This week, global leaders gathered at the 5th Global Health Security Agenda Ministerial Meetings in Bali under the overarching theme of “advancing global partnerships” for greater health security. Alongside this event, the World Bank hosted a discussion on preparedness financing at the country level. The panel acknowledged that while countries have begun to pay more attention to pandemic preparedness, much work remains to increase domestic and donor support to national preparedness systems.
As the discussions wrap up in Bali and the World Bank heads to its IDA18 midterm review in Zambia next week, we share a few thoughts:
The world is not prepared for the next pandemic
To date, more than 80 countries have undertaken a joint external evaluation (JEE) assessing their national capacity to prevent, detect, and respond to epidemics and pandemics in the years following the 2014–2016 West African Ebola crisis. From these JEE assessments, more than 6,000 critical capacity gaps have been identified, but there remains no systematic financing to address them.
Concurrently, while countries are undertaking assessments and creating plans, health systems in high-risk countries are being constantly tested. The latest protracted Ebola outbreak in DRC is a sobering reminder of the failure to prepare and respond adequately, with ensuing costs not only to DRC itself but to neighboring countries. There is thus an urgent need to move beyond assessment and planning to measurable progress at the national level—supporting countries to build capacity across 19 technical areas, with a focus on the “core four”: surveillance, laboratory, response, and workforce.
The benefits seem obvious. Whereas the cost of response and economic loss from a pandemic is estimated to be as much as $60 billion per year, it is estimated that $4.6 billion per year, or 0.65 cents per person, would be enough to address current capacity gaps in epidemic readiness.
Yet despite clear recommendations to mobilize domestic resources, and a number of funding mechanisms available via the World Bank, examples of substantial investments in preparedness are still limited, the funds that are available are fragmented and slow to disburse, and progress on JEE-identified gaps remains unclear at best.
There is a clear need to create stronger incentives to accelerate investment and progress toward improved health security preparedness.
Many mechanisms, uncertain progress
Bilateral funding comprises the bulk of money spent on global health security. Yet while bilateral external support for preparedness is vital, this assistance is mostly in-kind in the form of training and supplies. The World Bank has therefore emerged as the major source of direct monetary support for preparedness and response in low- and lower-middle-income countries. Several funding mechanisms are currently available:
Pandemic Emergency Financing Facility (PEF) – After the West Africa Ebola outbreak, a key innovation was the creation of the US$500 million PEF. Covering all 77 IDA-eligible countries, the PEF can quickly release funds to countries and international agencies in response to outbreaks of highly infectious diseases, including via an insurance mechanism for specific diseases. In addition, a financing window is available for other significant emerging events.
International Development Association (IDA) – IDA18 currently has a mandate to support 25 of 77 of its eligible countries in developing strategic pandemic preparedness plans, as well as frameworks for governance and institutional arrangements for multisectoral health emergency preparedness, response, and recovery. This, however, leaves 52 of the 77 countries without access to this mechanism, and the rationale for the selection of the 25 is unclear. Further, the demand for the use of the window to directly finance preparedness is unclear.
Crises Response Window (CRW) – In 2015, the World Bank Group’s board expanded IDA’s CRW to include public health emergencies. The CRW has an allocation of US$3 billion to support IDA countries’ response to severe natural disasters, economic crises, and health emergencies. Yet countries’ ability to access the fund early in a potential large-scale outbreak is limited, and currently, the fund cannot even be accessed for preparedness in countries surrounding an outbreak.
Immediate Response Mechanism (IRM) – The IRM allows up to 5 percent of undisbursed IDA investment project balances to be used for an immediate response to crises. This complements longer-term response mechanisms such as the CRW.
IDA Catastrophe Deferred Drawdown (Cat DDO) – The Cat DDO provides between $20 and $250 million as a contingent financial line to provide immediate liquidity to countries to address shocks including health-related events. Approval criteria include an adequate macroeconomic policy framework and a satisfactory disaster risk management program.
Regional Disease Surveillance Systems Enhancement (REDISSE) Program – From 2016, the World Bank committed nearly US$400 million to West African countries as part of the REDISSE Program. The program aims to promote both preparedness—by strengthening national and regional policy dialogue, surveillance, and health system capacity—as well as response, through its Contingency Emergency Response Component, which provides access to undisbursed IDA resources for countries to quickly respond to eligible crises. Progress in executing REDISSE’s first two phases so far has been slow. As of September 2018, less than 12 percent of REDISSE funding committed between 2016 and 2017 had been disbursed, about half of the amount projected at the time of approval.
Trust funds and other initiatives – The World Bank also hosts multiple trust funds with specific geographical or technical focus areas.
Little for preparedness, lots of fragmentation
Among these seven major categories of World Bank—mainly IDA—financing, most of the money is in response, not preparedness, a massive oversight given that a main goal is to prevent outbreaks from spreading in the first place.
And perhaps the problem is not only the amount of money available, but how the money is organized and the incentives it does and does not create for countries to invest in preparedness. The fragmentation of financing is in turn reflected in fragmented planning and implementation in-country, where disease-specific plans and funding streams complicate the development and implementation of a more overarching preparedness plan. Further, the multiple funding windows and eligibility criteria may in themselves dilute incentives for progress, despite the great potential of the JEE instrument and associated accountability mechanisms.
Do country governments have clarity on how to access funds and what mechanisms to use? How many have prioritized preparedness within their IDA allocation? Why has the pace of progress and execution of funds already allocated been slow? How does preparedness money interact with existing domestic and external health funding flows? These questions are difficult to answer, leading to lingering uncertainty within the international community about the effect this money, as currently operated through existing funding mechanisms, is generating. Getting a grasp on how all external and domestic financing for health collectively advances health security is an important first step (and not an easy one), but It may also result in a more rational understanding of the cost of and way forward to pandemic preparedness.
Next steps to speed progress
Money is far from the only obstacle to progress, but it is likely that clearer rules of the game and stronger financial incentives for preparedness could help to accelerate effort.
The IDA18 midterm review happens in Zambia next week. It is a perfect opportunity to look critically at the role of the World Bank and IDA (and its different windows and mandates) in outbreak preparedness and response.
One option is to rationalize the World Bank’s funding offer and restructure the incentives that currently operate around this funding. In this case, an important action would be to consolidate funding by joining multiple existing mechanisms to a single mechanism or umbrella, and to build clearer incentives for progress against the JEE baselines. No new windows are needed, but an effort could be made to harmonize eligibility requirements and related issues.
Even if funds are not consolidated, a portion of the existing funding windows could be structured as a “challenge fund,” a model that has been successfully used to motivate countries to invest their own resources and focus on progress towards mutually agreed outcomes or reforms (as was the case with the Salud Mesoamerica Initiative). A challenge fund could ask countries to put up a share (half) of the resources, with the other share (or half) coming from philanthropy or World Bank global public goods monies to fund preparedness gaps/programs. Countries would then get half their contribution back if they make annual (or 18-monthly) progress on a set of independently verified metrics, which could be the core four from JEE. This kind of structure can create incentives for domestic on-budget spending on preparedness, improve the quality of preparedness data by conducting rigorous independent verifications, provide opportunity for accountability at regular intervals, allow countries to correct course and “try again” to meet goals after an initial disappointment, and help to align multiple funders.
While the jury is still out on what the best financing setup might be, the need to streamline the money we do have is clear.
As input to an October meeting of the CSIS Commission on Strengthening America’s Health Security, we drafted a note in collaboration with Amanda McClelland and Tom Frieden that explored options for funding mechanisms within the World Bank. Part of this blog is based on that note. We plan to write a draft white paper for Commission review in 2019 based on the results of these evolving discussions.
Amanda McClelland is Senior Vice President of Resolve to Save Lives.