.
iii. The Panel also supports expeditious exploration of the feasibility of other mechanisms, such as establishing
new trust funds or channeling SDRs through MDBs, which aim to further increase the reallocation of
resources to support COVAX or the financing needs of countries not covered by the PRGT.
e. Critical too are efforts to help countries develop implementation plans for broad-based population accessto vaccines.
i. The World Bank has made significant efforts through its Vaccine Readiness Assessment Program39,
including the development of cold chain capacity, information campaigns and training of human resources,
but challenges remain, with only about 30% of total commitments out of the World Bank Multiphase
Programmatic Approach financing going to delivery and country readiness.
ii. The World Bank and RDBs should continue to scale up such programs to help countries fill gaps invaccine delivery, and the broader strengthening of the public health response.
iii. The IFIs should adjust their policies and work with country governments to assure that fiscal space or
lending envelopes do not represent a barrier to financing.

Financing Future Security from Pandemics
57.	The key focus of the Panel’s proposals is on the governance enhancements and financing required to avoid
future pandemics.
a. Effective pandemic PPR is the result of a continuum of investments at the national, regional and global levels.

39

In October 2020, the World Bank’s Board approved US$12 billion of fast-track financing to IBRD/IDA-eligible countries for purchasing vaccines as well as
strengthening primary health care systems to deliver the vaccines.

47

FINANCING PRIORITIES

b. Critically, it requires that investments be sustained, and not just made in response to each new crisis.
58.	We have made estimates of the scale of funding required — in total and for each function along the continuumof pandemic PPR.
a. Our work benefitted from the inputs of the GPMB on the scope of operations required for pandemic PPR (seeAnnex G). Our estimates also took detailed reference from two comprehensive exercises by the WHO and
McKinsey, which we complemented with other sources40. We have studied these various estimates carefully
and adopted estimates that we feel best match the scope of pandemic PPR for the purpose of this report.
b. We have grouped the estimates under three main categories of prevention and preparedness.
i. Robust Surveillance and detection networks
ii. Building resilience in health systems
iii. Supply capacity for medical countermeasures
The costs for each are presented at Annex H. For simplicity below, we have reduced the ranges to a set ofcentral figures. These are current best estimates based on WHO, McKinsey and others to size the various
requirements for future pandemic prevention and preparedness. The costings will have to evolve, and will
have to be reviewed regularly to ensure adequate overall funding across the global health security system.
c. We can only avoid future pandemics if we invest substantially more resources than we have been
willing to spend in the past, and which the world is now paying many times over in dealing with
COVID-19’s damage.
d. Much of this has to comprise domestic investments by national authorities in the key capacities needed
to prevent and contain future pandemics. These investments, specifically for pandemic prevention andpreparedness, must be part of broader national efforts for healthcare and public health system strengthening.
e. However, domestic actions alone will not prevent the next pandemic. We must collectively commit to
expanding international financing by US$75 billion over the next five years — or US$15 billion eachyear. This will comprise funding for both global-level functions and the support needed for LICs and LMICs
to invest in the country-level global public goods needed for pandemic PPR.
f. The scale of investments required reflects the need to catch up from a long period of underfunding.
Investing upfront in the next five years will lower the otherwise growing risks of pandemic, and reduce thetotal costs of preventing and responding to major outbreaks in future years.
g. The Panel believes that US$15 billion per year is the absolute minimum in the new international
investments required in global public goods that are at the core of effective pandemic prevention
and preparedness. This estimate excludes the cost of other complementary investments that will contributeto resilience against future pandemics, while providing benefits to countries in normal times.
i. It excludes the costs of containing antimicrobial resistance (AMR), which is a growing threat tohealth security nationally and globally. AMR may worsen the impact of future epidemics and pandemics
by rendering ineffective the treatment of such infections and associated co-infections, as evidenced
in previous influenza pandemics. Countering AMR is estimated to cost US$9 billion annually41. Since
AMR containment measures have benefits well beyond pandemic PPR and operate through ongoingprograms for more rational use of antimicrobials in health and agriculture, we have not included thesecosts in our estimates.

40	Including estimates by the Center for Global Health Science and Security at Georgetown University and Talus Analytics; the Coalition for Epidemic Preparedness
Innovations (CEPI); and the G-Finder survey Landscape of Emerging Infectious Disease Research and Development.

41	https://documents1.worldbank.org/curated/en/323311493396993758/pdf/final-report.pdf

48FINANCING PRIORITIES

ii. The estimated costs would also be much higher if they included upstream environmental investmentsfor prevention and a more extensive scope for One Health including upgrading of veterinary
services; basic and pre-clinical research; and the broader strengthening of healthcare systems
and delivery infrastructure beyond that directly related to pandemic PPR. These actions provide
continuous benefits to countries, and have therefore been excluded from our strict estimates of costs
specific to pandemic PPR.
iii. Further, the estimated minimum investments required are based on conservative assumptions on thescale of at-ready manufacturing capacity required for medical countermeasures42.
59.	The Panel hence calls for a concerted international effort to provide larger-scale and more predictable resources
to fill the major gaps in pandemic PPR. With contributions apportioned equitably, they are affordable to all
nations. They provide immense social returns, both nationally and globally:a. They will materially reduce the risk of events whose costs to government budgets alone are 700 times aslarge as the additional international investments per year that we propose, and 300 times as large as thetotal additional investments if we also take into account the domestic spending necessary.
b. The next major pandemic may come at any time. Even if it occurs only 10 or 20 years from now, thecosts to governments will still be 10 to 25 times the cumulative additional investments in prevention
and preparedness over the years until then, in present value terms43.
c. The full damage of another major pandemic, with its toll on lives and livelihoods, will be vastly larger. Basedon estimates by Metabiota, there will be 4 million expected deaths in the next decade from the threepathogen groups — pandemic influenza, epidemic coronaviruses and viral hemorrhagic fever — which isroughly equivalent to the losses to date in today’s pandemic.
60. We highlight our key financing proposals:(1) Adopt a systemic approach to ensure enhanced and predictable global financing for pandemic PPR(2) Establish a Global Health Threats Fund
(3) Develop resilient domestic finances for prevention and preparedness(4) Strengthen financing for the WHO and One Health, and put it on more predictable footing(5) Make financing of global public goods part of the core mandate of World Bank and other MDBs
(6) Enable fast-tracked surge financing by the IFIs in response to a pandemic(7) Ensure complementarity between multilateral and targeted bilateral funding(8) Leverage the capabilities and resources of the private and philanthropic sectors(9) Develop insurance solutions for adverse compensation events associated with use of medical
countermeasures

42

	Our costings for incentivizing supply capacity for all medical countermeasures are about half of the costs estimated for vaccines alone by the Accelerating
Health Technologies (AHT) group (comprising economists and statisticians, including G20 HLIP member Michael Kremer). The AHT group estimates thatinvestments in needed production capacity and supply chain inputs for vaccines alone require US$60 billion in public funding to enable the capacity to
be installed over a period of years, and about US$2 billion per year thereafter to maintain this capacity. Their estimates take into account that most vaccine
candidates fail, and in order to repurpose capacity in parallel with clinical trials, any vaccine capacity would need to be split between many candidates. Thereis therefore a need for significantly larger vaccine capacity. However, the added investments generate far greater benefits in future and far higher returns
than a small scale of investments would.

43	Even if we assume the investments in prevention and preparedness only reduce the probability of pandemic by 50%, and reduce the cost of any resulting
pandemic by 50% — hence saving 75% of the costs of a COVID-19-scale pandemic — the cost savings to government budgets are 8 to 18 times the cumulative
additional investments over the next 10 to 20 years, in present value terms.

49

FINANCING PRIORITIES

61.	The various proposals are individually necessary, but the real potential is in operating them in totality todevelop a strong and sustainable financing system for pandemic PPR.

(1) Adopt a systemic approach to ensure enhanced
and predictable global financing for pandemic PPR
62.	Our key financing proposals, taken as a whole, seek to ensure enhanced and predictable funding of pandemic
PPR across the system.
63.	The Global Health Threats Board that we have proposed will have the responsibility of systemic oversightof finance for pandemic PPR, to ensure that funding gaps are addressed, and build support for each of theorganizations’ resource mobilization strategies. (See Section B.)
a. There is some parallel in how the G20 has played a role in building consensus for recent IMF quota review
exercises.
	The Global Health Threats Board will also ensure coordination and joint accountability of the key organizations
involved in pandemic PPR.
64.	As set out above, the Panel has assessed that a minimum of US$75 billion in international support over the
next five years (US$15 billion per year) will be needed for investments in global public goods for prevention
and preparedness.
a. The Panel proposes that two-thirds of this additional amount, i.e. US$10 billion per year, should be pooled ina Global Health Threats Fund (Fund) to be deployed across the various organizations and global initiatives(Proposal 2). This new multilateral funding mechanism would enable effective and agile deployment acrossinstitutions and networks to meet the most critical priorities.
b. The remaining US$5 billion should go directly towards strengthening funding to existing institutions. This
must include enhanced and predictable support for the WHO (Proposal 4), strengthening MDB resources
for dedicated pandemic preparedness windows in IDA and other RDBs’ concessional bodies alongside theirmaking better use of grant resources from the global health intermediaries (Proposal 5); and a step-up ofbilateral and philanthropic funding for global health (Proposal 8).
65.	We believe this would be an effective and sustainable approach to international financing for pandemic
prevention and preparedness. Importantly, the new Fund must perform a catalytic function, so that it adds
resources rather than substitutes for the necessary and sustained funding of the various organizations.
66.	The IMF and the MDBs should also introduce pandemic response windows, building on their existing
emergency lending instruments, to scale up funding quickly during a crisis (Proposal 5), with relaxed rules
on country borrowing and automatic access for pre-qualified countries.
67.	The strengthening of the international financing must be accompanied by an agenda of reform in many countries
to mobilize and sustain additional domestic resources to enable investments in national capacities to preventand contain pandemics as well as in the broader strengthening of public health systems. (Proposal 3).

50

FINANCING PRIORITIES(2) E
 stablish a Global Health Threats Fund
68.	The Panel proposes the establishment of a new, dedicated Global Health Threats Fund, aimed at mobilizing
US$10 billion per year, to support and catalyze investments in global public goods for pandemic PPR.
69.	The Fund would serve as a needed multilateral financing mechanism to pool resources internationally, basedon pre-agreed contributions. This new Fund, at two-thirds of the minimum of US$15 billion in additional
international resources required, brings three necessary features into the financing of global health security.
a. Together with an enhanced multilateral component of funding for the WHO, it would provide a stronger
and more predictable layer of financing.
b. It would enable effective and agile deployment of funds across international and regional institutions
and networks, to plug gaps swiftly and meet evolving priorities in pandemic prevention and preparedness.
c. It would also serve to catalyze investments by governments and the private and philanthropic sectors,
for example through matching grants and co-investments.
70.	
We must view this proposed mechanism against the weaknesses of the traditional system of international
financing to address pandemic threats. Bilateral contributions, while valuable, have been unpredictable
and collectively inadequate, while encouraging free-riding on the part of others. Further, replenishment of
resources for the international institutions has been slow. The same system will not enable the world to
avoid the next pandemic.
71.	The Fund would support the following major global actions to plug key gaps in global public goods forpandemic PPR:
a. Building a transformed global network for surveillance of infectious disease threats. This will require amajor scale-up of the network, combining pre-existing and new nodes of expertise at the national, regionaland global levels, with the WHO at the center.
b. Providing stronger grant financing to complement MDBs’ and the global health intermediaries’ support
for country- and regional-level investments in global public goods.
c. Ensuring enhanced and reliable funding to enable public-private partnerships for supply capacity: therapid development, manufacturing and delivery of medical countermeasures on a global scale, so we canpreclude severe shortages anywhere and avoid prolonging a pandemic everywhere.
i. The Fund would provide a critical layer of multilateral support for a new, permanent, end-to-end supply
ecosystem that will build on the lessons learned from the ACT-A coalition of health partners. (See Section B.)
ii. Public investment, through a combination of push and pull contracts44, is needed to share risks andenable private investments in R&D and manufacturing capacity ahead of a pandemic, and ahead of
product use authorization, so that medical countermeasures can be quickly scaled up in a pandemic.
iii. Sufficient capacity is needed to ensure rapid and equitable global access, including by the LICs andLMICs, which is critical to containing a pandemic everywhere. This will require global support. In orderto fund these contracts, a pool of flexibly deployable funds will be needed.

44	Public resources are necessary for a combination of:a.	Push financing — to co-fund R&D and supply capacity. This includes risk-sharing for facility start-up/maintenance costs in the inter-pandemic period,and for scaling up manufacturing / production for a portfolio of candidates and platforms up to the regulatory endpoint.
b.	Pull financing — to assure demand via advance or concurrent purchase of medical countermeasures on behalf of countries via regional and global
procurement bodies such as the Global Fund, Gavi, AMSP, and others. This is especially critical during the initial phases of an epidemic or pandemic.

51

FINANCING PRIORITIESd. Supporting research and breakthrough innovations that can achieve transformational change in efforts toprevent and contain future pandemics, complementing existing global R&D funding mechanisms like CEPI.
72.	The new Fund would ensure that these gaps are addressed swiftly, and have the flexibility to deploy funds acrossthese functions based on emerging priorities. It would aim to augment the existing international organizations,as well as regional and non-state actors that are performing important roles. The Fund should complement, andnot substitute for, the other sources of financing noted in this report, in particular the concessional windows
of MDBs and funding for the existing global health organizations. The functions of the Fund should be definedto ensure complementarity and additionality in relation to financing for the various other institutions.
73.	The Fund will also seek to incentivize joined-up actions by the different organizations to enable forceful andcoherent preparedness and response plans. Funding must also drive progress on accountability for global
health outcomes, while not creating duplicative or onerous structures for reporting.
a. The Global Environment Facility (GEF), which is a financial mechanism for five conventions including the
UNFCCC and Convention on Biological Diversity, is a useful reference in how countries have come together
to finance the global commons, in an institutional landscape with many actors45.
74.	The Panel proposes the Fund be structured as a Financial Intermediary Fund (FIF)46 at the World Bank.
The Bank would perform the treasury functions, and could also leverage contributions on the market, as it doesfor other FIFs that it hosts — for example, Global Environment Facility and key global health intermediaries
like the Global Fund, Gavi and CEPI.
75.	Governance of the Fund will operate independently of the World Bank, as with other FIFs, and under an
Investment Board of its own.
a. This is necessary as the World Bank may be among the organizations that will receive funds.
b. The Investment Board could be constituted as a committee of the Global Health Threats Board,
to ensure that its operations are consistent with the Global Health Threats Board’s identificationof priorities and gaps.
c. The Investment Board should also tap on specialist and expert advice on detailed financing.
d. The Investment Board should ensure transparency on the allocation and usage of funds and their outcomes,
and provide updates to the Global Health Threats Board.
76.	As it may take time to reach a formal system of binding international commitments to the Fund, resources
should be kickstarted by direct contributions by G20 and other governments, ideally in amounts equivalent
to an assessed contribution scheme, as well as philanthropic and corporate contributions.
77.	The Panel considered carefully the scope for the Fund to contribute to the surge financing that will be required
for response to a pandemic, in particular by borrowing resources from financial markets. This option could
entail borrowing against guarantees of repayment from future national contributions. The Panel’s assessment
is that the surge financing role, and the associated market borrowing to support this, would be more
effectively placed at the World Bank. The World Bank has the balance sheet and market presence to raise
funds more quickly, and the institutional muscles to disburse funds to countries more flexibly in a crisis.
(See Proposal 6.) The Global Health Threats Board’s role in systemic financial oversight will be essential incoordinating actions with the World Bank to raise funds swiftly when a pandemic strikes.
45

	There are useful lessons in the GEF’s experience: providing a comprehensive strategy for managing the global environmental commons; loose burden-sharing;
provision of funding to leverage funding from MDBs, foundations, the private sector and other non-state actors, as well as countries; its relationship with theWorld Bank as Trustee of the facility.

46

	A FIF is a type of trust fund for which the World Bank provides tailored administrative, operational, legal and financial services, but in which the Bank’s roleis limited to providing these services unless otherwise specified. (See https://fiftrustee.worldbank.org/en/about/unit/dfi/fiftrusteeI) In this case, the Panelrecommends that the Global Health Threats Fund operate in a functionally independent and effective manner, reporting only to its Board, following on theexample of the Global Environment Facility and the Adaptation Fund. This independence is necessary as the World Bank will be among the organizations
that will receive funds, and there would be a conflict of interest otherwise. It is for this same reason that the Fund cannot be a part of an existing arrangement
such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.

52

FINANCING PRIORITIES(3) Develop resilient domestic finances for prevention
and preparedness78.	National actions remain the foundation of global efforts to prevent and prepare for future pandemics. The
Panel calls on governments everywhere to significantly scale up national capabilities for surveillance, detection
and containment of any new outbreaks. These should ensure that they meet existing and new WHO, OIE, FAO
and other international standards for preparedness and global health security.
79.	Besides investing in the public goods directly related to pandemics, governments should also work towards
more resilient health systems, as they provide foundational supports in avoiding future pandemics andminimize excess mortality in pandemic conditions. These include broader investments in national healthcare
and public health systems to address ongoing endemic diseases and improve basic sanitation. Governments
should also design safety nets able to expand in response to pandemic shocks.
80.	To achieve this, we need a long-term strategy to enhance domestic resource mobilization for national andglobal public goods, complemented by international financial support for the LICs and LMICs especially.
81.	The mix of domestic and international financing reflects the different levels of global public goods needed
to reduce pandemic risk:
a. A system of globally networked surveillance and research requires both international- and country-level
capacities, but the benefits are mainly not internalized by individual countries. In the case of LICs and LMICs
in particular, these should be largely financed by collective mechanisms.
b. Strengthened national capacities to stop the spread of infectious diseases have clear benefits for individual
countries, but nonetheless have positive externalities for the global community. Domestic financing by
national authorities must remain the primary source, augmented by external financing support for the LICs
and LMICs.
82.	The challenges today are considerably larger than they already were before the current pandemic. Poorer
countries have very limited capacity to buffer their populations and economies through fiscal and monetary
policies, apart from their scarce access to diagnostic tools and vaccines resulting in a much more prolonged
crisis. Further, many entered the crisis with elevated debt levels, and are vulnerable to increased debt servicing
costs in the years to come.
83.	
There is now also a significant risk of lasting health and economic damage in poorer nations over the medium
term, more so than they experienced after the Global Financial Crisis. This will make it harder for themto cope with an endemic COVID-19 pandemic, as well as future outbreaks. Further, the consequences ofincreased poverty, conflict and displacement will not be purely economic, nor contained within individual nations.
84.	Governments working with the IFIs must embark on a major agenda of reform to mobilize and sustain
additional domestic resources to invest in the key capacities needed to prevent and contain future pandemicrisks, integrated with efforts to strengthen national health systems and achieve Universal Health Coverage47,
while enabling their economies to return to durable growth. Low- and middle-income countries will need to
add about 1% of GDP to public spending on health over the next five years.
a. The IFIs should work with national governments to develop a plan for more resilient tax revenues over the
medium term. Efforts to improve tax collection capacity, plug tax loopholes, and strengthen enforcement
against illicit financial flows and other leakages must remain critical priorities. Taxing tobacco products andother ‘health bads’ to reflect their full health and economic costs remains a promising option in many countries.
	Sustained investments in global health towards achieving UHC with primary healthcare at its center was included in the recent Rome Declaration of the Global
Health Summit. Promoting and strengthening partnerships to achieving UHC for all continues to be a focus of the G20 Health Working Group.

47

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FINANCING PRIORITIES

b. Governments should clearly define and track budgetary expenditures on outbreak prevention andpreparedness, building on newly established expenditure categories for preparedness as part of national
health accounts at the OECD and WHO, and how these enable them to meet the WHO’s IHR, with consistency
across different levels of government.
c. Building on the findings of the proposed Health Security Assessment Program (HSAP) to be conductedby the WHO and the World Bank, and other metrics such as the JEEs, State Party Self-Assessment
Annual Reporting (SPAR), and GHS Index, every country should prioritize the development, costing andimplementation of a national action plan for health security to identify gaps and financing requirements.
Finance and Health Ministries should be full partners in this effort.
i. This must include a concerted plan to develop the skilled human resources needed for both surveillanceof emerging infectious diseases and resilience in healthcare and public health systems.
ii. Performance-based budget policies and matching fund schemes between national and sub-national
governments are promising strategies. They can incentivize more accurate, timely, complete, andopen reporting of pathogens, diseases and deaths in human and animal populations, if accompanied
by independent verification or audit of sub-nationally reported figures.
iii. Increased resources to prevent and contain infectious disease outbreaks are necessary, to avoid
crowding out other critical healthcare needs. Evidence from COVID-19 shows a sharp rise in deaths
from non-communicable diseases equal in some cases to COVID-19 deaths, due to delays or a lack ofcare for persons with other illnesses.
iv. These expenditures must however be regularly assessed for value for money — for example, defining
the minimum samples needed to representatively conduct genomic surveillance.
d. The IFIs, together with the WHO, bilateral development partners, and global health intermediaries likethe Global Fund, should work with governments to develop these strategies, provide technical assistanceand ensure the necessary external financial assistance to complement governments’ efforts to enhancenational domestic financing.
e. Multilateral and bilateral development partners can also incentivize investments in pandemic prevention
and preparedness at the country level, via various financial instruments. (See also Proposal 5.) These
include:i. Making lending for pandemic preparedness more concessional
ii. Complementing grants and greater concessionality in financing (e.g. IBRD rate buydowns) with existing
instruments such as results-based and programmatic lending to support progress towards standardsiii. Incentivizing governments by requiring that grants are co-matched by national fiscal commitments(4) Strengthen financing for the WHO and One Health,and put it on more predictable footing85.	
We need enhanced, reliable and sustainable financing for WHO and its One Health partners to performtheir critical functions.
a. The WHO plays a key role in each of the three major gaps we have identified in this report.

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FINANCING PRIORITIES

i. Surveillance. The WHO must be at the center of a global network of expertise for genomic andepidemiological surveillance. The One Health approach must be supported, with the WHO ensuringthat there are no gaps in the surveillance-to-action loop.
ii. Resilient national systems. The WHO, through its IHR, provides guidance to countries to develop wholeof-government health security plans, with the IHR serving as a benchmark against which to track progress.
iii. Supply of medical countermeasures. WHO has a leading role within the ACT-A coalition of health partners.
b. The WHO is heavily dependent on voluntary funding. It is also under-resourced and lacks predictable
funding to meet its key functions in global health48. The Panel agrees with the IPPPR’s assessment on the
weaknesses of the funding for WHO, and its proposal to enhance the share of multilateral funding for the
WHO through increased assessment-based contributions — with Member States’ fees to be increased
from the current one-quarter to two-thirds of the budget for the WHO base program, and an organized
replenishment process for the remainder of the budget.
i. The latest two-year budget for the WHO is about US$4.8 billion49, of which its base program comprises
about US$3.8 billion.
ii. Increasing assessed contributions to two-thirds of the WHO’s base program will represent more thana US$1.5 billion increase, or an additional US$0.8 billion per year.
iii. This increase can be funded in part by a reallocation of existing voluntary contributions from countries,
but will also require modest increased contributions from most countries50.
c. Our proposed overall financing framework for global health security calls for strengthened funding to bechanneled towards the WHO and other existing institutions, as well as the effective and agile deploymentof funds by the Global Health Threats Fund across international and regional institutions and networks toensure that gaps are plugged on a timely basis and to meet evolving priorities in pandemic PPR.

(5) Make financing of global public goods part of thecore mandate of World Bank and other MDBs
86.	G20 leaders should work with other shareholders to make global public goods part of the core mandate of
the MDBs.
87. The MDBs are uniquely placed to do so, by their ability to:a. Mobilize international resourcesb. Leverage capital or guarantees
c. Incentivize countries to invest in global public goods, as part of their broader country operations
d. Support country and regional investments with direct development impact as well as global healthsecurity benefits48

49

	T he IPPPR highlighted that: “The way that WHO is financed today has serious impacts on the quality of the organization’s performance. Its precarious
financing is a major risk to the integrity and independence of its work. Incremental attempts in recent decades to improve the present funding model
have not been successful.”	This excludes US$1 billion for “emergency operations and appeals”, which is a one-off, extraordinary item catered for COVID-19 pandemic response.

50	The largest share of voluntary contributions comes from the Bill & Melinda Gates Foundation and the US Government.

55

FINANCING PRIORITIESe. Provide multi-sectoral coverage and activate robust crisis response mechanisms
f. Catalyze private investments
They are also moving towards working with other development partners in country and regional platforms.
88. Pandemic PPR should be incorporated as a core activity of the WBG, akin to climate.
a. The World Bank Board should set IBRD lending and performance targets for pandemic prevention andpreparedness that are then assessed and tracked as a matter of routine.
b. IDA donors should establish a dedicated pandemic prevention and preparedness window in an expanded
IDA, as part of a successful IDA20 replenishment and leading to a more permanent mechanism. This would
ensure that lending for pandemic prevention and preparedness programs is not constrained by countryspecific IDA allocations. To ensure that the funds for this are both additional to regular IDA contributions
and on sufficiently concessional terms, funding of this window should rely more heavily on new grant
contributions from IDA donors.
c. RDB Boards should ask for each institution’s strategy to support pandemic preparedness and reduce risks,
including through dedicated strategies and lending targets/windows as appropriate.
89.	In deploying funds, World Bank and other MDBs have a suite of financial instruments that can incentivize
investments in pandemic prevention and preparedness at the country level.
a. Make lending for pandemic preparedness more concessional. IBRD lending for these projects could bemade more concessional through accompanying grants which could be provided through the proposed
Global Health Threats Fund. IDA lending for this purpose could rely more heavily on grants provided under
the new IDA pandemic preparedness window.
b. Grants and greater concessionality in financing (e.g. IBRD rate buydowns) can be complemented withexisting instruments such as results-based and programmatic lending to support progress towards
agreed global standards on preparedness. The World Bank should develop a strategy to effect this throughits lending and technical assistance. This would facilitate tracking of progress towards agreed global
standards on preparedness.
c. IDA support for pandemic prevention and preparedness should also be made more concessional andshould seek to incentivize domestic investments through matching grants to LIC governments.
d. The MDBs must also work in concert with other grant-making mechanisms including the global healthintermediaries like Global Fund and Gavi, bilateral aid agencies, and the new, multilateral Global HealthThreats Fund, to leverage each other’s funding for investments that will strengthen health system resilience.
This would build on existing co-financing framework agreements, e.g. between World Bank and Global Fund.
90.	
Shareholders should be prepared to provide MDBs with additional capital and concessional resources
to enhance their role in pandemic PPR:
a. An immediate priority is to ensure the successful completion of the upcoming replenishment of IDA,
and other concessional financing windows, at a level that is able to respond to the heightened needs of
LICs in the post-COVID recovery.
b. The MDBs should explore greater leveraging of their shareholder capital. The Panel calls on the G20
to commission an independent review of the scope for doing so. This will determine the needed scaleof future capital increases which should then be forthcoming as required.

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FINANCING PRIORITIES

c. MDB capital requirements can also be met by more innovative mechanisms along the lines of IFFEd51,
which uses donor guarantees to enable MDBs to raise resources on the capital markets, and go above
their lending limits. This will enable donors to leverage their grant contributions by an estimated 27 times,
much higher than the IBRD loan to paid-in capital ratio of at most five times. (See Annex I.)
d. Existing trust funds at the MDB for preparedness should also be increased and used to leverage andcomplement greater IDA and IBRD lending for this purpose.

(6) Enable fast-tracked surge financing by the IFIs in
response to a pandemic
91. We need at-ready surge financing mechanisms to respond effectively to a pandemic.
a. Unlike the resourcing needs for pandemic prevention and preparedness (discussed above), we do not know
in advance the scale of financing required in a pandemic.
i. The size of the resource needs depends on the nature and spread of the pandemic.
b. Funding for pandemic response must include both health-related funding needs as well as the more
traditional fiscal and balance of payments support.
i. The latter is fundamentally important as countries lacking access to funding cannot provide an adequate
health response.
ii. It would be short-sighted to force countries to meet these pandemic costs by cutting other vital
expenditures in education, social protection, etc.
c. The MDBs have a major role in supporting countries to respond to a pandemic.
i. In the Panel’s view, the World Bank and other MDBs should substantially scale up net financial flows
to borrowing countries during a pandemic. They should do so with the assurance of shareholders thatthe resulting requirements for replenishments of concessional funding or for capital increases will be
addressed in a timely way. To this end, single borrower and other country lending limits and IDA
country allocation ceilings need to be relaxed during a pandemic period.
ii. The World Bank should support countries to participate in pooled global procurement mechanisms
for medical countermeasures, through its grants and lending programs. Ensuring guaranteed accessto such financing would enable countries without adequate fiscal resources to still enter into advancepurchase contracts in the early phase of a pandemic.
iii. Access to MDB crisis response windows should be simplified and made more automatic. The
World Bank and many RDBs have existing financing instruments or mechanisms to provide rapid
support in response to natural disasters or other catastrophes.
iv. The World Bank should use its resources to support countries’ safety net surge responses —to enable lockdowns and other pandemic response measures — as it has done in the current crisis.
Supporting the establishment of scalable cash transfer and other safety net mechanisms in at least
50 countries within five years should be a feasible target for the institution.

51

	IFFEd provides additional capacity to MDBs, underpinned by paid-in capital and contingent commitments from donors (15% in cash and 85% in donor
commitments). In turn, the MDBs would leverage this quasi-equity to mobilize additional financing in capital markets. The vehicle would also provide grants
to buy down MDB loans as required to more concessional terms.

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FINANCING PRIORITIES

v. The World Bank and RDBs should work to complement each other’s efforts in financing pandemic
response. The RDBs have stepped up their roles in the current crisis and are preparing to do more ina future pandemic.
vi. MDBs should be enabled to raise funds immediately on the market should their resources needaugmenting during a pandemic. They should do so with the assurance that any borrowing over andabove their regular market operations would result in associated capital increases or be taken off theirbalance sheets through shareholder guarantees52. The World Bank and other MDBs are well-placed toundertake borrowing from the market during a pandemic, leveraging their triple-A ratings.
d. The IMF has a primary role in ensuring a rapid and adequately sized financial response to help
countries deal with a pandemic.
i. The IMF should establish a pandemic response window that provides rapid, automatic and sizeable
financing to members in good standing. This window could be established as part of its rapid
financing facilities — Rapid Credit Facility (RCF)/Rapid Financing Instrument (RFI) — and would be
automatically triggered, for example, upon the WHO’s declaration of a PHEIC.
1. The IMF can use this window to make available up to 100% of quota for all members in good standing
2. Financing would be made upon demand on presentation of the health situation. It would beconcessional and low on conditionality other than health conditionality. The financial conditions
would be comparable to existing RCF and RFI lending. In some cases, additional measures might
be needed to limit the impact on countries’ debt sustainability.
3. Loans disbursed through this window would not be subject to surcharges based on other outstanding
IMF loans to the borrowing country, nor would the amount accessed under this emergency financing
count towards the calculation of surcharges on other loans.
ii. Access limits for regular IMF facilities should also be relaxed during a pandemic. The IMF Board
should also consider whether the policies on surcharges linked to the duration and size of outstanding
IMF loans need to be relaxed during a pandemic.
iii. While the best use has to be made of the currently proposed IMF SDR allocation, its utility in future
crises should be principally to respond to a global need for liquidity. As currently constituted, SDRs area blunt instrument for supporting the liquidity needs of developing countries because of their small
share in total SDR allocations.
e. Appropriately designed debt service relief by other creditors should complement surge lending by
the IFIs in responding to future pandemics. The G20 sponsored Debt Service Suspension Initiative (DSSI)
made a significant contribution from bilateral official creditors to helping (mostly) low-income countries
during this pandemic. However, delays in reaching agreement on its scope and application slowed down
the flow of relief and limited its impact because of the non-participation of some hybrid and most private
creditors. Learning from this experience, the G20 should ask the IMF, working with the relevant stakeholders,
to propose a framework to involve the participation of all creditors — official, hybrid and private — inrestructurings to be instituted in future pandemics.

52

	This market borrowing would have to be above and beyond the MDBs’ existing borrowing operations to leverage their equity to borrow from the market for
ongoing lending operations.

58

FINANCING PRIORITIES(7) E
 nsure complementarity between multilateral andtargeted bilateral funding
92. Multilateral efforts should leverage and tighten coordination with targeted bilateral funding.
a. Bilateral funding has historically been a source of support to pandemic PPR, and finances technical assistanceand know-how exchange in field epidemiology, lab safety, disease surveillance, and general preparedness.
b. Further, much of the capacity that exists today in preparedness is the result of several decades of bilateral
investments in cross-cutting functions under the auspices of HIV/AIDS and Ebola focused programs of funding.
c. Bilateral funding should continue to play an important catalytic role, such as providing seed money as
incentive for LICs and LMICs to make the necessary investments, providing a grant element to complement
multilateral funding, and mitigating risks to attract private sector participation.
d. However, bilateral funding must be better coordinated, so each bilateral development partner’s efforts
are situated within a broader international framework, with a proper division of responsibilities, to avoid
gaps and overlaps.
e. This will mean tighter coordination within country and regional platforms — led by the relevant authorities— and mobilizing multilateral and bilateral development partners, the private sector and philanthropies.
f. This will continue to recognize the contributions of each development partner, but generate greater
development impact.
93.	We have to ensure too that other critical development needs are still met, and targeted bilateral funding is
not diverted away from them to fund better pandemic preparedness, prevention and response, which is a
global public good.
a. It would be short-sighted to bolster our efforts for pandemic prevention and preparedness by reallocating
resources from other critical development priorities in poverty alleviation and human capital development.
b. This is particularly as the crisis has escalated the challenges facing the developing world.
c. Doing so will roll back the gains we have made on the Sustainable Development Goals, and impose larger
costs on the international community eventually.
d. Scarce ODA should only be used for investments that primarily benefit LICs and LMICs, while investmentsthat benefit the world as a whole or primarily HICs or UMICs should be funded from non-ODA budgets
and the private sector.

(8) Leverage the capabilities and resources of theprivate and philanthropic sectors
94.	The scale of financing for pandemic PPR requires significant and sustained increases in resources from every
source — public, private and philanthropic.
95.	However, we need a different construct for partnerships as well as policy, with the official sector engaging
the private and philanthropic sectors continuously, not only once a pandemic strikes.

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FINANCING PRIORITIES

96. The private sector has a key role to play in several dimensions of pandemic PPR.
a. First, in working with governments and international organizations, through public-private-philanthropic
partnerships, to scale up global manufacturing capacity and end-to-end supply chains for vaccines andother medical countermeasures, and other critical supplies.
i. We set out the need for a major scale-up of at-ready manufacturing capacity through partnerships
with the private sector in Section B (Item 3) of the report. These partnerships are critically requiredin order to make adequate capacity in the non-pandemic years viable, and will give extremely high social
returns. In particular, the payoffs to having sufficient at-ready capacity for multiple vaccine candidates
are very large.
ii. Six months into the current pandemic, global demand for ventilators and face masks was ten times
higher than supply. Even 18 months on, PPE and oxygen cylinders and concentrators remain in grossly
short supply.
iii. The IFC and the private sector arms of other MDBs have the tools to catalyze private sector investments
in capacity for medical supplies, and should scale this up.
1. A good example during the current pandemic has been the IFC’s US$4 billion Global Health Platform(US$2 billion from its own account and an additional US$2 billion from its private sector partners),
aimed at increasing access to critical healthcare supplies required to fight the pandemic, including
masks, ventilators, test kits, and vaccines53.
iv. Countries should work with the MDBs and other organizations like UNICEF to mobilize private sector
resources to develop the whole delivery system needed within countries to receive and transport
medical supplies, including cold chain infrastructure, and provide the necessary technical training.
b. Second, in broadening access to care. Pandemic PPR plans must consider all health providers in the
sector, and the ways in which people can most readily access care. In most LICs and LMICs, private sector
providers are important sources of care. They have to be mobilized and properly regulated in supportof public policy objectives, even as governments working with external partners seek to build up more
resilient national healthcare systems over the longer term.
c. Third, there is scope to develop private contingency financing tools to help governments to pool andmanage pandemic risks (Proposal 9).
97.	Beyond the private sector role in pandemic PPR itself, there is need for a very significant increase in private
sector investments in broader development financing, especially for infrastructure. There is significant
scope for expanding the use of risk mitigation tools, including appropriately designed blended financeinstruments, to crowd in and augment private investment and optimize official balance sheets forinvestments in both global public goods and economic development (Proposal 5).
a. The private sector has had very limited involvement in investing in infrastructure in Africa in particular,
where the scale of future infrastructure needs will overwhelm the capacity of the public sector.
b. If we do not make bold changes in strategies of governments and MDBs to mobilize private financing
for infrastructure, we face a permanent reduction in economic growth, a slowdown in poverty
alleviation, and a neglect of critical public investments for pandemic PPR and other public goods
in a large part of the developing world. With well-designed and transparent risk-sharing features andstrengthened regulatory capacity, governments can maximize the efficiency and impact of public incentives.

53	Projects include partnerships with health technology company Philips and the Co-operative Bank of Kenya to help smaller businesses in Africa's health sector
purchase essential medical equipment; and with global standards organization ASTM International to raise standards and compliance requirements for PPE
and promote its use globally.

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98.	The major philanthropic foundations have been playing a critical role in supporting investments withhigh-risk and/or low-commercial incentives. However, the major scale-up of research on infectious diseases
and countermeasures needed will have to involve stronger partnerships between the public, private andphilanthropic sectors, nationally and globally.
a. These include early-stage investments, e.g. the search for vaccines and therapeutics that can provide
broad protection against a range of pathogens; and interventions that can address the rising threat ofdrug resistance.
b. They could also be strong partners in supporting research for interventions where commercial interest is
low, including many ongoing regional epidemics for which global demand is weak.
99.	Governments and international organizations must seek to broaden the base, incentivize and leveragephilanthropic foundations that are engaged in supporting discovery science and R&D that contribute tonational health resilience and pandemic PPR.
a. CEPI is an example of a philanthropy inspired, public-private partnership working at the interface between
science, R&D, and manufacturing for global public goods.
100. De-risking by philanthropic and official funders can potentially mobilize significant resources from patient
capital, including pension funds and sovereign wealth funds, for R&D and other longer-term investments.
a. These investments may have high social returns but will often be beyond the risk appetite of institutional
investors. Public and philanthropic participation can bridge this risk gap.
b. For instance, a project to develop a new tuberculosis vaccine could be organized with commercial discipline,
while partly financed by philanthropy, and with official entities contributing to de-risk the project.

(9) D evelop insurance solutions for adverse
compensation events associated with use of
medical countermeasures101.	The best insurance for the world against pandemic risks is to invest in global public goods for pandemic
prevention and preparedness, as we have laid out in this report. The investments required to avoid apandemic amount to a miniscule proportion of the financial costs to governments in a pandemic, not counting
the costs of human lives lost, long-term health impairment and broader economic and social costs.
102.	I nsurance solutions should also be developed to cover adverse effects associated with medical
countermeasures.
a. Where vaccines and treatments are developed and regulated using emergency authorization, manufacturers
are not generally able to obtain insurance in the usual way that would happen if a product has been licensed
under non-emergency arrangements.
b. To address this constraint during the COVID-19 pandemic, COVAX used donor funds to enable a vaccine
injury compensation program through a contract with private insurers — the first of its nature
on an international scale. The COVAX No-Fault Compensation Program offers eligible people in 92
LICs and LMICs compensation for rare but serious adverse effects associated with COVID-19 vaccines
distributed through COVAX, thereby protecting participating governments and providers as well as
vaccine manufacturers from liability. However, this scheme only applies to vaccines acquired through
COVAX. A more comprehensive scheme does not exist today.
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c. While high-income countries have been able to waive manufacturer liability by law and regulation, andcover the costs of compensation of adverse events directly, other country governments do not have thearrangements or financing in place. Indeed, for various bilateral procurement deals in COVID-19, vaccine
manufacturers have asked governments to grant them immunity from civil liability arising fromadverse events that could result from the use of the vaccines.
i. A number of jurisdictions had given vaccine manufacturers indemnity from covering adverse events,
placing national assets as collateral.
103.	The MDBs should work with countries and private insurers to develop risk financing solutions to cover
adverse compensation events, particularly in the form of no-fault compensation schemes or an explicit
compensation fund with pre-determined compensation awards.
a. These schemes can be pooled internationally, including amongst G20 governments, and could be put inplace in the inter-pandemic period, supported by international financing.
104. We have also considered the broader application of insurance solutions to better manage pandemic risks.
a. The experience with the World Bank Pandemic Emergency Facility (PEF)54 points to the significant difficulties
in deploying insurance solutions, including the need for transparency, better design of risk triggers, and arigorous assessment of whether the benefits of protection outweigh the costs.
b. Any viable insurance solution will require that we first do much better at improving the data, science,
surveillance and analytics needed to forecast, assess, and price pandemic risks.
i. The data to model risks in most countries is not available. There is potential for innovative methods for
capturing this data, for example via social media.
ii. More work is needed to develop better data and models over time, to quantify pandemic risks and thepotential impact of future pandemics.
c. There may be risk pooling solutions between countries 55 that can enable better management ofpandemic risk:
i. Risk Diversification. Risk pools can achieve some degree of diversification, as there may be more
localized/regional outbreaks requiring a quick fiscal response, especially in the earlier stages of a pandemic.
ii. Risk Reduction and Tranching. In a risk pooling agreement, governments need to be ready to manage
the impact of such residual risks through pre-agreed post-disaster plans, backed by pre-planned
financing. The process of developing such post-disaster actions plans and identifying related costs canalso generate risk information and create incentives to step up investments in prevention and adaptation
to reduce risks in the first place56. The incentive to reduce the cost of insurance premiums by voluntarily
reducing exposure to risk is particularly compelling and insurance can therefore contribute to a positiverisk-reducing feedback loop57.
iii. Cost Efficiencies. The pooling of risk also has the advantage of improving the affordability of coveragethrough lowering costs of reinsurance, and sharing of fixed costs (e.g. cost of capital, operating costs
and cost of risk information)58.

54

	The PEF has drawn criticism for failing to provide coverage during the Ebola outbreak, and for being too slow in pay-out to poor nations suffering from the
COVID-19 outbreak.

	The Africa Risk Capacity is adding coronavirus protection to its planned outbreaks and epidemics parametric insurance product, expected to be launchedin 2021. Prior to the inclusion of coronavirus protection, the product was covering Ebola, Marburg, meningitis, and Lassa fever. The product aims to provide
countries with early intervention financing to allow more proactive response to an outbreak or epidemic — be it public health or economic recovery response.

55

56	Disaster Risk Financing & Insurance Program, World Bank Group. 10 Lessons for Policy Makers to Bring Catastrophe Risk Pools to Scale.

57

Poole, L. (July 2014). A Calculated Risk: How Donors Should Engage with Risk Financing and Transfer Mechanisms.

58

Such risk pools can also gradually accumulate capital, allowing insurance premiums paid by countries to gradually decrease over time.

62

D. CONCLUSION

Celso Pu

po/Shutt

ers tock.comD. Conclusion
105.	COVID-19 was not a black swan event. It may also constitute a dress rehearsal for a far worse pandemic,
which could come at any time.
106.	We must prepare for a world where pandemics are more frequent and increasingly dangerous. Preventing
them, and never again allowing the human costs and economic damage that we have seen in the current
crisis, must be a central obligation of national and global governance.
107. It fundamentally requires thinking internationally and not just domestically. We cannot prevent or
quickly contain the next pandemic through domestic measures alone.
108. In a historically unprecedented way, security for people around the world now depends on global
cooperation. Acting and investing collectively for pandemic security, together with climate change,
represents the primary international challenge of our times. Failure to build the basis for international
cooperation will make it almost impossible to address these existential challenges.
109.	We must not let exhaustion from efforts to get past the COVID-19 pandemic defer actions to address
the growing risks ahead. The threat to humanity is too great.

64

ANNEX

Annex A
G20 High Level Independent Panel on
Financing the Global Commons for Pandemic Preparedness and Response:
Members, Project Team and Administrative Secretariat
Members:
Tharman Shanmugaratnam*

Senior Minister, Singapore; Former Deputy Prime Minister andMinister for Finance
Chair, G20 Eminent Persons Group on Global Financial Governance (2017/18)

Lawrence Summers*

Charles W. Eliot University Professor, Harvard Kennedy School
Former United States Treasury Secretary
Former Finance and Foreign Minister, Nigeria
Director-General, World Trade Organization (WTO)

Ngozi Okonjo-Iweala*

Former MD, World Bank
Former Chair, Gavi, the Vaccine Alliance
African Union Special Envoy on COVID-19

Ana Botín
Mohamed El-Erian

Group Executive Chairman, Santander Group
Chief Economic Adviser, Allianz
President, Queens’ College, Cambridge University
Chairman, Board of Trustees, Group of Thirty (G30)

Jacob Frenkel

Former Chairman, JPMorgan Chase International
Former Governor, Bank of Israel
Former Economic Counsellor, IMF
Secretary General, Ibero-American General Secretariat

Rebeca Grynspan

Former UN Under-Secretary General and Associate Administrator, UNDP
Former Vice-President of Costa Rica
Executive Vice President and Director, Center for Global Commons,

Naoko Ishii

Professor, Institute for Future Initiatives, University of Tokyo
Former CEO and Chairperson, Global Environment Facility
Former Deputy Vice Minister of Finance, Japan

Michael Kremer

University Professor and Director, Development Innovation Lab,The University of Chicago
2019 Nobel Laureate
Founder and Chairperson, Biocon

Kiran Mazumdar-Shaw

Founder and Managing Trustee, Biocon Foundation
Chairperson, Mazumdar-Shaw Medical Foundation

Luis Alberto Moreno

Former President, Inter-American Development Bank
Former Minister of Economic Development, Colombia
Professor of Economics, London Business School

Lucrezia Reichlin

Chairman & Co-Founder, Now-Casting Economics
Former Director General of Research, European Central Bank
Ambassador for Global Health, Ministry of Foreign Affairs, Norway

John-Arne Røttingen

65

Founding Chief Executive Officer, Coalition for Epidemic Preparedness
Innovations (CEPI)

ANNEXUN Under-Secretary General and Executive Secretary

Vera Songwe

UN Economic Commission for Africa

Mark Suzman

CEO, Bill and Melinda Gates Foundation
African Union Special Envoy on COVID-19
Executive Chairman, Freedom Acquisition 1 Corporation

Tidjane Thiam

Former CEO, Credit Suisse and Prudential
Former Minister of Planning and Development, Cote d’Ivoire
European Chairman, Trilateral Commission

Jean-Claude Trichet

Former President, European Central Bank
Honorary Governor of the Banque de France

Ngaire Woods

Dean, Blavatnik School of Government, University of Oxford
Chair, National Institute of Financial Research, Tsinghua University

Zhu MinFormer Deputy Managing Director, IMF

Masood Ahmed#

President, Center for Global Development

Guntram Wolff#

Director, Bruegel* Co-Chairs# Project Directors

Advisors:
Victor Dzau

President, National Academy of Medicine, US

Jeremy Farrar

Director, Wellcome Trust

Project Team:
BruegelCenter for Global Development

Guntram Wolff (Project Director)

Masood Ahmed (Project Director)

Anne Bucher (Lead)

Amanda Glassman (Lead)

Scarlett Varga

Carolyn Reynolds

Alma Kurtovic

Eleni Smitham

Marta Dominquez

Hannah Brown

Ben McWilliams

Administrative Secretariat:
National Academy of Medicine

Wellcome Trust

Cecilia Mundaca Shah

Megan Challis

Morgan Kanarek

Alice Jamieson

Stephen Chukwurah

Beth Thompson
66

ANNEX

Annex B
Terms of Reference
Issued by the 2021 G20 Italian Presidency on January 27, 2021

G20 High Level Independent Panel (HLIP) on Financing the Global
Commons for Pandemic Preparedness and Response•	A G20 High Level Independent Panel (HLIP) on Financing the Global Commons for Pandemic Preparedness
and Response is established on 26 January 2021.
•

The HLIP is mandated by the G20 to fulfil the following responsibilities:– Identify the gaps in the financing system for the global commons for pandemic prevention, surveillance,
preparedness and response.
– Propose actionable solutions to meet these gaps on a systematic and sustainable basis, and optimally leverage
resources from the public, private and philanthropic sectors and the international financial institutions.
Solutions should take into account and build on related ongoing international initiatives, undertaken by
relevant bodies, such as the Independent Panel for Pandemic Preparedness and Response (IPPPR) and the
Global Preparedness Monitoring Board (GPMB), to ensure coherence and avoid duplication.

•	The members of the independent Panel comprise eminent individuals who collectively bring deep knowledge
and experience in finance and governance. Members will contribute in their personal capacities. The Panel
will be supported by a Project Team constituted by Bruegel and the Center for Global Development and a
Secretariat from the US National Academy of Medicine and Wellcome Trust.
•	The HLIP will provide an update of its work to the G20 Finance Ministers and Central Bank Governors(G20 FMCBGs) at their meeting in April 2021, before presenting its report at the July 2021 meeting of
the G20 FMCBGs.

67

ANNEX

Annex C
List of Institutions and Persons Consulted
The G20 High Level Independent Panel benefited significantly from extensive consultations with the global healthcommunity, including the major international health organizations, infectious disease and public health experts, theprivate sector, and philanthropic and civil society organizations with deep engagements in the field. The Global
Preparedness Monitoring Board, in particular, provided the Panel with a comprehensive assessment of requirementsfor pandemic prevention, preparedness and response. We also drew on the insights of the top management andstaff of the International Financial Institutions and leading economic and financial professionals.
The Panel also gained useful insights from discussions with members of the Independent Panel for Pandemic
Preparedness and Response (IPPPR), the Pandemic Preparedness Partnership, the Pan-European Commission on
Health and Sustainable Development, and the Lancet COVID-19 Commission.
A non-exhaustive list of institutions and persons we consulted is set out below. The Panel also had informative
consultations with the official sector.

Institutions:•

The Access to COVID-19 Tools Accelerator (ACT-A)•

International Finance Corporation (IFC)•

Accelerating Health Technologies Group (AHT)•

International Monetary Fund (IMF)•

Afreximbank•

Lancet COVID-19 Commission•

Bill & Melinda Gates Foundation (BMGF)•

McKinsey & Company•

Civil20 (C20)•

McGovern Foundation•

Center for Global Development (CGD)•

Metabiota•

Coalition for Epidemic Preparedness
Innovations (CEPI)•

Organisation for Economic Co-operation
and Development (OECD)•The Foundation for Innovative
New Diagnostics (FIND)•

Pan-European Commission on Healthand Sustainable Development•

G7 Pandemic Preparedness Partnership•

Pandemic Action Network•

Gavi, The Vaccine Alliance (Gavi)•

Preventing Pandemics at the Source•

GHSA Sustainable Financing Action Package
Working Group (GHSA SF AP WG)•

UN Economic Commission for Africa (UNECA)•

UNICEF•

Global Virome Project•

Unitaid•

Global Fund to Fight AIDS, Tuberculosis
and Malaria (GFATM)•World Bank Group (WBG)•

Global Preparedness Monitoring Board (GPMB)•World Economic Forum (WEF)•

Imperial College London•

World Health Organization (WHO)•Independent Panel for Pandemic
Preparedness & Response (IPPPR)•

WHO Council on the Economics of Health for All•

International Federation of Pharmaceutical
Manufacturers & Associations (IFPMA)

68

ANNEX

Individuals:•

Stefania Burbo (C20)•

Tedros Adhanom Ghebreyesus (WHO)•Agnès Buzyn (WHO)•Ruchir Agarwal (IMF)•

Mauricio Cardenas (IPPPR)•

Philippe Aghion (London School of Economics)•

Dennis Carroll (Global Virome Project)•

Ximena Aguilera (Universidad del Desarrollo, Chile)•

Sergio Carmona (FIND)•

Robert Agyarko (African Risk Capacity)•

Joanne Carter (RESULTS)•

Pedro Alba (The Brookings Institute)•Juan Camilo Castillo (The AHT Group)•

Pascale Allotey (UN University International
Institute for Global Health)•

Guillaume Chabert (IMF)•

Jagan Chapagain (International Federationof Red Cross and Red Crescent Societies)•

James Anderson (IFPMA)•

Susanne Andreae (World Economic Forum)•

Mukesh Chawla (WBG)•

Alan AtKisson (Sida)•

Helen Clark (IPPPR)•Paul Astrup (Boston Consulting Group)•

Lorcan Clarke (WHO)•Susan Athey (Stanford University)•

Sonila Cook (Dalberg)•

Hala Audi (The Trinity Challenge)•

Matt Craven (McKinsey)•

Bruce Aylward (WHO)•Thomas Cueni (IFPMA)•

Chandrika Bahadur (SDG Academy)••

Arthur Baker (The AHT Group)

Monica de Bolle (Peterson Institutefor International Economics)•

Stéphane Bancel (Moderna)•

Kieran Daly (BMGF)•

Chatib Basri (Creco Research Institute)•

Genya Dana (WEF)•

Priya Basu (WBG)•

Jeff Davies (Legal & General)•

Carolin Baumgartner (The Trinity Challenge)•

Nicoletta Dentico (Society forInternational Development)•

Dan Bausch (UK Public Health
Rapid Response Team)•

Vilas Dhar (McGovern Foundation)•

Erik Berglof (Asian Infrastructure Investment Bank)•

Makhtar Diop (IFC)•

Stanley M. Bergman (Henry Schein)•

Kate Dodson (UN Foundation)•

Seth Berkley (Gavi)•

Simon Duffield (Gavi)•

Stefano Bertozzi (UC Berkeley
School of Public Health)•

Steph Eaneff (Georgetown University)••

Manisha Bhinge (The Rockefeller Foundation)

Chris Eleftheriades (International
Rescue Committee)•

Agnes Binagwaho (University of
Global Health Equity)•

Chris Elias (GPMB)•

Anas El Turabi (McKinsey)•

Laurence Boone (OECD)•

Valeria Emmi (C20)•

George Bridges (Banco Santander)•

Meaghan English (McGovern Foundation)•

Gordon Brown (UN Special Envoy
for Global Education)•

Tamer Farag (Facebook)•

Manuela V. Ferro (WBG)•

Gro Brundtland (GPMB)•

Karin Finkelston (IFC)•

Eric Budish (University of Chicago)•

Kevin Fletcher (IMF)•

Annabelle Burgett (BMGF)•

Stephen Flynn (Northeastern University)

69

ANNEX•

Giovanni Forchini (Imperial College London)•

Nisia Trindade Lima (Fiocruz)•

Henrietta Fore (UNICEF)•

Alessandra Løchen (Imperial College London)•

Tom Frieden (Resolve to Save Lives)•

Nita Madhav (Metabiota)•

Kurt Frieder (C20)•David Malpass (WBG)•

Vitor Gaspar (IMF)•

Robert Matiru (Unitaid)•

Kristalina Georgieva (IMF)••

Githinji Gitahi (Amref Health Africa)

Mariana Mazzucato (WHO Council on
the Economics of Health for All)•

Tore Godal (GPMB)•

Rosemary Mburu (WACI Health)•

Rebeca Godoy (African Risk Capacity)•

Amanda Meadows (Metabiota)•

Ian Goldin (Oxford University)•

Conor Meenan (Centre for Disaster Protection)•

Ellie Graeden (Talus Analytics)•

Roshni Mehta (Imperial College London)•Peter Greiff (Banco Santander)•

Mariska Meurs (Wemos)•

Frederico Guanais (OECD)•David Milliband (IPPPR)•

Jaclyn Guerrero (Metabiota)•

Patricia Miranda (C20)•

Peggy Hamburg (Nuclear Threat Initiative)•

Suerie Moon (The Graduate Institute of Geneva)•

Richard Hatchett (CEPI)•

Susanna Moorehead (OECD)•John Hicklin (CGD)••Tom Hart (ONE)Mario Monti (Pan-European Commission on
Health and Sustainable Development)•

Katharina Hauck (Imperial College London)•

Melinda Moree (BMGF)•

Kim Holloway (Northeastern University)•

Riccardo Moro (C20)•

Amanda Hosken (Swiss Re)•

Owen Morris (Aviva)•

Daniel Hougendobler (GPMB)•

Stephen Morrison (Center for Strategic
and International Studies)•

Chikwe Ihekweazu (Nigerian
Centre for Disease Control)•

Edward Mountfield (WBG)•

Bikas Joshi (IMF)•

Nanthalile Mugala (PATH)•

Madhav Joshi (India Health Fund)•

Mamta Murthi (WBG)•

Donald Kaberuka (GFATM)•

Bob Nelsen (ARCH Venture Partners)•

Shobana Kamineni (Apollo Hospitals Enterprise)•Aurélia Nguyen (Gavi)•

Nirmal Kandel (WHO)•Jamie Bay Nishi (Global HealthTechnologies Coalition)•

Rebecca Katz (Georgetown University)•

Akihiko Nishio (WBG)•

Michel Kazatchkine (IPPPR)••

Oanh Khuất (Centre for Supporting
Community Development Initiatives)

John Nkengasong (Africa Centres for
Disease Control and Prevention)•

Anders Nordström (IPPPR)•

Gunther Kraut (Munich Re)••

Ilona Kickbusch (GPMB)Jim O'Neill (Pan-European Commission on
Health and Sustainable Development)•

Justin Koonin (ACON)•

Rachel Ong (C20)•

Soonman Kwon (Seoul National University)•

Ben Oppenheim (Metabiota)•

Acha Leke (McKinsey)•

Muhammad Pate (WBG)
70

ANNEX•

Mari Pangestu (WBG)•

Peter Smith (Imperial College London)•

Rosa Pavanelli (Public Services International)•

Ian Smith (GPMB)•

Ceyla Pazarbasioglu (IMF)•

Antonio Spilimbergo (IMF)•

Adrian Peralta-Alva (IMF)•

Devi Sridhar (The University of Edinburgh)•Nicolas Pinaud (OECD)•

Liesbet Steer (The Education Commission)•Peter Piot (London School of Hygiene
and Tropical Medicine)•

Nicole Stephenson (Metabiota)•

Elena Sterlin (IFC)•

Jean Pisani-Ferry (Sciences Po)••

Mark Plant (CGD)

Arvind Subramanian (Peterson Institutefor International Economics)•

Stefano Prato (C20)•

Preeti Sudan (IPPPR)•

Ben Pyne (Skoll Foundation)•

Alex Tabarrok (George Mason University)•

Elizabeth Radin (International Rescue Committee)•

Katherine Tan (BMGF)•

Uma Ramakrishnan (IMF)•

Brandon Joel Tan (The AHT Group)•

Sheila Redzepi (WBG)••

Tristan Reed (WBG)

Chorh Chuan Tan (Office for
Healthcare Transformation)•

Ferdinando Regalia (IDB)•

Tomasz A. Telma (IFC)•

Carmen Reinhart (WBG)•

Adrian Thomas (Johnson & Johnson)•

Amelie Rioux (GPMB)•

Eloise Todd (Pandemic Action Network)•

Alberto Rodriguez (WBG)•

Brad Tytel (BMGF)•

Jeffrey Sachs (Lancet COVID-19 Commission)•

Axel van Trotsenburg (WBG)•

Rodrigo Salvado (BMGF)•

Jeanette Vega (Red de Salud UC-Christus)•Peter Sands (GFATM)•

Andres Velasco (London School of Economics)•

Benjamin Sarda (Boston Consulting Group)•

Reinhilde Veugelers (Bruegel)•Bill Savedoff (Inter-American Development Bank)•

Stephanie von Friedeburg (IFC)•

Stefano Scarpetta (OECD)•

Trae Wallace (Talus Analytics)•

Haje Schutte (OECD)•

Kevin Watkins (Save the Children UK)•

Klaus Schwab (WEF)••

Nina Schwalbe (UN University International
Institute for Global Health)Beatrice Weder di Mauro (Center
for Economic Policy Research)•

Nick White (Oxford University
and Mahidol University)•

Yakhara Ngally Sembene (IFC)•

Minouche Shafik (G7 Pandemic
Preparedness Partnership)•

Suwit Wibulpolprasert (Folk Doctor Foundation)•

Matt Wilson (McKinsey)•

Anant Shah (Merck)•

Prashant Yadav (CGD)•

Michael Sheldrick (Global Citizen)•

Gary Young (Northeastern University)•

Rahul Singhvi (Resilience, Inc.)•

Simon Young (Willis Towers Watson)•

Ellen Johnson Sirleaf (IPPPR)•

Ernesto Zedillo (IPPPR)•

Nigel Sizer (Rainforest Alliance)•

Olivia Zetter (Resilience, Inc.)

71

ANNEX

Annex D
Table 1: Major Infectious Disease Outbreaks in the Past Two Decades
YEAR

OUTBREAK

2019

SARS-CoV-2

2018

Lassa

2017

Zika

2017

Ebola

2014

Chikungunya

2014

Ebola

2012

MERS

2010

Cholera2009

H1N1 Influenza

2004

H5N1 Influenza

2003

SARS-CoV-1

2001

Enterovirus 71

2001

Nipah

72

ANNEX

Annex E
Increasing Frequency of Wildlife Zoonotic and Influenza Spillover Events
The Panel studied data from Metabiota on historical trends in wildlife zoonotic and influenza spillover events.
Chart 1 shows the frequency of epidemics caused by wildlife zoonoses. (It fits a log-linear model to the observed
data.) There has been a clear exponential increase of such epidemics, which increased in frequency by a factor
of about 3 every 20 years.
Chart 2 shows the number of influenza spillover events. (It applies a linear best fit to the data.) There have beenaround 10 influenza spillover events each year in recent years, compared to hardly any 25 years ago.
Source: Metabiota
Chart 1: Increasing Frequency of Epidemics caused by Wildlife Zoonoses(excluding Influenza) (log-normal scale)

Reported Events

30

10

3

19
60
−
19 19
65 64
−
19 19
70 69
−
19 19
75 74
−
19 19
80 79
−
19 19
85 84
−
19 19
90 89
−
19 19
95 94
−
20 19
00 99
−
20 20
05 04
−
20 20
10 09
−
20 20
15 14
−
20 20
20 19
−
20 20
25 24
−
20 20
30 29
−2
03
4

1

Year

Chart 2: Increasing Frequency of Reported Influenza Spillover Events

Reported Influenza Spillover Events

15

10

5

Year

73

20
35

20
30

20
25

20
20

20
15

20
10

20
05

20
00

19
95

0

ANNEX

Annex F
COVID-19 African Vaccine Acquisition Task TeamThe COVID-19 African Vaccine Acquisition Task Team (AVATT) was established to support the Africa Vaccine Strategy
and endorsed by the African Union Bureau of Heads of State and Government on 20 August 2020. The AVATT seeks
to complement the ACT Accelerator’s COVAX pillar by securing vaccine doses for 15% of the African population andwith a view to increase this figure until the target of 60% herd immunity is achieved.
This note summarizes information obtained from the United Nations Economic Commission for Africa (UNECA) andAfreximbank on AVATT, which illustrates the potential for regional initiatives to boost access to medical countermeasures.
The AVATT works collaboratively with key regional and international partners to achieve its mandated objectives:
1.

The African Vaccine Acquisition Trust is a Special Purpose Vehicle that serves as a central entity for thenegotiation, procurement and payment for vaccines. It also acts as the interface between AU Member States
and the vaccine manufacturers.

2.

The Africa Centres for Disease Control and Prevention (Africa CDC) serves as the secretariat to the AVATT
and offers scientific guidance. The Africa CDC also reviews documentation from vaccine suppliers and provides
guidance to the national regulatory bodies on Emergency Use Authorization.

3.

The African Medical Supplies Platform (AMSP) was mandated by the AVATT to support the ordering andallocation process for the vaccine procurement mechanism. The AMSP is a not-for-profit initiative launched by
the AU as an immediate, integrated and practical response to the COVID-19 pandemic, to facilitate access to an
African & global base of vetted manufacturers and enables Africa Union Member States to purchase certified
medical equipment such as diagnostic kits, personal protection equipment, and clinical management devices
with increased cost effectiveness and transparency.

4.

The Afreximbank was mandated by the AU to urgently put in place financing mechanisms and instruments
to achieve the vaccination target of 60% of the African continent’s population and to support post-COVID-19
economic recovery. Under the AVATT, Afreximbank plays the role of financial and transaction adviser, partaking
in negotiations with vaccine suppliers, and facilitating payments.
a. The Afreximbank has supported the AVATT by putting in place a US$2 billion Advance Procurement
Commitment Guarantee Facility (APC). The APC aims to ensure (1) timely, equitable and cost-effective
availability of COVID-19 vaccine supplies within the African continent, (2) providing a credible platform aroundwhich a blend of funding to support Africa’s vaccine procurement requirements, and (3) providing assurance
to vaccine manufacturers that orders placed by the AMSP are firm and will be paid for.
b. The Afreximbank also put in place an Instalment Payment Plan (IPP) facility that supports countries thatare unable to pay for their orders with cash upon delivery so they can make the payments in accordance
to their fiscal situation.

5.

The UNICEF supports the AVATT through procurement, logistics and payment services since it is one of theleading players in the procurement and delivery of vaccines globally.

6.

The UNECA provides technical backstopping to the AVATT, especially on the economic dimensions of the vaccine
access and rollout. The UNECA ensured that the AVATT process had critical information and data to support
the negotiations.

7.

In June 2021, the World Bank and the African Union announced a partnership, with World Bank financing
supporting the purchase and deployment of doses secured by AVATT to help countries vaccinate up to 400
million people across Africa.
74

ANNEX

Annex GKey Capacities and Functions of Preparedness and Response
The G20 High Level Independent Panel requested the Global Preparedness Monitoring Board (GPMB) to provide
an assessment of the key capacities and function requirements for pandemic prevention, preparedness, andresponse (PPR), including standards and performance required for public health capacities.
The framework59 below is based on the GPMB’s work in developing its Monitoring Framework, and describes
specific key capacities and functions of preparedness and response needed at the national, regional andglobal levels.

CAPACITIES &FUNCTIONSPREVENTION

NATIONAL STANDARDSREGIONAL/GLOBALSTANDARDS

One Healthsurveillance and risk
assessment

All countries have integrated
systems for detecting andreporting novel and emerging
pathogens across the onehealth spectrum, including
genetic analysis capacity.

There is a global mechanism
for surveillance with data
management, analytics,
modelling and real-timecommunication at theone health interface.

Immunization

All countries have
implemented routine
immunization for diseases
with pandemic potential,
including measles, influenza,
yellow fever, and others.

Health system capacity
and accessAll countries have adequate
workforce, facilities andequipment within national
health systems to handle
a surge of cases from
respiratory pathogens orother infectious hazards.

Pandemic planningand exercising

All countries hold regularsimulations, trainings
and after-action reviews(and other methods tooperationalize capacitybuilding measures)and publish andimplement findings.

andPREPAREDNESS

59

There is a global deployable
surge workforce of healthworkers with plans forupskilling, partnerships,
shortages and deployment.

	This reflects the GPMB’s current views. The Monitoring Framework is in development and it is expected that the Board’s views will evolve over time as theyreceive more inputs and further consider the issue.

75

ANNEXCAPACITIES &FUNCTIONS
Data and information
sharing

NATIONAL STANDARDSAll countries have madecommitments to sharing
genetic data, clinicalspecimens, and/or isolated
specimens (biological materials)
in both emergency andnonemergency contexts.

Norms, standards,
evidence-based policy,
technical support

R&D on future andemerging infectious
diseases

REGIONAL/GLOBALSTANDARDS
There is a data sharing
platform with open centralized
access to data and rapid
pathogen sharing.
There is a global platform forsharing data and information
integrated across sectors
to support decision-making
and resource allocation.
There is a global mechanism
to develop, review, anddisseminate norms,
standards, evidence-based
policy and provide technicalsupport to countries.

There is deployable
research capacity.

There are regional laboratories
responsible for conducting
research, growing virus
samples, curating themand sharing them, andcreating animal models.
Multi-sector discovery
networks for medical
countermeasures.
There are global mechanisms
to support technology transfers
and R&D capacity building.
There are existing vaccine
platforms or agents thathave gone through phase 1,
are ready, and are broadly
cross-protective against
a range of pathogens.
There is sufficient deployable
regional manufacturing
capacity, measured as
number of vaccine doses/
diagnostic tests/therapeutics
needed versus capacity
to manufacture them.

76ANNEXCAPACITIES &FUNCTIONSClinical trial andregulatory capacity

NATIONAL STANDARDSAll countries have national
emergency regulatory
approval procedures
and capacity.

REGIONAL/GLOBALSTANDARDS
There are global and regional
platforms that are operationaland ready to conduct
large-scale clinical trials.

Mechanisms for
ensuring advanceequitable access tocountermeasures

There are global mechanisms
to enable equitable accessto future safe and effective
vaccines and therapeutics,
including advancepurchase agreements
and pooled demand.

Supply chain networks
and stockpiles

There are mechanisms for
procurement, supply chain
networks and regional
stockpiles for essential
commodities, such as oxygen,
PPE, and essential medicineswith capacity for scaled
replenishment and planning for
regulatory issues accessible toall countries in WHO regions.
There are robust regional
supply chains to ensure freeand rapid flow of raw materials
for medical countermeasures.

Community
engagement and trust

All countries have establishedconsultation processes,
engagement mechanisms
and platforms in place
to capture the views andexperiences of communities,
including the most vulnerable
in society, in order thatthese can be incorporated
into preparedness.
All countries have an infodemic
management plan andestablished communications
channels to share informationtransparently, including
plans to utilize digitaland social media.

77

There is a global mechanism
to monitor digital/social
information sources, tomeasure and build knowledgeof relevant communities, tocoordinate fact-checking
initiatives and to produce
and disseminate informationand educate the public.

ANNEXCAPACITIES &FUNCTIONS
Governance andcoordination

NATIONAL STANDARDSAll countries have regulatory
frameworks and independent
public health bodies withthe authority and politicalaccountability to lead wholeof-government and wholeof-society preparedness andto lead and direct actions inthese sectors in the event ofa public health emergency.

REGIONAL/GLOBALSTANDARDS
There is a dedicated global
platform for the governanceof health emergencies
preparedness and response,
where national, regionaland global stakeholders cancoordinate, plan, and agree
on priorities and that canbe leveraged in the eventof a health emergency.
There is an independent
monitoring and accountability
mechanism for preparedness
and response.
There is a global agendasetting and coordination
mechanism for R&D.

RESPONSE

Surge financing
mechanisms

All countries have establishednational contingency funds
for health emergencies.

There is a global, adequately
financed and sustainably
replenished mechanism
for rapid funding of healthemergency response.

One Health surveillance
and risk assessment

There is active surveillanceof cases, including
genetic analyses.

Global and regional support
to affected and vulnerable
countries, including provisionof technical guidance.

Health system

Deployment of healthsystem capacity, including
health workforce, facilities
and equipment.

Global health workforce
is deployed.

Emergency development
of diagnostics, vaccines,
and therapeutics(in response toactual outbreaks)

Affected and vulnerable
countries deploy data sharing,surveillance, research andregulatory capacities.

Global research capacity,
clinical trial capacity andregulatory capacity is
deployed and coordinated.

Manufacturing ofcountermeasures

Existing manufacturing
capacity for vaccines,
diagnostics andtherapeutics is activated.
Supply chain for raw materials
is upsurged and crossborder flow is coordinated.

78

ANNEXCAPACITIES &FUNCTIONS
Procurement,
logistics, anddistribution of medical
products and supplies

NATIONAL STANDARDSNational procurement andsupply chains mechanisms
are activated.

REGIONAL/GLOBALSTANDARDS
Mechanisms for procurement,
logistics and distributionof medical products andsupplies are activated.
There is support for
procurement of medical
products and supplies forlower-income countries
and countries in need.

Procurement, logistics
and distribution of
vaccines, diagnostics,
and therapeutics

National procurement andsupply chains mechanisms
are activated.

Deployment of vaccines,
diagnostics and therapeutics
is coordinated and medical
countermeasures are
deployed rapidly, equitably
based on a public healthneed assessment. This
includes deployment ofworkforce and healthsystem capacities.
There is support for
procurement of medical
countermeasures forlower-income countries
and countries in need.

79

Knowledge generationand communication

Countries deploy
community engagement andcommunication activities.

Process to develop,
review and disseminate
information is activated.

Governance andcoordination

There is multisectoral,
multistakeholder
coordination and governanceplatforms are activated.

There is multisectoral,
multistakeholder
coordination and governanceplatforms are activated.

ANNEX

Annex H
Estimated Financing Needs for Global Public Goods for
Pandemic Prevention and Preparedness
This Annex explains the approach undertaken by the Panel and its Project Team to derive estimates of internationaland national financing needs for pandemic prevention and preparedness. The estimates represent the additional
investment required in the global public goods that are at the core of effective pandemic prevention andpreparedness. They do not include the costs of response, as this will depend on the nature of future outbreaks
and the degree of implementation of pre-crisis pandemic prevention and preparedness measures at the national,
regional and global levels.
The two tables below summarize the total public funding needs over the first five years. Investments would haveto be sustained in subsequent years; a key lesson from outbreaks to date has been how the absence of continuous
investments in prevention and preparedness leaves the global system vulnerable.
The explanatory notes that follow Tables 1 and 2 set out the definitions and assumptions used in this costing exercise.
It has to be emphasized that we have on the whole adopted very strict definitions of global public goods forpurposes of pandemic prevention and preparedness, and conservative assumptions of the required scale.
Table 1: Additional Public Funding for Prevention and Preparedness over 5 Years(US$ billion)
Category

Total

International Financing

National Budgets

Robust surveillance & detection networks

74

26

49

Building resilience in health systems

63

19

44

Supply capacity for medical countermeasures

34

34

-

Total

171

78

93

Average Annual Investment

34

16

18

Table 2: A dditional Public Funding for Prevention and Preparedness over 5 Years(US$ billion) (Breakdown by Global- and Country-Level)
Country-level Global Public Goods

Category

Total

GlobalLevel
Capacities

Robust surveillance &detection networks

74

5

11

11

36

10

1

Building resiliencein health systems

63

-

4

9

39

10

1

Supply capacity
for medical
countermeasures60

34

34

-

-

-

-

-

Total

171

39

15

20

75

20

2

Average Annual
Investment

34

8

3

4

15

4

0.4

MIC

LIC

HIC

International
Financing

National
Budgets

International
Financing

National
Budgets	This refers to the additional financing required to meet global-scale demand, and is additional to what countries would invest on their own for national needs.
See ‘Explanatory Notes’ below.

60

80

ANNEX

Explanatory Notes
This report divides spending into three major gaps of global public goods: (1) robust surveillance and detection
networks; (2) building resilience in health systems; and (3) supply chains for medical countermeasures.
These global public goods reside at both the national and global levels. International financing is required forboth the global-level capacities and to support a portion of LICs’ and MICs’ national-level global public goods.
Our work benefited from the inputs of the Global Preparedness Monitoring Board (GPMB) on the scope of operations
required for pandemic PPR (see Annex G for the GPMB’s submission to the Panel).
•

Robust surveillance and detection networks. This covers the GPMB’s categories of One Health surveillance
and risk assessment; data and information sharing; and R&D on future and emerging infectious diseases61.
Most needs are at the national level, where ongoing data collection, integration, analysis and dissemination
systems will need to be put in place. Diligent detection of infections requires a distributed infrastructure oflaboratory facilities. National public health institutes play a key role in providing robust surveillance systems
at national, sub-national, and local levels. At the global level, WHO with its six regional offices is the anchor
to coordinate and organize global surveillance; the system also relies on key regional centres, like the Africa
CDC. These different structures all need some strengthening going forward. Our cost estimates have also
taken into account the need to implement the One Health approach for the monitoring and detection of
zoonotic spillovers.

•

Building resilience in health systems. This encompasses the GPMB’s categories of immunisation; healthsystem capacity and access; pandemic planning and exercising; norms, standards, evidence-based policy,
technical support; and community engagement and trust. This function is mainly at the country-level. The
gaps in health system resilience are primarily found in low- and middle-income countries, and include essential
public health services and equipment, in particular, the ability of health systems to detect and treat infectious
cases and to organize emergency operations.

•

Supply chains for medical countermeasures. This includes the GPMB’s categories of R&D on future and emerging
infectious diseases; clinical trial and regulatory capacity; mechanisms for ensuring advance equitable access tocountermeasures; supply chain networks and stockpiles and surge financing mechanisms. The GPMB definition
covers vaccines, therapeutics, and diagnostics, as well as personal protective equipment. This will require moredeveloped global R&D structures and investments in capacity to ensure availability for all countries.
• For the sake of simplicity, national stockpiles of essential medical supplies are recorded within the second
category above (building resilience in health systems), as they are a key component of resilience.
• Investments in supply capacity for medical countermeasures for the current purpose are therefore focused
exclusively on the global networks for research, manufacturing and procurement.
• These investments are additional to those that countries would make for their own national needs. The
major scale-up of supply capacity that we estimate to be necessary is to provide for global-scale demand,
which as the report discusses extensively, is critical to containing a pandemic everywhere including within
the HICs. For the present costing exercise, we have classified the incremental spending required under‘global level’ spending.
• However, it should be noted that our estimates for supply capacity for medical countermeasures are, tobegin with, very conservative; alternative estimates by the Accelerating Health Technologies (AHT) groupsuggest much larger requirements. (See below.)61	This category is covered by both ‘Robust surveillance and detection networks’ and ‘Supply chains for medical countermeasures’.

81ANNEX

Sources of estimates and additional assumptions
The estimates provided in these tables are primarily based on two studies: the WHO’s report to the G20 “Assessmentof Gaps in Pandemic Preparedness” in 2020, and McKinsey & Company’s report “Not the last pandemic: Investing
now to reimagine public-health systems”. While a number of studies have attempted to measure pandemic PPR
investment needs, recent estimates converge to a range which is higher than pre-COVID estimates, and point toa need to significantly scale up current financing. The Panel had chosen to use data from the WHO and McKinsey
studies as they were the most recent and systematic estimates of needs at the global and country levels 62 .
However, while these two reports are used as the primary baseline, we have modified certain estimates following
our consultations with industry experts to be consistent with GPMB’s categories. This included triangulating theestimates with those from the Coalition for Epidemic Preparedness and Innovations (CEPI) for the development
costs of new diagnostics, vaccines, and therapeutics, and from Georgetown University on country-level financing.
Both the WHO and McKinsey studies apply a bottom-up methodology estimating total prevention and preparedness
needs by identifying the set of functions or institutions necessary at global level, including coordination functions
and the key functions which surveillance and health systems need to provide at country-level. The estimatesat country-level are broken down according to income groups: High Income Countries (HIC), Medium Income
Countries (MIC), and Low Income Countries (LIC). The Panel’s approach defines international financing as the
public financing needed for global commons: the global-level capacities and the funding to incentivize countries
to make the necessary investment in their surveillance and health systems. McKinsey computes only total needs,
while WHO estimates both total needs and international financing requirements.
The WHO and McKinsey approaches differ in a number of respects, in particular in the scope and cost calculation
methods or references. It is hence difficult to make straightforward comparisons of the estimates yielded by thetwo approaches. Some additional triangulation of data and judgments had to be made so that the two sets of data
could be incorporated within the GPMB’s framework, and our best estimates derived.
The report has not retained the WHO’s estimate for HIC spending as it was a significant outlier when compared withother estimates of needs63. McKinsey provided additional information to the Panel to break down all prevention andpreparedness estimates between global- and country-level investment requirements, according to country income groups.
Estimates provided in the report cover a five-year period; both WHO and McKinsey have identified the need for somefrontloading of spending. McKinsey’s approach identifies gaps compared to pre-defined targets for each function of
prevention and preparedness, and distributes the total costs over a ten-year period with some degree of frontloading.
For the purpose of this report, the frontloading embedded in McKinsey’s calculations has been slightly amplified,reflecting the need to catch up from a long period of underfunding, and the required urgency. Our estimates forthe first five years assume that they would require the spending of 60% of the total ten-year figure. However, as
highlighted above, our estimates for supply capacity for medical countermeasures are very conservative.
Additionally, the cost of antimicrobial resistance (AMR) has been excluded from the McKinsey estimates, for reasons
explained below. (The WHO estimates had not included AMR.) The WHO estimates for R&D and manufacturing of
medical countermeasures have been updated to take into account more recent projections by CEPI and ACT-A64.
The WHO estimates have also been adjusted to incorporate annual replenishments of the Contingency Fund for
Emergencies (CFE) as part of a strengthened surveillance as in McKinsey’s estimates.
Calculation of public sector contribution
Finally, the report is focused only on the needs for public funding. The private sector plays a role in pandemic
PPR, especially in R&D and supply of medical countermeasures. Concretely, arising from our consultations with62	In particular they use the most up to date and robust country estimates: D. H. Peters, O. Hanssen, J. Gutierrez, J. Abrahams & Tolbert Nyenswah (2019):
Financing Common Goods for Health: Core Government Functions in Health Emergency and Disaster Risk Management, Health Systems & Reform https://doi.org/10.1080/23288604.2019.1660104

63

Preliminary results of Georgetown University estimates based on the IHR costing tool are very close to McKinsey's as well.

64

See CEPI's report titled "The Urgency of Now: Turning the Tide Against Epidemic and Pandemic Infectious Disease" published in March 2021.

82

ANNEX

various experts, it is estimated the private sector will cover 15% of research needs65 for global countermeasures,and 30% of the cost of building and maintaining manufacturing capacity66. These private sector costs havebeen excluded from the estimates presented in our costing tables here.
Calculation of international financing
In line with the global public goods approach adopted by the Panel, international financing is needed tosupport prevention and preparedness expenditures at the global level, but it should also account for somespending at country-level. National-level financing needs encompass measures that should be executednationally, whose success, however, has direct global implications given the existence of global externalities.
To avoid underinvestment and in light of existing budget constraints, we propose a formula for partial externalfinancing of national level measures in low- and middle-income countries.
The estimates provided are computed under the assumption that low-income countries receive international
support to cover 88%67 of financing needs. While a certain degree of local ownership is beneficial, these countries
face severe budget constraints and a large opportunity cost to financing prevention and preparedness activities.
They also cover a set of conflict states which are more fragile. Further, the benefits of these investments inglobal public goods do not accrue primarily to the countries themselves; this is in their nature as global public
goods. The report uses the WHO’s assumption on international support covers one-off capital expenditures;
and a large share of recurrent expenditures.
Similarly, the estimates provided are computed under the assumption that middle-income countries will cover
76% 68 of expenditure domestically, and receive international support for the remaining 24%. The WHO also
assumes that support should be especially concentrated on capital expenditure, with recurrent expenditures
being largely nationally financed. When using McKinsey’s figures, the estimates in the report assume a higher
international co-financing rate for surveillance (30%) than for resilience in health systems (15%) which should
be a national responsibility.
The ranges provided can generally be considered conservative. First and foremost, the cost focuses on theneeds within the health sector. It does not make a costing of the whole-of-government approach, which would
include prevention and preparedness activities in other sectors, such as water and sanitation or continuity of
key services such as electricity supplies or transportation. Moreover, there is no unique definition of PPR andmore or less extensive scope can be defined for some categories of prevention and preparedness.
In particular, some restrictive assumptions have been made in four areas to exclude certain activities that haveindirect but still significant impact on prevention and preparedness.
• Firstly, antimicrobial resistance (AMR) which erodes the capacity to treat infections has been referred
to as one of the big threats to future global health, which will be compounded by pandemics. AMR
containment measures are considered to be an integral part of effective infection prevention andpreparedness systems. The World Bank (2017)69 estimated the cost of AMR containment measures
at US$9 billion annually. This cost is partly integrated into the McKinsey estimates but we exclude it
from the values presented in our report. While there is some overlap and synergies between pandemic
prevention and preparedness and AMR containment, AMR requirements for both animal and humanhealth are relatively distinct. The World Bank’s estimates would increase investment needs presented
for LMICs by nearly 40%, compared to the estimates presented in this report.

65	This is in line with the G-Finder survey: https://policy-cures-website-assets.s3.ap-southeast-2.amazonaws.com/wp-content/uploads/2021/04/15055816/GFINDER-2020_Final-Report.pdf

66

The assumption of a 30% funding share for the private sector in establishing scaled-up at-ready manufacturing capacity is in-line with the analyses by the
AHT group and others. The large majority of funding will have to come from the public sector to enable these investments in capacity. This is discussed fullyin Section B (Item 3) of the Panel’s Report.

	The Panel used the overall intensity of aid provided by the WHO with more granular assumptions: for LICs, domestic budgets cover 15% of recurrent costs
but no capital costs over 5 years.

67

68

WHO assumes that Lower-middle income countries cover 50% of capital costs and 70% of recurrent costs over 5 years, while Upper-middle income countries
cover 100% of capital and recurrent costs over 5 years.

69

See World Bank's report titled "Drug-Resistant Infections: A Threat to Our Economic Future" published in March 2017.

83

ANNEX• Secondly, the zoonotic nature of many viruses calls for a One Health approach to surveillance, meaning
surveillance that also covers animal health and veterinary services. The estimates take a One Health approach
when considering surveillance requirements for research, data collection and processing or, in the case of
the McKinsey costing, some cost of biosecurity in farms and of wildlife and wild meat trade. However, it
would have been difficult to provide comprehensive and up-to-date estimates of the wider approach forthis report, thus estimates for a full One Health approach are not included in our calculations70.
• Thirdly, the estimates presented in this report include R&D investment, specifically research linked
to new pathogens, as part of surveillance and research into vaccines, therapeutics and diagnostics.
However, basic research is excluded from these estimates. Basic research has been defined as scientificinvestigation that involves the generation of new knowledge or development of new theories. That is,research with results that often cannot be applied directly to specific clinical situations and therefore
will only be indirectly beneficial to pandemic prevention and preparedness. Pre-clinical and basic
research can nonetheless have a significant impact on pandemic prevention and preparedness71.
• Fourthly, in the category of medical countermeasures, our estimates for the cost of manufacturing
are very conservative. The dedicated stream of work from the AHT group for the Panel indicates thatinvesting in US$60 billion upfront to expand production capacity for vaccines and supply chain inputs(US$2.2 billion per year thereafter to maintain capacity) would provide far greater benefits72.
• Finally, outbreaks occur more frequently in countries that have overall weak health systems and building
resilience in health systems to best prepare them against pandemics requires, as a prerequisite, a muchbroader strengthening in many low- and middle-income countries. The cost of such measures has also
been excluded from the main estimates of the report as being only indirectly related to the global
public good approach on which the report focuses. The WHO estimates the health system financing
needs towards the objective of universal health coverage at US$555 billion over five years. Following
the same financing formula employed for the main estimates, this would result in an additional
US$89 billion in international finance over five years — compared to the estimate we have givenof US$75 billion. The broader strength of the health system can be a determinant to countries’ ability
to contain and manage an outbreak and as such is an important source of externalities. It is not partof the prevention and preparedness global public goods but should be properly integrated in country
programs and allocation of ODA to the health sector.
Based on the methodology we have described above, Tables 1 and 2 show the estimates that the Panel has
employed in this report. For more details referencing the respective estimates based on those by the WHO
and McKinsey, please refer to Tables 3 and 4 below. (There are two estimates for each item in these tables.
The figures on the left have been derived on the basis of WHO estimates, while those on the right have been
derived from McKinsey.)	The World Bank's study titled "People, Pathogens, and Our Planet: The Economics of One Health", published in June 2012, shows that the total cost of One
Health prevention and preparedness comprised 45% for animal health, 41% for human health, and 14% for joint planning and communication.

70

71

Di Masi et al. (2016): Innovation in the pharmaceutical industry: New estimates of R&D costs. In Journal of Health economics — May 2016.

72	In the event of a pandemic, this investment would have expected benefits of US$1.6 trillion, relative to a scenario where countries made no further advanceinvestments. This would fund 25 billion units of capacity, enough to vaccinate 80% of the global population with each of four vaccine candidates. This differsfrom the methodology of McKinsey which computes the costs for producing 7.5 billion courses of vaccine in six months: the AHT methodology takes into
account that the production capacity is shared by different technology platforms (mRNA versus traditional platforms) and with the non-negligible probabilityof failure of different vaccine candidates, part of the capacity will have to be repurposed. Since repurposing capacity takes time, it would be hugely beneficial
to install substantially more capacity to cover the reference needs of 7.5 billion of vaccination courses.

84

ANNEX

Table 3: Additional Public Funding for Prevention and Preparedness over 5 Years(US$ billion)
Category

Total

International Financing

National Budgets

Robust surveillance & detection networks

53/94

20/35

33/59

Building resilience in health systems

60/66

19/18

41/48

Supply capacity for medical countermeasures

19/34

19/34

-

of which R&D

8/13

-

-

of which manufacturing

11/20

-

-

Total

131/194

58/87

74/107

Average Annual Investment

26/39

12/17

15/21

Table 4: Additional Public Funding for Prevention and Preparedness over 5 Years(US$ billion) (Breakdown by Global- and Country-Level)
Country-level Global Public Goods

Category

Total

GlobalLevel
Capacities

Robust surveillance &detection networks

53/94

5/5

5/15

8/18

27/43

7/11

1/2

Building resiliencein health systems

60/66

-

6/1

10/8

33/45

8/10

1/1

Supply capacity
for medical
countermeasures

19/34

19/34

-

-

-

-

-

of which R&D

8/13

-

-

-

-

-

-

of which
manufacturing

11/20

-

-

-

-

-

-

Total

131/194

24/39

11/16

19/26

60/88

15/22

2/3

Average Annual
Investment

26/39

5/8

2/3

4/5

12/18

3/4

0/1

85

MIC

LIC

HIC

International
Financing

National
Budgets

International
Financing

National
Budgets

ANNEX

Annex I
The International Finance Facility for Education (IFFEd)
Model and Pandemic PPR Financing
The IFFEd, an independent non-profit legal entity set up in 2020, aims to expand Multilateral Development Bank
(MDB) lending capacity for education by strengthening MDB balance sheets through the use of portfolio support
as well as grants to make these loans more concessional.
In the IFFEd model, a combination of paid-in grants as capital and guarantees by donors can provide development
institutions, including MDBs, RDBs, or single-purpose credit facilities, with quasi-equity that they in turn canleverage on capital markets. This leveraging would depend on the capital requirements of each institution and the
IFFEd’s credit rating. The financial efficiency of IFFEd also depends on the additional leveraging that comes fromthe treatment of donor guarantees as paid-in capital in IFFEd’s balance sheet. Under this model, additional grants
can also be deployed ‘pari passu’ with the loan to make the terms of the finance more concessional.
Using the parameters developed for IFFEd — that have been reviewed and assured by credit-rating agencies — theproposed vehicle would require from donors commitments of 15 per cent in cash and 85 per cent in contingent
commitments (guarantees) for every US$1 dollar of portfolio insurance. In turn, consultations with four large MDBs
indicated that they would leverage this portfolio insurance four times if IFFEd was rated very strongly. Thus, forevery 15 cents of cash, the vehicle would produce US$4 of financial support to clients, resulting in an overall
leverage rate of 27 times.
Cost Calculations for Applying the IFFEd Model to Pandemic Prevention and Preparedness
Although the IFFEd financing instrument was developed to increase education lending, its design can also be applied
to vaccines, pandemic preparedness, or other global public health goods as long as the institutions have a strong
credit rating and preferred creditor treatment with the capacity to manage these donor commitments and loans.
The governance of any IFFEd-type vehicle for pandemic prevention and preparedness would rely as much as
possible on existing arrangements and accountabilities. Donors would fund the paid-in capital and guarantees
required, the vehicle’s independent board and contributors would decide on the magnitude and timing of theportfolio insurance to the MDBs, and the MDBs would make lending decisions.
As an illustration, to provide an extra US$4.5 billion annually in financing to Middle-Income Countries (MICs) by theWorld Bank’s IBRD with the same grant element or concession equal to IDA-regular terms through a combinationof a loan and a grant, would require an annual grant inflow of US$1.57 billion if this was done by using a standard
capital increase mechanism and grants to recipients in conjunction with the loan to increase the grant element.
This annual grant inflow from donors would be split between an increase in paid-in capital of US$0.73 billion (20percent of the US$3.66 billion IBRD loan) and US$0.84 billion for the grant to the recipient to bring the total financeprovided to IDA terms.
With the IFFEd model, in comparison, the same increase in lending would require an annual grant inflow of US$0.98
billion split between paid-in capital of US$0.14 billion (accompanied by guarantees of US$0.78 billion) to support the loan,
and the same grant of US$0.84 billion to recipients. Additional illustrative calculations are presented in the table below:
Financing IBRD countries (Group B) with a grant element equal to IDA-regularFinance

Grant

Loan

$4.00
$4.50
$5.00

$0.75
$0.84
$0.94

$3.25
$3.66
$4.06

Paid-in capital

Guarantees

IBRD

IFFEd

IFFEd

$0.65
$0.73
$0.81

$0.12
$0.14
$0.15

$0.69
$0.78
$0.86
86

ANNEX

The portfolio insurance provided by the IFFEd to the institution executing the loans, as noted above, is backed
by cash or paid-in capital provided through donor grants. These donor grants could be provided by sovereigns
or ‘Public’ actors but this financing instrument could also work with grants from Private actors.
While the use of guarantees as quasi-equity is financially attractive, it is important to note that these guarantees
must fulfill key necessary properties. The technical requirements under the IFFEd model are:1.

Portfolio guarantees offered by the entity must be long term to underpin the additional loans that theparticipating MDBs will offer to eligible borrowers.

2.

These Guarantees must be applied to a portfolio of loans and not to any individual loan.

3.

Guarantees must originate from a strongly rated independent entity that is very likely to maintain that credit
rating over the long term.

4.

The entity must be able to meet its obligations on a timely basis and not be subject to donor political andadministrative complications.

5.

The entity needs to be financially viable, able to meet over time annual administrative and financial costs fromself-generated resources.

87www.pandemic-financing.org