Day Zero Dollars: Unlocking Immediate Funds for Global Pandemic Response

JAVIER GUZMAN: 
Good afternoon, and welcome to the Center for Global Development. My name is Javier Guzman. I'm the director of Global Health Policy and Senior Fellow here. And it is a pleasure to have a conversation on a very important topic. We all went through COVID, a lot of lessons learned, but one of the key lessons was the importance of timely financing. And we learned the lesson, not because we did well, but because we actually didn't do well. So, we know that in early 2022, 70% of people living in high income countries were vaccinated, compared to only 10% in Africa. And of course, there's a lot of research on the reasons behind this. A paper by Ruchir Agarwal and Tristan Reed basically shows that about 60 to 75% of that delay was because, of that inequity was because of the delay in financing. COVAX, for instance, as well, it was a very difficult mechanism to get off the ground. It took 15 months for COVAX to raise $10 billion. So, I guess, time is of the essence in this conversation. This has been recognized not just by a lot of high level panels. 

We were very much involved in the G20 high level panel on funding pandemic preparedness, but also the G7, the G20 communiques, and we also saw it in the Mpox outbreak, the public health emergency. But despite all that, we still have a gap in what we call surge financing, Day Zero financing, at risk financing. And I guess, all those names have different connotations. But I guess the important thing here is we need to have money that is ready to go, and we need to have money that could actually be used at risk. And at risk, meaning that sometimes that money will be lost because the product might fail, because the demand might fail, because of many things might fail. So, having said all that, I'm very pleased to be here with a very group, very high level group of experts who are going to discuss this issue. We're going to have a short panel and then we have a Q&A session. This is a conversation. so please do chime in and let us know what you think. So, I will start here on my left, I've got Augustin Flory, who is the Managing Director of Innovative Partnership and Development Finance at the Gavi, the Vaccine Alliance. 

Nafisa Jiwani, Managing Director, Health initiatives at the US International Development Finance Corporation. Leah Rosenzweig, who is just on a new CGD Fellow who started a few weeks ago here, coming from the University of Chicago, Market Shaping Accelerator, where she is the director of that initiative. Serena Ng, who is the executive head of the G20 Joint Finance and Health Task Force Secretariat. She is at the World Health Organization. And finally, last but not least, of course, Juan Pablo Uribe, who is the Global Director for Health, Nutrition and Population, also the Director of the GFF at the World Bank. So, the initial question is basically, where are we now and what next? And of course, we have different options and we have different possibilities. So, I want to start with Leah telling us a bit more about the work the Market Shaping Accelerator has done in terms of what are the key options or the key features that you see as how you bridge that gap in surge financing. 

LEAH ROSENZWEIG: 
Thanks, Javier. So, we're starting from the same starting point, you nicely framed. In addition, I would say that we believe in a pandemic, borrowing to buy medical countermeasures early is incredibly cost effective. And there are two fold benefits. The first is to the country buying those medical countermeasures for their citizens. The second is a global benefit. If we structure contracts appropriately, we can expand supply and set demand early so that manufacturers can ramp up supply early, which has global benefits. So, we put out a blog yesterday with five key steps that the MDBs can take to allow countries to buy at risk. And when I say at risk, I mean buying medical countermeasures before they're approved or authorized for emergency use. I want to be clear, what I do not mean is putting jabs into arms for vaccines, say, before they're found to be safe and effective. Again, the purpose here is to put in purchases early to signal strong demand to manufacturers so that they can ramp up capacity and supply. 

So, we have this five step proposal. The first step is allowing countries to do this through loans that they would take out from the MDBs. This was not possible during COVID. For example, the World Bank required in-country regulatory authorization and either WHO prequalification and approval by one stringent regulatory authority or approved by three SRAs. So, let's see if we can maybe relax some of those rules and restrictions. Second is to set up an expert panel. So, we need to know what's a good bet and what's not a good bet to buy early on. Setting up a panel, whether that's in the bank or some existing structure already that has both health experts and economics experts to decide and evaluate what's a good bet and not. Third is to create model loan templates. This is something we should do now. Obviously, it would have been nice to have that during COVID so that countries didn't have to go and do it on a one off basis individually. As much as possible, can we iron out these things early on? 

Number four is drafting purchase agreements. Again, we're not going to get all the details right in advance. We're not going to know exactly what medical countermeasures we need with which manufacturers. But as much as possible, can we think about these issues of indemnity and liability? MDBs are going to have some purchasing power with these manufacturers, given that if they allow countries to use loans to buy at risk, that could be a large amount of demand for these manufacturers, who might be then willing to negotiate with the MDBs and draft some of these purchase agreements, at least the outlines of them in advance. And then finally, step five is what we're suggesting would be an optional guarantee mechanism. Again, this is highly cost effective in pandemics for countries to buy in early. But obviously that, you know, threshold will vary depending on income levels. So, allowing high income countries to either repay in full or in part, a loan taken out by a low or lower middle income country, an IDA eligible country would, you know, de-risk that part for that country, and again, de-risk the sort of technology risk because someone is still paying for that risk that the vaccine or other medical countermeasure fails. 

So, that's our proposal. We think there are some benefits to it. It operates with the existing country based model that the MDBs have. It, you know, doesn't rely on grant financing. It's also not mutually exclusive with other proposals. We could do these things now. Not to say that we can't do other things later, perhaps more ambitious projects. There are also some considerations and maybe some downsides. One concern that I've heard a lot is countries won't do this. And one response is, well, that's OK. It's an option. It's an opt in opportunity. Again, our guarantee mechanism, we hope, will make it more attractive for low income countries to take this opportunity. We think that for middle income countries who might be willing to invest their own resources in this endeavor, it actually, again, is quite cost effective. I did some numbers for Peru just to put a finer point on this. So, Peru waited until vaccines were approved before procuring them, which corresponded to about a three month delay, say compared to the US or other high income countries. 

In that period, they spent about $1 billion per month on COVID policies, like cash transfers. Some modeling by economists suggests that the optimal portfolio for Peru would be to spend $2 billion in 2020 at the start of COVID on 11 candidates, and this would have an estimated benefit of about $5 billion. We know that vaccines and other medical countermeasures are much more beneficial and valuable early on. You know, $5 billion in benefits is a lot. This is just accounting for, you know, reduced health and economic harm. It's not accounting for getting schools open earlier. I think Peru had sort of the longest school closure in the region. And again, some estimates suggest that accounting for World Bank estimates based on learning losses, you know, summed over the 6.5 million school children, it would have saved $42 billion. So, again... 

JAVIER GUZMAN: 
Can I stop you there? 

LEAH ROSENZWEIG: 
Yes. 

JAVIER GUZMAN: 
Because it seems that we can't get into the specifics. 

LEAH ROSENZWEIG: 
That was my last point.(LAUGH) 

JAVIER GUZMAN: 
I guess, is there any new money in that proposal or is it best about tweaking the existing model? 

LEAH ROSENZWEIG: 
Tweaking the existing model. 

JAVIER GUZMAN: 
So, OK, we go with this option of tweaking the existing model. No new money, country-based, and countries doing it themselves. Now, Serina, I know the G20 has done a lot of work, not just on mapping where we are, but also on possibilities going forward. I know you guys said that there's a nine billion gap. What are your thoughts or what is the G20 thinking about options in terms of surge financing and Day Zero financing. 

SERINA NG: 
So, thank you, Javier. So, the work that we do has been the sort of technical work, figuring out sort of what were the gaps in during COVID. And that's with the luxury of sort of hindsight and being able to sort of look back and see. And the nine billion gap was what we saw at, you know, at that time. In terms of kind of therefore how you fill that gap, I mean, there are sort of, you know, you have the basic options. It's like, what do you have that you can make work better? Do you need something new? And also, how do you make it sort of country center? I think that is really, really important. In terms of actually, though, sort of, we as a technical zone representing the work of the secretariat rather than the sort of G20 writ large. And you know, what we've done is, you know, set out sort of various sort of options in terms of how you, I think my mic just sort of died, but so in terms of how you can approach that, but I think there's a very strong view that you need to look back at what your ultimate aim is, and that is to get vaccine equity. It's to get developing countries to access vaccines as rapidly as possible. And then I think you need to work back from that and sort of what are the ways to do that? And in terms of the sort of cost benefit analysis and the certain things that you, that Leah mentioned, I think, absolutely, you need to have, make it as easy as possible to contract, either countries themselves or, you know, in a sort of pooling with others. But you also need to make sure that the money is there available as rapidly as possible. And you know, the sort of a route using existing mechanisms is quite attractive, but only if we're sort of fully confident that it can get, you know, you can access that finance really, really rapidly. And so, I think the issue that we saw in, during COVID was between grants and loans is that the loans actually meant that you accessed, you sort of contracted, etc, much, much later. And the incentives for countries to sort of wait and see is quite high. So, in terms of sort of how you fill that gap, I think there are a range of options. 

I don't think G20 itself is saying we should do X, Y or Z. We can look at the sort of pools of finance that were there before. So, the bank obviously was a significant amount, regional development banks were a significant amount. The IMF also provided a significant amount of support, and there was also a lot of bilateral support. So, these are all sort of pools of finance. And I think it's really trying to sort of figure out which one gives you that access to medical countermeasures, whatever they are, as rapidly as possible. 

JAVIER GUZMAN: 
OK. Well, Juan Pablo, all eyes are on the bank and are on you about what next, right? And some people talk about, well, we just heard some short term, minimalistic. Others talk about ambitious, more long term. Talk about the possibility of aggregating financing. So, even before countries say I want vaccines, the bank basically pulling financing and discussing either with companies or with procurement mechanisms. Some people talk about the bank actually procuring. What is actually, what are your thoughts on the possibilities and how the bank is looking at it at this point in time? 

JUAN PABLO URIBE: 
OK. It's a very good question. It has a long answer because it's not about only one mechanism. It's not only about financing from the bank's perspective, no, our short and longer term engagement has to be, of course, addressing this question, but much more comprehensive. In that regard, I do want Javier to thank you and CGD for this space. And I want to thank the panel colleagues and others who could be in this panel for their insistence and persistence in having this very important question of the Zero Day financing at-risk. But look, quickly on context, there's a huge uncertainty with the face, the future pandemic will bring. And one of the important elements in whatever we define will need to be flexibility and the capacity to adapt to very different needs, probably not a vaccine, to many different orders of magnitude in the different responses that go beyond medical countermeasures. And we need to, again, have the capacity to quickly adapt and effectively respond to that. 

What are we doing? And we shouldn't take it for granted. The first thing is we need to maintain visibility on this topic. And you're going to say about Juan Pablo, you're not answering that question, I will get to the answer. But look, there are so many competing needs and neglect is so proper of human nature that it's very easy that this topic will fall down the agenda unless we have another pandemic or we insist, as you are doing, very well done. We're making this a priority in the bank. And it is a priority. Magnus Lindelow is here, and he leads a lot of the work that we're doing on PPR, and it includes a global challenge program where we're working on the medical countermeasures manufacturing site and regions. We're working with partnerships. I do want us to think that we right now have a pandemic fund, that we now have Serina; RST with IMF coming in, which I think is important, And the great work that the G20 is doing with the task force. Concretely on the response from Day Zero, we continue to work on health systems strengthening at the country level. 

Why is this important? Let me bring Mpox. Mpox is a beautiful test to what we learned or we didn't learn from COVID or yet, and it's happening as we speak. In DRC, in Burundi, in other ten neighbor countries, when Mpox outbreak happened, there were ongoing projects that had all the elements for the immediate financing that was needed there. And DRC and Burundi have used those resources at the local context to buy what they need for the Mpox response. I know it's different from the magnitude of the vaccine requirement in COVID, but it's important to signal that there are Zero Day response mechanisms at that level that should be used and they're working. We have adjusted and you know, it very well, the country emergency response toolkit, so that the countries can also take their decisions and deciding when to use additional resources or restructure resources that they had for other means to, again, respond to a health emergency of any type of nature. Now, in at risk financing and at risk procurement, and with this I will end, I think that we are still in an important ongoing debate inside the bank. 

I cannot say that we don't have an open debate. It's a debate where the EDS, our members of the board, are participating with a lot of interest, discussing what are the alternatives that the bank can bring as one of many other responders to that Zero Day. As we do this, Gavi has created, Augustin, a very interesting fund, and I'm looking forward to hearing from you and the experience with it. And we also recognize Leah, very useful ideas. I do believe that the templates for risk purchasing or for purchasing agreements are going to be useful. They won't be perfect. Countries have their own legal frameworks. Countries have their own interpretation of liabilities and indemnities. There was a huge problem with COVID. It will not be easily resolved because it cannot be brought down into the autonomy of country legal frameworks, but we need to further discuss triggers. We all saw what happened in Mpox when now we don't have one authority, but two authorities coming in. Imagine a scenario tomorrow where there's different readings of a risk situation. 

We're advancing with a tracker mechanism, Serina, that you are leading. And I think also we're exploring in depth the financing guarantee mechanism, Leah, that you have also presented. I just want to conclude, I know that I didn't answer the question. No. So, we still need to answer it together. But we've been doing a lot. That's what I wanted to tell you. But I wanted to conclude, Javier and you know me, we've seen again that we need to close the Zero Day financing and at risk procurement answer. But we also need complement it with things that a flood of money, I'm saying it, a flood of money would not resolve. I'm talking about nationalism and protectionism. I was close to Peru. Peru was blocked from ventilators because a country decided that all the ventilators it was producing had to stay within the country. I know countries that had the money and were ready to sign from the first day agreements with the manufacturers, but the manufacturers were ordered to provide all the initial stock of vaccines to a given set of countries. 

So, protectionism and nationalism will always be there. And it's very important because, again, a flood of money will not resolve it. Second, the capacity of the health system to absorb the money. The money or the result of the money, the vaccines. We saw it in COVID. Tomorrow, medical countermeasures, antibiotics, oxygen, you name it. Look at the reality in DRC in the response to Mpox or in Burundi, and you will understand that it's not sufficient with a flood of money or a flood of contracts or a flood of supplies if we do not invest in their capacity to absorb these mechanisms. And third, and with this, I finish, trust. Any mechanism that we work out, any mechanism, any financial guarantee, any anticipated procurement, any relationship with the industry that you know better than I do, must come with a lot of trust in the behavior so that the communities will really engage in an effective response to the crisis. 

JAVIER GUZMAN: 
Thank you, Juan Pablo, you broaden the conversation, but brought very interesting points about it's not just the money, and we need to go back to what other elements are important to have in place. But let's look at the Mpox example. And I think, I, when I presented the situation, I was not very optimistic or I didn't actually highlight the positives. We're going to hear about the positives. So, yes, we do have a first response fund now. Gavi created a first response fund and it has been operational during the Mpox. Clearly, there are questions about sustainability, questions about size, questions about triggers. What can you tell us about how it's worked and what the future of the first response fund is, Augustin? and thanks for being here. 

AUGUSTIN FLORY: 
Thank you very much, Javier, and good afternoon. It's great to be here for this conversation, which you know, is timely and relevant, as we see with Mpox and then maybe Marburg tomorrow, etc. So, maybe let me start by saying a few words about the First Response Fund for those who don't necessarily know it. The First Response Fund was created as a result of some of the learnings of the pandemic, you know, that were, where they were described before. So, that, you know, kind of capital financing is available much earlier in case of emergencies. And it's part of a suite of tools that we have created called the Day Zero Financing Facility. The first response fund is the window that is meant to be triggered and disbursed within the first 45 days. So, that's really the first response and the first response only. And I'll come back to that. And then we have various front loading or liquidity facilities run with the DFC. And we'll probably hear about that soon after this. And then we have one with the European Investment Bank as well. 

And we are negotiating additional ones. The first response fund is a $500 million pool of at risk capital, you know, that can be mobilized within 45 days on an emergency. And if two criteria are met, the first one is that it needs to be either declared as a fake by WHO or a grade two or three emergency. And the second one is that Gavi must not have an existing vaccine program for the disease. And as you noted, it's already been put to test. The first drawdown of the fund was approved 33 days after the declaration of the FIG by WHO. So, within the 45 days, an advanced purchase agreement was signed within 40 days for with Bavarian Nordic. And the first doses are going to roll out soon and will all be procured by the end of the year. So, I think we were, you know, we were not expecting that three months after the board approval, it would already be used. And it is. And, you know, Marburg, the Marburg epidemic now has been classified also as grade two. And so, you know we're, you know, it's potentially eligible and we're looking at that. 

Now, to directly address your question, you know, kind of how does the, we see the first response fund evolving and how do we ensure alignment. I'd like to start by sharing three factors that made our rapid response to Mpox possible, and which point to how the fund, we see the fund evolving. The first one, and to echo what Juan Pablo was saying is trust from our donors and our partners. So, without that trust, it would not have been possible to move so fast with an instrument. We didn't have all the processes in place. We put them together and we put it to test. And we'll continue to nurture this trust going forward. That's really important to be able to continue to move at pace, especially, you know, when every emergency is different and so you can't prescribe everything. The second one is clear scope and disbursement processes. You need to have this if you want to be able to move fast. And so, just a couple of points here. It's clear to have, it's important to have clarity about what's eligible and what's not eligible. 

Otherwise, you spend a lot of time discussing, you know, what's in and what's not in. In the case of the first response fund, the instrument clarifies that it's mostly vaccines, but also health system, you know, kind of support, as well as some other medical countermeasures. And so, we were, you know, didn't have to discuss this at length. The second thing, which is really important also in terms of scope, is to be clear, this is the first response. We're not going to commit resources or argue about resources over the next several years. This is for the first respond, pending additional resources becoming available. 

AUGUSTIN FLORY: 
And so, we move fast and agreed on that first response package of up to $50 million for mpox. And then the third one is the partnerships and that decision to trigger the first response fund and the determination about the drawdown was done because of the close collaboration with WHO, with UNICEF and Africa CDC, obviously. And that's critical for any further emergency, as far as the future of the first response fund and surge financing mechanism is concerned. So first of all, we really welcome the discussion and the emergence of new surge mechanism. The first response fund is limited in scope and in capacity. It's linked to immunization only. And it's only $500 million. And it's crucial that, you know, there's, there are the right instruments in place and the longer term financing. Otherwise, you draw all your resources of your surge financing mechanism at the first, or the first two or three emergencies, and then you're left without the ability to respond when there are other ones. 

And so, we welcome the creation of new instruments. It's really important that they are complementary so that we don't duplicate the dollars and we really spread the dollars and make them work as far as possible. And really by working together, we can create this, this coherent network of surge financing tools, which are going to be able to be triggered, not only for the delivery of vaccines and support of the health systems around that, but for all the other medical countermeasures that we can, that are needed. 

JAVIER GUZMAN: 
Thank you, Augustin. Nafisa, you are the other element in terms of the good news and you represent the DFIs and there was a big announcement in New York a few weeks ago about working together and we want to hear from you in terms of how this initiative fits within the overall architecture. And how do you see the relevance of all the players like the bank or Gavi, just to make that point that Augustin just made about having an architecture that is not working against each other and across purposes? 

NAFISA JIWANI: 
Sure. But I will have to echo what Juan Pablo said in that yes, we need vaccines and yes, we need diagnostics, and yes, we need medical countermeasures, but we 100% need strong health systems to support that because we will otherwise just have vaccines sitting in a locker or in a cooler not being utilized, which is also what happened. And so, I can't stress that enough because as a DFI that is responsible for also investing in health systems, we find that as a big responsibility for ourselves as well. So, I want to echo that. The DFIs, the Development Finance Institutions, learned a lot during the pandemic. And I think what's fascinating is that I've been able to work with investment officers who have been in development finance for over 30 years and who had never seen this level of cooperation across so many different types of institutions. And I mean, so many different types of institutions, DFIs, grant-making institutions, you know, global health partners all coming together to say, how do we work together? 

So, Juan Pablo was correct. It wasn't that there was a lack of financing. It was how do we create a structure that works for our private sector partners. And so, during the pandemic, you know, when there was a need for financing for Gavi to be able to make purchases when they needed it, or when a manufacturer was able to manufacture vaccines but didn't have the working capital to build the fill finish lines that they needed, you know, what was it that the private sector needed and how do we share that risk across the DFI community? And so, through the last four or five years, we created seven financing solutions for vaccines in particular that really worked. And we built those financing solutions across production of vaccines, procurement of vaccines and delivery of vaccines. And that's across all of the development finance institutions including the IFC and the World Bank, including the European Investment Bank and the G7 DFIs. And from that, we didn't want to lose that learning. And there was a G7 commitment made to create an infrastructure across the G7 DFIs that would bind us together and ensure that we would have surge financing solutions today so that tomorrow we're not in this situation. 

And so, I'm proud to say that we signed a memorandum of understanding that is not fluff. And I say that because we really did, we tried to look for something that existed in another sector, whether it was energy or infrastructure to say, could we build off something that existed before? Nothing like this has ever been created, that's of substance, that's binding the G7 DFIs, you know, EIB and IFC together, that's forcing us to really put money where our mouth is and roll up our sleeves to create these financing solutions. And so, we've signed this agreement and now we're ticking away. So, the next sort of step of this is to create a working CapEx facility where IFC has the baton and hopefully a term sheet will be signed at UNGA for our next deal together. And so, I think that that shows you, while we can't be everything, and we shouldn't be everything to everyone, we're being very clear with what we can do around surge financing. And I just want to take a minute to explain what that means and what it doesn't mean. 

We are being very clear that we want to be able to support, from a production standpoint, manufacturers, because we know that regional vaccine manufacturing or regional manufacturing, whether it's for diagnostics or therapeutics, is going to  be critically important. I think we all learned that during the pandemic. And so, how do we start to support that regional manufacturing capacity and build an ecosystem where it's not just about the manufacturing site, but it is the regulatory system and it's working with, you know, ensuring that you got vials being manufactured there and you've got syringes being manufactured there. So, you're actually building biotechnology in an area that maybe didn't exist before. So, we're being very intentional about how we're building surge capacity because it can't just be in name. So, this is the architecture that we're trying to build. It is not going to happen overnight, but what it does mean is that hopefully five years, ten years, we're starting to build this capacity so that manufacturers can then pivot to surge when there's a health emergency. 

But that's not going to happen overnight, and we can't expect it to happen overnight. If I can't expect Merck to tomorrow build 2 million vaccines off the whim on mpox, I can't expect a manufacturer on the content to that either. And so, we're going to have to start being a little bit sensitive to the fact that it's going to take time. It took India 40, 50 years to get to where they are today. So, we're going to have to take some time to see what that looks like in Sub-Saharan Africa and regions across Latin America and the Caribbean, across Asia as well. But we're looking to do this across, again, all three of those areas around production, around procurement, and around delivery. So, with Gavi, just to be very clear, we are all brilliant people, I would argue, across both institutions. We're sitting on the phone April of 2020. This is how the sausage is made, as people would say. It's not made by these like, pretty term sheets right away, but it's made by people well intentioned saying, how do we make this work? 

What do you need? Two years, two years to create a structure that made sense, two years to make a structure that made sense so that now Gavi has a suite of tools so that tomorrow, if you need to use that money as a pledge comes in, you're not waiting for that pledge to actually come into your bank account. You can go ahead and buy vaccines, whether it's for an outbreak, routine vaccines, or COVID-19. And that's us being creative and creating a financial structure that just didn't exist before. So, that's what we mean by being innovative. It's not like a trendy word that we're just using, but it really is rolling up our sleeves and understanding what our partners need. So, that's the example for Gavi, for Institut Pasteur in Dakar in Senegal. It was a capital structure that that was unique to them. We needed grant money, we needed commercial loans that needed to be there, not concessional, but commercial loans that made sense for them. And we also need technical assistance. And so, that's what's going to be required as we move forward if we want to see success in this space. 

JAVIER GUZMAN: 
Nafisa, just to clarify, does this new MOU come with new money or not? 

NAFISA JIWANI: 
Yeah, I mean, it's coming from loans, right? It's coming. You're getting DFI loans and you're getting hopefully grant money coming in as well. 

JAVIER GUZMAN: 
Because I guess the key question for you all is a lot of people say, and I agree that what we need is, is pledges, what we need is countries saying I've got the money. Would you agree with that? And maybe you start Nafisa. 

NAFISA JIWANI: 
I'm looking at it. Yeah, I'm looking at it from a very different perspective. I think like we're looking at it from a DFI perspective. We work with the private sector. And so, that is how most development finance institutions work. We're working with the private sector to create sustainability in the long term. And so, that capital structure that we're talking about could be new money and that we're providing long tenors with really competitive interest rates so that you can make sustainable, sustainable financing for a private sector entity to be able to make money in the long run, but then be able to then hopefully produce at the rate that we want them to produce. And so, I guess it kind of depends on how you're thinking about new money. 

SERINA NG: 
But I think getting to your point, Javier, though, I think what you're saying is that to spend that 9 billion, you need to have it in your back pocket, right? And so, all the sort of, you can have a range of initiatives, but someone's got to backstop them at the end of the day. And that could be the sort of backing that you as organizations that you have. But the sort of proposals that you've mentioned, Leah, that could be, you know, it's basically using more of your loan capacity or sort of access to funding at the bank. But ultimately, does that add up to 9 billion on day zero? And I think the answer is probably not quite. And then if we think about sort of where those sources of financing might come from, you need to think about sort of where you can get that scale and bring it together. And there aren't that many institutions or donors that can do that. And I do think that it's about how we put this picture together and what sort of, what actually is money that can come in now, but then sort of ultimately needs to be backed up and he backs it up. 

And also, so for example, for the bank, you know, the Bank has this sort of huge bank, actually, huge capacity, but how much does it actually need to be backed up and what will it actually be able to do? And I think though, that's the sort of, and that's how you get to your sort of 

NAFISA JIWANI: 
9 billion. 

SERINA NG: 
9 billion on day zero. 

NAFISA JIWANI: 
And the cost, maybe the cost of that 9 billion today versus the economic cost of not doing in the health. 

SERINA NG: 
And I think, I think the economic cost is very strong, but I think the issue is, is that it was very back of the envelope under high uncertainty during COVID and I assume that should we confront something similar, it will be as uncertain. So, you need to have something that gives you certainty, and that is the sort of the backstop. 

JAVIER GUZMAN: 
Any comment on that, Juan Pablo? 

JUAN PABLO URIBE: 
No, I'm not a financing expert, even though I work in the World Bank, so I'm sorry to frustrate many of you... 

NAFISA JIWANI: 
(CROSSTALK) as we got you. (LAUGHTER) 

JUAN PABLO URIBE: 
I'm just a general physician, so I'm sorry. But I think, I think that this idea of the guarantee or the pledges or the future promises or the whatever you want to call that future capital coming in without a big opportunity cost today, which I do understand very well is something of course of importance and interest. I think that's where the discussion will focus. Oh, yet, why 9 million? Why not five? Why not 30? Or what's the amount of money that we're going to need tomorrow? I'm sorry. We cannot look back at COVID and say that's what we need tomorrow. I think that's a mistake in strategy. You don't win the next war by replicating what you did in the past war. You learn from the past war. But you need to be adaptable. You need to be flexible. You need, you know what? We need. It's so basic that nobody talks about it. We need to come together in an agreement on how we would work together in a future pandemic. What is the role of each institution? How do we coordinate? How do we pick up the phone and call the right person? 

Who is tracking the efforts? With you, Serina, today we're trying to track the response to mpox. You will correct me. It's almost impossible to do so in a complete way. It's a huge task. We need to be able to be organized, to not compete, to not be redundant, to hopefully step on the side when we're not bringing value. And I think that's basic and it's fundamental for the financing aspects and for the procurement aspects. And the industry needs to be part of this. It's like if we were all running to buy things from the industry in an emergency, in an emergency, in an extraordinary event, and we're not asking the industry to be part of this. They have to be part of this, of course. And I know that many of them are, but this overall organization I think is a critical piece. We're seeing and following carefully the discussions in Geneva and the Accord, no, the pandemic treaty. And I think that's reflective of a fundamental question. It's how do we organize ourselves to really work, sorry, as a one team in the face of a pandemic. 

Again, I'm sorry, I do believe there are answers to the financing at risk day zero element. Probably they will need to be very flexible because they don't know what they need to resolve today, what they need to procure. I think they're very good ideas, Leah, and I want to appreciate them again, because I think they help us be better prepared. But it's gonna take a little bit more. 

JAVIER GUZMAN: 
With that, I will open the session for questions. Please raise your hand. One, two... 

NAFISA JIWANI: 
I agree with Juan Pablo (CROSSTALK) 

JUAN PABLO URIBE: 
(CROSSTALK) 

NAFISA JIWANI: 
I agree with you. 

JAVIER GUZMAN: 
The people.... 

NAFISA JIWANI: 
I agree with you. I agree with you. I agree with you. 

JAVIER GUZMAN: 
..virtually please do send your questions in the YouTube channel. 

CHARLIE MATTHEWS: 
Thank you. I'm Charlie Matthews from WaterAid, and it's been a really interesting discussion and I'm really excited to hear so much enthusiasm about helping countries get the new technologies they need to help them fight pandemics. But of course, there's a very old technology that they need to fight pandemics, which is water and soap, which is still lacking in two-thirds of health facilities in less developed countries. I know the bank is doing a lot of work in sort of the long term to try and address that issue. But how can we make sure that when countries are in an emergency situation and they need to surge that access to water and sanitation, as, you know, with the mpox response at the moment, how can we make sure that it's not just new technologies they are able to access through these mechanisms, but that old technology as well? Thank you. 

JAVIER GUZMAN: 
Let's get all the questions first. 

CAROLYN REYNOLDS: 
Hi, Carolyn Reynolds, Pandemic Action Network. Here, here, Juan Pablo. So, the $9 billion question there is why, what will it take for the international community to come together? We learned this lesson, but here we are and it's playing out again in mpox. There's some level of coordination, whatever, but like, we still don't have a nerve center for the world to deal with the emergencies. That's what it's about. Exactly. I mean, and then the money flows to that and we create the way to do it, but somebody has to decide how it's spent in a coordinated way. The institutions, we created it during COVID, imperfect as it was, but like, there was a way to come together. We learned all the lessons, we studied it to death, and then we've had three years, 2.5 plus years of Johannesburg process and ICM net process and all of this. And we've tried to do it around surge financing and there's been some progress, but, so, but it's, because it's political. It's a political question at the end of the day of the desire of institutions to share power, to work differently, to not be the claim to maybe not be the only one to access the money. 

It's a power, apolitical issue. So, unless our political leaders want to make that happen, if they wanted to make it happen, they could. So, how do we solve that? 

JAVIER GUZMAN: 
Any other question from..? Yes, please, Stephanie? 

STEPHANIE PSAKI: 
Hi, thanks, everyone. Stephanie Psaki, I'm the US Coordinator for Global Health Security at the White House. Thank you so much for this panel and for the comments from others. I guess I will share a few reflections and maybe push back on a couple of points. So, one, I do think it's important to acknowledge, and I think this is part of what's coming out, that there has been some real progress since COVID. It's not going to be fixed overnight. I think this, some parts of this conversation are frustrating that it's four years later and we're still trying to figure out how to solve the problem. But I also think a lot of things have changed. And the work, my colleague, Nafisa, I'm very biased, but the work that she has led at DFC with the other DFIs, the work that Gavi has done is incredible and a real accomplishment. And we should just take a moment to recognize that because it can be pretty depressing to think that no progress has been made. So, I just wanna make that point. I think second point on mpox, it's really important to just be clear-eyed about what we are dealing with here. 

One, the US was ready to donate doses in 2023. The PQ was not offered by WHO. There was no regulatory approval for over a year. And now, we have a million doses ready to go, and many other doses from other countries that are sitting in warehouses and they're not being distributed because we don't have guidance from WHO and Africa CDC. So, I think we need to just be clear about the different types of barriers we're facing. It's not just about resources to purchase countermeasures. It's not just about a willingness to donate. It's about a lot of other parts of the system. The last piece I just wanna add is on the Pandemic Accord. The conversation you're having here is about changing the system long term, changing the structure, changing the different pieces. That is not really the conversation that's happening in those negotiations. The conversation in those negotiations is about set asides and donations and the US supports that. We are on board, we are at the table, but it's not a long-term solution. 

And I think that is something we have to grapple with if that's gonna be effective at fixing the problem. We have to talk about regulatory system strengthening. We have to talk about domestic investments. We have to talk about demand for countermeasures. That's not the conversation right now. So, would encourage everyone who's engaging in that process to really push that conversation to a different place. 

JUAN PABLO URIBE: 
Very good. 

JAVIER GUZMAN: 
Excellent comments. Well, you want any, any response? Endorsement contradiction, please. 

JUAN PABLO URIBE: 
No, no, I'm ready to jump in. First, I want to acknowledge, Stephanie, and thank you for the comments. I think they're great and I fully endorse all of them. I want to emphasize that a lot of progress has been made. I think we're better off with a pandemic fund that is already there investment, investing in the long term in core public health functions in these countries. I think it has all to do with strengthening health system capacity and building future resilience and better capacity to absorb whatever shock comes. So, a huge congratulations to all of you who have participated in that, and I hope we all come around the pandemic fund and further support it because what happens here is, OK, we created it and now we look somewhere else. No, we need to insist in strengthening the pandemic fund. Second, I believe that having an RST with the IMF is also a very important signal to countries and to their leadership. And I think we need to build on that. I think that Gavi's example with the fund, Augustin is a great example. 

And of course, I have a conflict of interest because I'm sitting the board of Gavi. But what else? The barriers are very true. One that concerns me a lot is that many times we go for the hard technology while in public health is the soft technology that has the biggest cost-effectiveness capacity. Let me just signal how quickly we lost during the COVID pandemic, at least in the countries where I was, the importance of hand washing, which was displaced by the rush for the vaccine and by many mysterious elements that had no evidence behind. But handwashing has been for centuries, the most important defense mechanism that we have. It's very important for us in the bank as we work in a comprehensive way in human development that, for example, in the mpox response, Javier, the money allocated for medical countermeasures, for clinical care, for fuel, for per diems, for cold chain does not displace that money that is needed for water and sanitation and other basic needs. It cannot be that competition carrying the money there. 

And just to conclude, I do believe that the discussion Stephanie needs to go into those elements that you presented. I think that it's what's happening will not resolve what we need, basically.  

JAVIER GUZMAN: 

Thank you, Juan Pablo. Serina? 

SERINA NG: 
I'm happy to come in. So, I think, so firstly, sort of agree with a lot of those comments. I think there's a couple of things I'd like to add. I think firstly on the importance of washing the sort of basic, you know, not the snazzy stuff. I think Brazil this year in their G20 really championed inequalities and the social determinants of health. And we have incorporated that into the work that we have done. And we have included, you know, we have a set of indicators. We're trying to just better understand the interconnectedness between health, social and economic. And we have included a lot more in terms of better looking at the state of access to sanitation, water, education by gender as well. And all these factors that really determine ultimately your susceptibility and your ability to access healthcare when you need it. And also, looking at health spending and the proportion that is government versus out-of-pocket and what that really means. And then, so just building on that and looking at sort of what's happening with mpox because we were tasked by finance and health ministers on the 27th of September to produce some notes on this. 

And with many thanks to colleagues at the WHO and the Bank for their work on this. Firstly, with mpox, there has been a much more rapid response. It's a lot more certain, right? It is very different. It's a lot more certain, but this is like, there's some muscle memory left. And Africa Development Bank and the World Bank rapidly reprogrammed because they have the existing mechanisms in place. And that goes back to this issue about they might not be perfect, but you can at least start to think about what you need to know, what the contracts need to look like. So, you're just much more further down the road. And that's a big part of speed. And that also is what in, you know, quite a few of the evaluations talk about. So, I think that's the first thing on mpox. So, I think the second thing is though there is better coordination. I think that the Africa CDC and the WHO have work to try and ensure that there is more coordination. It's not going to be perfect. So, I'm not saying that, you know, but we, and we have a better idea of where what's been pledged and where it is. 

This is all sort of progress. It is not, absolutely not, you know, this is absolutely perfect now, but I think just to give an indication of what we can observe at this stage. I think the really important thing is to continue to sort of try and learn the lessons and look ahead as Juan Pablo says and also accept these are, there are different scenarios. There's scenarios where we have a fair amount of certainty, like as it may, you knew that you had the vaccines and that they didn't have the approvals. But that's a very different situation. So, I think it's also thinking about what we need in these different situations. And also, sorry, just to say the sort of the Gavi, you know, that that was also really rapidly came. So, I think there are things to be more positive about going forwards. 

JAVIER GUZMAN: 
Augustin? 

AUGUSTIN FLORY: 
Just a few comment or reactions to the, some of the challenges that were raised, which are real, and also some of the, I think, the more positive messages. I mean, we have a lot of learnings that we're working on where you haven't forgotten everything. We talked about the surge financing mechanism. One of the other initiatives that we're involved in is, how do we support greater local manufacturing so that these vaccines inequity don't happen? And we launched this African Vaccine Manufacturing Accelerator also in June. And this is a straight learning from the pandemic and how to be better prepared when there is the next one. We're collaborating with kind of almost everyone around this panel. I was, this morning, I was in a meeting with Juan Pablo's team on how to accelerate our partnership including on PPR. And so, so I mean, we're in the absence of, I think, you know, maybe the agreement that we want at the pandemic accord level. We're still moving on in many different ways. Then we are working on strengthening health systems. 

Juan Pablo said it. And in our case also routine immunization. That's your first line of defense. And that's how you reduce the cost. The 9 billion might not be 9 billion because we have the systems that we need. And then we're also working on better integration. So, handwashing and immunization, for instance. We have partnerships to try to build the evidence about how that works. And so, so that we're kind of, we're better ready for the next time. So, I think there's a lot going on and we should, we should, we should, you know, kind of aim for the big prize in terms of where we wanna go with the pandemic negotiations. But in the meantime, move ahead and build on the, all these learnings. And there are lot of them. 

JAVIER GUZMAN: 
Nafisa, Leah, any responses? 

NAFISA JIWANI: 
Yeah, maybe a couple of things. One is, do I think that we need money; 100%? Do I think it's 9 billion? I'm not quite sure. I'm not quite sure. And I'm 100% sure though, that, that it's not just the money. And I'm 100% sure because I am on the ground and I can, I'm talking to the manufacturers, I'm talking to Ministers of health, I'm talking to governments. It is not just money. And so, if we don't fix a system, we're not getting anywhere. And so, I really just wanna be very, very clear that these are complex issues. And if we start to like just simplify them in a way where it's just money or it's just a vaccine we're doing a disservice to what we're hopefully we're trying to solve for. So, I just wanna make that very, very clear. In terms of like, again, I think for DFIs and for DFC, we're gonna continue to invest alongside with the private sector. I think it's critically important. The private sector brings innovation in a way that I think is really great and we see the opportunity to bring the public health system along. 

And so, I think that's critical and important where we're creating these financing solutions. Today, Gavi, I don't know what, you mentioned a few numbers yesterday I thought was really, really interesting. But if you've got this financing facility today, it allows for you to purchase vaccines. How much earlier now? 

AUGUSTIN FLORY: 
So now we purchase, I mean, we can purchase, we see it with the mpox in 40 days. We had the agreements in place versus nine to 12 months in the pandemic. 

NAFISA JIWANI: 
Which is what time is what money. 

AUGUSTIN FLORY: 
Exactly. And if you talk about a billion dollar a month... 

NAFISA JIWANI: 
And lives and lives, right? So, it's a billion dollar liquidity facility with Gavi. That is no small fee. It just didn't exist before. And I think having the CEO come into a place where she's not wondering what tools do I have in my toolbox? I've got these three tools in my toolbox is a massive difference from where we were before. So, do we have a long ways to go? 100%. But I think the DFIs are coordinating, whereas before at the beginning of the pandemic, they were fighting for the deal that was there. And now, we're coordinating alongside with our global health partners to make sure that we're making strategic investments. And so, I think we're making progress. Are we perfect? 100% no. But are we getting there? I think so. 

JAVIER GUZMAN: 
Yeah. Any comments? 

LEAH ROSENZWEIG: 
I would just say I am optimistic after hearing everyone on this panel speak and hearing the comments and questions in the room, it's easy to feel paralyzed by the daunting task that is pandemic preparedness. But it's encouraging to hear, you know, it sounds like we already have multiple new tools in our toolkit and we have thoughts on new ones to add. Obviously, there's gonna be a spectrum of complexity and coordination that's required. But again, it sounds like folks are going after the really hard problems. So, I'm encouraged. 

JAVIER GUZMAN: 
OK. Well, with that, I just want to thank you all for being here. I just want to summarize by saying half full, let's think about a glass that is half full. So, we see some of the improvements and some of the progress that we've made. We clearly hear that it's not just about the money that, but we do know that 9 billion or maybe, you know, a bit more, a bit less is needed. And there are things that can be done without the money and there are things that will need to be done with the money. But we would all be watching this space because we are very eager to hear the outcomes of the internal conversations that you're having at the bank. So, here we'll be watching and trying to help in terms of bringing different voices and different options. So, thank you all very much. Please allow me to give you a round of applause. (APPLAUSE)