Investing in pandemic prevention, preparedness, and response

Summary

If resources for public health and decision makers are limited, what are the highest-priority investments they can make? Drawing on the Disease Control Priorities report on pandemic prevention, preparedness, and response, in this Viewpoint we summarise our reflections and recommendations for the next decade in public health and focus on the highest return actions for pandemic preparedness, prevention, and response that countries can take to protect themselves and others. We identified 85 feasible national-level and local-level actions, categorising 40 of them as high-priority investments. At regional and global levels, we identified and recommend 33 high-priority actions. These investments could have pay-offs substantially exceeding their cost. Ensuring adequate funding will require countries to contribute according to their fiscal capacity, with some countries requiring external support. Importantly, financing response to an outbreak should be timely and therefore prearranged.

Introduction

After the COVID-19 pandemic, the world has entered a phase of pandemic neglect, turning its attention to other crises.¹ However, pandemics tend to burst onto the scene whereas preparedness happens slowly and needs long-term commitment. Yet, failing to prepare for another pandemic would be unreasonable, inefficient, and unfair:^{2, 3} unreasonable because the risks of new disease outbreaks are substantial; inefficient because the expected societal benefits of pandemic resilience, including lower mortality and morbidity, averted economic harms, and reduced learning losses, outweigh the costs; and unfair because pandemics impose the largest burdens on the most vulnerable and can have lasting effects.

Although the exact timing of a future pandemic cannot be accurately predicted, Madhav and colleagues—using historical epidemiological data and probabilistic modelling—estimate that the likelihood of another zoonotic respiratory pandemic with mortality on the scale of COVID-19 or worse (including excess deaths) occurring within the next decade is roughly 20%.⁴ A high global burden of death is not inevitable—much can be done cost-effectively to prevent pandemics and improve future responses. Based on our work for the World Bank's Disease Control Priorities report,¹ in this Viewpoint we summarise and reflect on the key findings and recommendations (panel 1). First, we discuss key lessons for pandemic policy, and classify phases for pandemic prevention, preparedness, and response (figure). Second, we identify a menu of priority investments to strengthen pandemic resilience, introducing a set of tables that rank these investments. Third, we estimate the financing required for pandemics and provide relevant historical context. Last, we discuss how the pandemic financing architecture can be adapted.

Panel 1. Methods.

As part of the Disease Control Priorities report, the World Bank Group has published a volume on investing in pandemic prevention, preparedness, and response that identifies and synthesises evidence for actions that work and shows how timely, evidence-based, and context-specific measures can save millions of lives and trillions in economic losses, even in today's era of fractured global cooperation.¹ Leading experts from various fields—eg, One Health, biosecurity, surveillance, public health, epidemiology, infectious diseases, clinical care, education, social science, economics and finance, demography, ethics, and vaccine developers and vaccine modellers—summarised the lessons learned and identified 85 priority actions based on the available evidence, while acknowledging that economic evaluations of those actions remain scarce. We developed a list of prioritised interventions via a synthesis of literature review and expert opinion from the more than 100 experts who coauthored chapters in this volume.¹ We then classified interventions into either high, medium, or low priority, considering factors such as potential impact, feasibility, and cost, aiming to identify interventions offering considerable value for money. Our analysis importantly includes interventions that specifically address pandemic prevention, preparedness, and response across the local, national, and regional levels, going beyond the typical focus on global programmes and multilateral instruments. Because few formal economic evaluations are available, cost assessments are mostly expert judgements based on literature reviews and analyses and should be viewed as provisional. We used relative cost indicators to convey the relative cost of the different interventions. Our results offer a reasonable menu for local decision makers to choose from, and tables that are not meant to be prescriptive. We provide a menu of what we consider best buys while recognising severe resource constraints in some countries and the need to take numerous contextual factors into account.

Figure.

Phases of the pandemic cycle

The prevention phase includes systems, policies, and actions to assess, avoid, and reduce the likelihood of emergence or spillover of animal or human pathogens. The preparedness involves strategies and actions implemented before an outbreak occurs (ie, ex ante) that strengthen capacities and capabilities to detect, contain, and respond to outbreaks when they happen. The response phase includes strategies and actions taken during an epidemic (ie, ex post) or pandemic to reduce its economic, social, and health impacts. The recovery and reconstruction phase involves policies, strategies, and actions to rebuild affected communities, systems, and infrastructure after the acute response phase of a pandemic. Of note, the trigger indicates the point at which an outbreak prompts the activation of response actions. Specific financing triggers vary by instrument and can occur at different points within the response phase. Pandemic phases are not distinct and can overlap as appropriate to the emergency context and needs. Adapted from the Disease Control Priorities report¹ with permission.

Lessons for pandemic policy

Analysts have defined several dimensions of a good environment for pandemic prevention, preparedness, and response.^{5, 6, 7, 8, 9, 10, 11, 12} First, national governments and international organisations could enable early detection of new pathogens, closely monitor high-risk research, and improve practices involving the high risk of animal-to-human transmission. Second, major international organisations need to be well financed and have appropriate tools to respond quickly to global and country needs. International collaborations would benefit from investing in the development and manufacturing capacity of medical countermeasures (eg, vaccines, drugs, and diagnostics) so that countermeasures can be quickly and broadly available when needed. Third, there are evidence-based steps national governments could take to reduce the effects of the pandemic. Last, better-informed media would help to explain the need for preparedness and the uncertainty and trade-offs involved in responding appropriately to pandemics.

Although challenges such as attention cycles and the public-good nature of pandemic policy make sustained commitment difficult, meaningful opportunities for progress remain, especially at national and regional levels. For example, aligning preparedness initiatives with areas of clear national interest and with existing non-pandemic health system priorities might allow policy makers to make progress even when political support for pandemic-specific policy is low. Panel 2 summarises our lessons for pandemic policy at the national level.

Panel 2. Crucial lessons learned.

• 1.National policy makers should plan for pandemics on the assumption that international support might be restricted: vaccines could arrive late, other governments might be unprepared, financial assistance could be uncertain, and domestic public and media cooperation might be uneven.
• 2.Basic public health measures, including border controls, quarantine, testing, and isolation, can slow transmission. Yet, during COVID-19, many countries failed to use these established tools consistently or at all.
• 3.Prolonged school closures offer limited benefit when children are at relatively low risk, while imposing substantial social costs. Future pandemics could justify rapid closures if children are severely affected but schools should be reopened as soon as conditions allow.
• 4.Effective emergency, critical, and surgical care can reduce deaths and economic losses. Rapid clinical learning is equally important to identify effective treatments and quickly rule out ineffective ones.
• 5.Making full use of vaccines, if and when they become available, will require ensuring easy access for people at high risk and those most willing to be vaccinated.
• 6.Science is essential to pandemic response, including locally generated research. Policy makers should use evolving evidence to inform decisions but science alone cannot determine policy: elected leaders should weigh the benefits, burdens, and competing values; make the final choices; and justify them publicly.

Adapted from the Disease Control Priorities report¹ with permission.

Policy matters; for example, the consequences of COVID-19 lockdowns were enormous, yet their trade-offs are difficult to assess. These policies helped prevent illness and death but also imposed substantial costs. Even the best-performing countries had severe losses of life and economic and social harms, and where the economic and social harms affected schoolchildren, the consequences are potentially lifelong. The specific causal chains leading from policy to success or failure remain undetermined, will differ by country and pandemic to pandemic, and might never be definitively known. Even success will be incomplete. Policy nonetheless makes an important difference: by establishing reasonable trade-offs between loss of life and social harms, it can separate merely bad outcomes from terrible ones.

Collective striving for a better global environment for pandemic preparedness could well succeed, which is to be hoped for but not planned for. The next section offers pathways that committed policy makers and governments can pursue within the constraints of restricted global cooperation and solidarity.

Priority investments for resilience to pandemics

Pandemic risk can be substantially reduced at relatively low cost via targeted local and national efforts (panel 3). Although economic evaluations remain limited for many interventions, several investments show considerable value, including those that address current health issues while simultaneously building pandemic readiness. Such investments are less vulnerable to the cycle of panic and neglect—ie, ramping up efforts during outbreaks and then withdrawing resources once the immediate threat subsides.¹³

Panel 3. National and local priority investments.

High-priority interventions related to prevention

One Health

• •Strengthen livestock biosecurity and biosurveillance
• •Establish intersectoral One Health coordination (eg, risk assessment and data sharing)
• •Train front-line human and animal health staff within hotspots in zoonoses

Biosafety and biosecurity

• •Enforce mandatory laboratory biosafety standards, licensing, and incident reporting
• •Implement biological research governance (eg, review boards and risk–benefit assessments)

High-priority interventions related to preparedness

Targeted measures

• •Build local capacity for contact tracing
• •Plan repurposing of existing venues for isolation and quarantine facilities

Public health and social measures

• •Establish evidence-based decision frameworks
• •Develop and maintain essential service continuity plans
• •Develop community engagement and risk communication plans
• •Implement low-cost ventilation and filtration upgrades, especially for priority settings such as health care and education

Health systems

• •Develop clinical care surge plans
• •Invest in dual-purpose capacity (eg, basic emergency and surgical care, including infrastructure and workforce)
• •Strengthen critical supply chains (eg, oxygen, personal protective equipment, and therapeutics)

Surveillance

• •Strengthen disease notification systems
• •Build essential public health laboratory capacity
• •Strengthen syndromic and event-based surveillance capabilities

Products and manufacturing

• •Develop rapid procurement processes
• •Build and manage stockpiles
• •Invest in cold chain infrastructure
• •Establish expedited regulatory review for emergencies
• •Establish lines of credit to finance at-risk capacity investments

High-priority interventions related to response

Targeted measures

• •Implement contact tracing for high-risk contexts and settings
• •Provide guidance and support for isolation and quarantine
• •Test symptomatic contacts

Public health and social measures

• •Develop and activate emergency operations centres to coordinate surveillance, planning, and operational response
• •Deliver timely, transparent, and factual risk communication
• •Promote and enable core personal protective behaviours (eg, indoor distancing, mask use, and hand hygiene)
• •Improve ventilation and air quality in high-traffic areas, prioritising low-cost solutions
• •Adopt school modifications that minimally disrupt in-person education

Health systems

• •Activate national and subnational surge plans (as mentioned in the high-priority interventions related to preparedness heading)
• •Redirect resources to essential interventions: (1) health centres and clinics (eg, triage and basic life support, including oxygen), and (2) first-level hospitals (eg, basic diagnostics and supportive care for respiratory failure and shock, such as mechanical ventilation)
• •Manage supplies of key commodities, especially oxygen

Surveillance

• •Monitor and openly report key indicators (eg, cases, hospitalisations, and deaths)
• •Ensure laboratory capacity for essential pandemic diagnostics (eg, PCR and culture)
• •Conduct targeted genomic surveillance
• •Apply epidemiological analyses to inform response actions
• •Products and manufacturing
• •Activate emergency procurement plans for diagnostics, therapeutics, oxygen, and basic personal protective equipment
• •Streamline emergency regulatory pathways for pandemic products

Adapted from the Disease Control Priorities report¹ with permission.

We highlight three investments tailored to respiratory pandemics caused by viruses such as influenza and coronaviruses because these present the most probable cause of future pandemics. First, investing in foundational health-care capabilities, particularly basic clinical care, and strengthening supply chains to ensure adequate stocks of personal protective equipment, essential therapeutics, reagents, and medical oxygen might be among the highest-priority actions that nations can take. Clinical interventions are frequently overlooked in pandemic preparedness discussions, yet emergency, critical, and operative care have saved lives during COVID-19.^{14, 15} Second, ensuring rapid procurement processes and adequate stockpiles of essential countermeasures is crucial. High-quality respiratory protection, particularly N95 respirators or equivalents, could be stockpiled. Third, public health and social measures remain crucial for lowering peak death rates, reducing strains on clinical facilities and personnel, and decreasing death tolls, particularly early in a pandemic when vaccines are unavailable.¹⁶ Identifying and isolating individuals who are infectious—in accordance with national norms that can be effectively communicated and socially accepted as legitimate with adequate public buy-in—is a fundamental public health capability that many countries did not have during COVID-19. Additionally, improving ventilation and air filtration in crowded indoor settings, particularly health-care facilities, schools, and bars and restaurants, reduces transmission risk for multiple respiratory pathogens. These engineering controls can represent relatively low-cost interventions with potentially substantial benefits during interpandemic and pandemic periods.

Although tailored to airborne respiratory threats, these investments would also strengthen responses to other epidemic and pandemic diseases, such as sexually transmitted and vector-borne diseases and haemorrhagic fever. COVID-19 showed that outcomes improved when countries acted decisively without waiting for complete information and when they tailored their response to the pathogen and the local context. Beyond high-priority investments, we identified 31 medium-priority interventions for countries to consider, depending on resource availability and further analysis of costs and benefits.

Some priorities lie outside of any single country's reach. At the regional and global level, we identified 33 high-priority interventions requiring international collaboration and financing (panel 4). For prevention, harmonised wildlife trade regulation across countries can mitigate spillover risk and includes coordinated monitoring, bans, and enforcement targeting trade in the riskiest species.¹⁷ We recognise that this approach can be operationally very difficult, as these activities are linked to livelihood, culture, food security, and survival. Indeed, many health-related recommendations have economic consequences at the individual level and consequent potential implications for social welfare systems. For preparedness, robust early detection depends on coordinated surveillance across multiple layers: animal–human interfaces where spillovers occur, clinical settings where unusual cases appear, wastewater surveillance that detects early signs of spread, and travel hubs where pathogens cross borders. Building manufacturing capacity is a regional and global priority. COVID-19 vaccines faced production bottlenecks and hoarding by high-income countries (HICs), not demand shortages. Building factories from scratch takes more than a year, which can introduce catastrophic delays during a pandemic. Contracting to maintain a state of readiness for distributed manufacturing capacity can address this issue. Manufacturers could receive fees to maintain excess capacity that can rapidly convert to pandemic production. A US$60 billion upfront investment, plus $5 billion annually, could avert $539 billion in losses by accelerating vaccine roll-out.¹⁸ The broad value of COVID-19 vaccines incorporating gross domestic product (GDP), mortality, and direct and indirect cost impacts is estimated to be $5·2 trillion.¹⁹ Similarly, prepositioned clinical trial networks enable faster evaluation of medical countermeasures. Furthermore, additional efforts should ensure equitable distribution of countermeasures. The COVID-19 Vaccines Global Access initiative represented progress in this direction but came too late and fell short of its ambitions, largely superseded by bilateral purchasing agreements that favoured higher-income nations.²⁰

Panel 4. Regional and global priority investments.

High-priority interventions related to prevention

One Health

• •Develop coordinated animal–human interface surveillance networks (eg, testing humans at spillover hotspots and cross-border and intersectoral data sharing)
• •Implement harmonised wildlife trade regulation (eg, coordinated monitoring, bans, and enforcement on the riskiest zoonotic species)

Biosecurity and biosafety

• •Develop and implement international biosafety standards and peer-review audits
• •Establish multilateral research governance norms and funding conditions (eg, mandatory risk reviews in donor requirements and journal policies)
• •Form a global DNA synthesis security consortium (eg, access-controlled sequence databases, uniform screening protocols, and cross-border enforcement)
• •Establish a global registry of biosafety level 3 and 4 laboratories, public and private

High-priority interventions related to preparedness

Public health and social measures

• •Support evidence generation to establish the effectiveness of public health and social measures (PHSMs)
• •Invest in research and development for improved environmental controls (eg, ventilation, filtration, and germicidal ultraviolet light) and personal protective equipment (PPE)

Surveillance

• •Strengthen global pathogen data-sharing platforms (eg, genetic sequences, test protocols, and validation data)
• •Strengthen global pathogen alert and rapid-response systems (eg, rules for escalating high-risk signals and triggering regional and global support)
• •Implement strategic genomic surveillance at novel pathogen emergence hotspots
• •Implement and strengthen strategic wastewater surveillance in high-risk areas (eg, major transportation hubs)
• •Drive research and development for broad-spectrum point-of-care diagnostics

Products and manufacturing

• •Invest in warm (ie, rapidly repurposable) global manufacturing capacity
• •Fund research and development for countermeasure platform technologies (eg, vaccines, therapeutics, and diagnostics)
• •Prioritise research and development for high-priority pathogens (eg, influenza viruses and coronaviruses)
• •Strengthen global clinical trial infrastructure (eg, recruit preselected cohorts who have given consent ex ante)
• •Strengthen oxygen supply chain and production capacity
• •Push for multilateral development banks to establish credit mechanisms to help low-income and middle-income countries finance at-risk capacity investments in the event of a pandemic

High-priority interventions related to response

Public health and social measures

• •Facilitate rapid evidence synthesis and disseminate updated PHSM guidance for the current pathogen and its variants
• •Support systematic evidence generation to evaluate PHSM guidance

Surveillance

• •Standardise and facilitate global reporting of core epidemiological indicators (eg, cases, deaths, and hospitalisations)
• •Coordinate global surveillance (genomic and phenotypic) and enable rapid data sharing
• •Provide global and regional epidemiological modelling, forecasting, and technical support to countries
• •Conduct rapid risk assessments of transmission and disease potential to guide country responses
• •Support and coordinate international wastewater surveillance to monitor pathogen trends

Products and manufacturing

• •Mobilise and coordinate global manufacturing capacity for the rapid scale-up of needed countermeasures
• •Coordinate equitable global allocation and distribution of essential countermeasures (eg, diagnostics, therapeutics, vaccines, and PPE)
• •Support and expedite the rapid development, evaluation (including clinical trials), and adaptation of countermeasures
• •Coordinate global efforts to ensure access to medical oxygen and essential related clinical supplies
• •Incentivise vaccine manufacturing firms to build at-risk capacity
• •Use vaccine capacity efficiently (eg, first doses first policy)
• •Invest in a diverse portfolio of vaccine candidates (across vaccine platforms)

Adapted from the Disease Control Priorities report¹ with permission.

During pandemic response, speed and coordination are crucial. Countries need rapid synthesis of fragmentary and evolving scientific evidence, including rapid and ongoing appraisal of pathogen characteristics. The COVID-19 pandemic revealed the cost of delay: weeks to months passed before authorities confirmed human-to-human transmission and recognised airborne spread, limiting the implementation of potentially efficacious early interventions. Sustained mechanisms for scientific evidence synthesis during interpandemic periods could support ongoing assessment of risks and provide a platform for rapid, ad hoc risk assessment during incipient pandemics.

Risks can also be assessed beyond health. 1·6 billion children were affected by school closures at the peak of the lockdowns—for many and their parents, the consequences are still real and present.²¹ To prepare for these aspects for the next pandemic, the considerable differences in consequences between rushing to close schools—which had massive and unforeseen side-effects that often exacerbated existing inequalities—and protecting the integrity of the school system and introducing specific school-based measures should be considered. Even when pandemic characteristics put children at high risk and make them major drivers of transmission, rapid closing of schools with careful reopening strategies could help to balance between the possible epidemiological gains and the expected societal harm. Better understanding of the implications of these two options could be crucial to appropriate decision making during future pandemics.²¹

Financing resilience to pandemics

What level of financing is required to address pandemic risk? How does the investment needed to avert or mitigate the impact of future pandemics compare with expected economic losses from future health crises? The investment required to avert or mitigate pandemics is substantial, yet modest compared with the losses that pandemics cause.^{14, 22}

Although we recommend high-priority actions that local and national decision makers can implement, we recognise that actions at the regional and global level, mitigating global risks, should be a shared responsibility. The economic impacts of outbreaks, epidemics, and pandemics are large, and go beyond the cost of mortality and morbidity. Studies examine the tremendous losses from pandemics on an annualised or ongoing basis.^{3, 23} Numerous studies estimate the economic losses of pandemics and epidemics in recent history, such as SARS, Ebola virus disease, and the COVID-19 pandemic.^{24, 25}

Unlike SARS in 2003 and Ebola in 2014, which both had relatively contained geographical spread, the COVID-19 pandemic had near-universal impact. In 2020, Cutler and Summers estimated the COVID-19 pandemic caused economic losses exceeding $16 trillion in the USA.²⁶ Gopinath described the COVID-19 pandemic as the worst economic downturn since the Great Depression, estimating cumulative output loss during 2020–21 at around $9 trillion.²⁷ Additional economic losses continue to accrue long after the acute phase, via the debt crises that the COVID-19 pandemic precipitated and via difficult-to-quantify but still substantial long-term damages due to COVID-19's impacts on educational attainment, long-term morbidity, and other factors. The Lancet Commission on investing in health estimated that the economic value of loss from mortality alone in COVID-19 was 34% of global annual income.¹⁴ Furthermore, the Commission estimated that the economic loss from an expected 2·5 million deaths per year from global respiratory pandemics (the World Bank's Disease Control Priorities estimate) amounts to 5·4% of global GDP per year.

By comparison, the amount of essential investment required to reduce pandemic damages is small. More financing is needed for pandemic preparedness and response.^{18, 23} Published reports provide several estimates based on different methodologies, which range from $5 billion annually to $50 billion.^{23, 28, 29, 30, 31, 32} These investments, even up to the level of $30 billion per year, could have pay-offs exceeding their cost.³³

These investments in pandemic prevention, preparedness, and response are minimal compared with collective HICs spending of $6·7 trillion on health care in 2019 alone; however, the needed funds exceed the available resources of low-income and lower middle-income countries. Health expenditure in low-income countries averaged $39 per person and totalled $20·7 billion for those 24 countries in 2019.³⁴

Greater investment by HICs is therefore necessary for global pandemic preparedness. A public good benefits everyone, cannot exclude anyone, and does not reduce availability for subsequent consumption. Failure to contain an outbreak harms not only the community or country that failed to contain it but potentially every country, as witnessed during the COVID-19 pandemic.³⁵ Standard economic theory justifies a collective intervention to address public goods with positive cross-border externalities. Additionally, ensuring adequate funding would require contributions from all countries to be based on their fiscal capacity to enable a fairer distribution of benefits across countries worldwide.³⁶ HICs could benefit more from overall reductions in pandemic risk, as they face larger economic costs in absolute terms from pandemics. Investment in mitigating crises, which might originate outside their borders but nonetheless pose a broader economic threat, is economically rational for HICs. However, such contributions from HICs did not materialise during the COVID-19 pandemic. Panel 5 summarises lessons learned from financing the COVID-19 pandemic response.

Panel 5. Lessons on pandemic financing from COVID-19.

• 1.COVID-19 financing largely followed established patterns in global health assistance. Bilateral donors provided most external funding, with multilateral development banks, Gavi, the Vaccine Alliance, and the Global Fund also playing major roles. By contrast, WHO and other UN agencies contributed only a very small share of the overall financing, underscoring their restricted role as direct funders despite their central normative and coordinating functions.
• 2.Countries often struggled to quickly mobilise and deploy domestic resources for the health response, while restricted fiscal space constrained broader economic and social support.
• 3.The absence of a dedicated pandemic financing mechanism helped justify the Pandemic Fund whose current focus overlaps with existing funding channels, raising questions about additionality and whether it should also provide rapid contingent financing during outbreaks.
• 4.Pandemic financing remains fragmented across institutions and instruments, increasing burdens and delaying access to funds. Weak coordination also slowed procurement and distribution, while new mechanisms such as the COVID-19 Vaccines Global Access initiative were established too late to prevent reliance on bilateral and national approaches.
• 5.Concessional financing dominated the COVID-19 response, with market-rate loans also important. Greater use of prearranged and contingent financing could reduce delays, drawing on emerging models from the World Bank Group, Barbados, and the African Risk Capacity group.
• 6.Financing was too slow in both the early and later phases of COVID-19, delaying access to vaccines, diagnostics, therapeutics, oxygen, and other supplies. Slow product evaluation, procurement, and financing also favoured higher-income countries that were able to secure supplies first, underscoring the need for prearranged surge financing to support equitable access to medical countermeasures.

Adapted from the Disease Control Priorities report¹ with permission.

Strengthening the pandemic financing architecture

Our evaluation of COVID-19 pandemic preparedness and response financing supports two key principles for stronger pandemic financing architecture domestically and globally. The first principle concerns domestic readiness, which requires timely—and therefore prearranged—financing. Because the next pandemic could occur at any time, populous countries with adequate domestic resources could find it advantageous to invest in requisite capacity. For less populous countries—for whom returns to pandemic preparedness and response investments might fall predominantly outside the country—and for lower-income countries, grant support from the international system could prove the best way to align domestic incentives with international priorities. Maintaining this capacity is far more affordable than responding after an outbreak has developed into a pandemic and will pay for itself by reducing pandemic losses. Given that infectious diseases spread exponentially, rapid action is essential.

Pandemics can rapidly create shortages of essential medical supplies. Prearranged financing, stockpiles, and at-risk investments can accelerate development, manufacturing, procurement, and distribution of vaccines and other countermeasures. Multilateral lenders can support such investments, including advance purchase agreements. Financing for global public goods should also address market failures, discourage free-riding, and ensure accountability.

The second principle of stronger pandemic financing architecture concerns the financing of global public goods, which should be designed to address market failures and create incentives for collective action.

Prevention and preparedness

The funding approach is grounded in the recognition that such efforts constitute a public good, at least at the regional level (eg, in the case of viral haemorrhagic fevers) if not globally (eg, in the case of highly transmissible pathogens, particularly respiratory pathogens). Pandemics transcend borders, and investments in one country's prevention and preparedness efforts can yield benefits for global health security. Ensuring adequate financing for prevention and preparedness therefore requires clear and transparent indicators that define a minimum acceptable level of preparedness. These indicators should be simple, measurable, achievable, relevant to pandemic financing, and time bound, and will clarify the gaps that additional financing can address.³⁷ It is also crucial that preparedness metrics are risk informed: a country might have systems that can respond effectively to a pandemic as severe as COVID-19 but be unprepared for an event with a mortality shock as severe as the 1918 influenza pandemic. Principles are needed to guide the distribution of global pandemic financing resources such as those from the Pandemic Fund that presume prevention and preparedness are global public goods. Such resources could be used to deliver investments that are large global positive externalities, are unlikely to be funded by other sources, and offer large preparedness and prevention returns per US dollar relative to other opportunities. These principles can inform allocation formula for expected country-specific costs for financing pandemic prevention and preparedness and establish standards for equity and the appropriate balance between domestic and external financing.

Response and reconstruction

Early response

New pandemic financing mechanisms, with a clear role for multilateral development banks, should establish precise and transparent triggers or a tiered scale of triggers for swift activation and deployment of financial, human, and material resources in response to an outbreak or epidemic of a new or re-emerging pathogen. Well defined triggers can clarify and accelerate complex decision-making processes that often occur, unrehearsed, in an active crisis.³⁸ Triggers can ensure that financing mechanisms are prearranged and designed for rapid release in response to different types of epidemic threats and scenarios. Disbursement of funds should be faster, more transparent, easy (but also simple to claw back if not justified or if misspent), and flexible enough to support actions within and outside the health sector.

Late-stage response and reconstruction

Countries need prearranged contingent financing for late-stage response and recovery, including grants, loans, and insurance tailored to the ability to pay. Unlike traditional health assistance, these instruments are negotiated in advance and triggered by a pandemic, similar to disaster-response financing. Because late-stage response and recovery generate fewer global externalities, financing can rely more heavily on country-specific mechanisms. Therefore, to the extent that the international system wishes to incentivise prevention, preparation, and transparent reporting, it will best be done with the promise of increased transfers at these stages and—most definitely—not by withholding support for early response. This is a point that the design of previous international financial mechanisms seems to have neglected.

Governance and science

Governance and political incentives clearly matter and need to be considered carefully and studied further.³⁹ The unfortunate cycle between pandemic panic and neglect has many drivers, including that pandemics are low-frequency, high-impact events prone to neglect by many (but not all) decision makers facing short-term election cycles, which leads them to be ignored, despite the need for sustained long-term preparedness. Countries’ international obligations for pandemic prevention, preparedness, and response are governed by WHO's International Health Regulations (IHR; including the 2024 amendments) and the new Pandemic Agreement adopted in 2025.^{40, 41} The IHR are legally binding rules requiring states to detect, assess, report, and respond to public health threats that could spread internationally. Countries should maintain surveillance systems, laboratory and response capacity, ensure equitable access to medical countermeasures, and notify WHO within 24 h of events that might constitute a so-called public health emergency of international concern. Countries are also expected to share accurate information, cooperate internationally, and avoid unnecessary travel or trade restrictions.

Effective collective action to address pandemic risk also requires a science–policy interface (SPI)—ie, a formalised process for the global scientific community to collaboratively synthesise evidence on pandemic risk, whether and how it is changing over time, why, and the most effective policy responses.

Conclusion

Because countries cannot rely solely on global action, in this paper, we propose a classification of phases for pandemic prevention, preparedness, and response and identify high-priority local actions that nations can implement in anticipation of slow or inefficient global-level preparedness. Yet, fragile states and low-income countries cannot reasonably be expected to finance a large proportion of the investments needed. Adequate funding requires that countries everywhere contribute according to their capacity and in a reliable and sustained way. Although such investments can run counter to political tendencies, they can yield health and economic dividends far exceeding their cost for both high-income and low-income countries.

Declaration of interests

We declare no competing interests.