In December 2013, the Commission on Investing in Health (CIH)—an international group of 25 experts in economics and global health—published its report Global Health 2035: A World Converging in a Generation. The report laid out an ambitious yet feasible pro-poor plan for transforming global health by 2035 through reducing avertable deaths from infections and maternal and child health conditions, tackling the global rise in non-communicable diseases, and attaining universal health coverage.

The Commission argued that the plan had to include pandemic preparedness. “Concern is growing”, said CIH, “that the world could soon face an especially deadly global pandemic, similar to the 1918 influenza pandemic, which will disproportionately affect poor populations.” The CIH warning was prescient. Today, the COVID-19 pandemic has left almost no country untouched; WHO estimates that there have been over 3.4 million confirmed cases and over 239,740 deaths as at 4 May 2020.

The 2014-2016 Ebola epidemic exposed longstanding weaknesses

Just 13 days after the publication of Global Health 2035, an 18-month-old boy in Guinea developed fever and vomiting and died two days later, the first case in what became the 2014-2016 Ebola epidemic in West Africa. The epidemic exposed how unprepared the international health “system” was for handling a major outbreak as well as the urgent need for reform.

National, regional and global health capabilities were all found wanting. Although the epidemic stimulated a number of reforms, such as the launch of the Coalition for Epidemic Preparedness Innovations, which funds the development of epidemic vaccines, these efforts still fell far short of preventing the devastation caused by COVID-19.

Today, many countries are still in crisis mode, doing what they can to control their COVID-19 outbreaks through measures such as social distancing, case detection and isolation, and treating hospitalized patients. Beyond the crisis stage, they will need improved public health capabilities to prevent a COVID-19 resurgence and to be ready for future pandemics.

What will it take to modernize public health systems to achieve this readiness? Modernization will require actions across multiple health system levels.

Strengthening national health systems

National health systems are the first line of defense against outbreaks. Yet they are often under-funded, leading to major gaps in the health workforce, infrastructure, health information systems and supply chains. Many countries that successfully contained their national COVID-19 outbreaks, such as South Korea, had previously addressed weaknesses revealed by the 2003 SARS outbreak or the 2015 MERS outbreak by increasing investments in these defense systems.  

All national health systems need to strengthen a set of core capacities for pandemic preparedness and response. Such capacities include establishing comprehensive surveillance systems to reliably and rapidly detect human and animal diseases, and training a health workforce that can carry out emergency and disaster risk management. Often ignored but critical is a strong primary health-care system that enables contact tracing, surveillance and evidence generation, and supplies the frontline workforce. There is also a crucial role for subnational, community-level health systems in containing outbreaks, and for strong coordination and communication between the national and subnational governments.

Modernizing national health systems in this way will increase their resilience—i.e. their ability to maintain core activities during a crisis. Resilient systems are able to cope with the surges in demand that pandemics bring, by quickly deploying additional health workers, for example. Improving resilience requires proactively addressing weaknesses in the system.

Regional and global cooperation

Beyond strengthening individual nations’ health systems, intensified regional cooperation will be needed. The Africa Centres for Disease Control and Prevention, established to “improve surveillance, emergency response, and prevention of infectious diseases”, has shown the value of such regional responses.

At the global, supranational level, the 2014–2016 Ebola outbreak highlighted weaknesses in what CIH calls “global functions”—global health activities that tackle transnational health challenges and have transnational benefits. When the outbreak began, no Ebola vaccine, treatment or rapid diagnostic test existed due to the underfunding of global health product development. The global surveillance and response system functioned inadequately. A panel of independent experts commissioned by the Director-General of the World Health Organization (WHO) to assess the Organization’s global Ebola response found that WHO was unable to deliver a full emergency public health response, due in part to a long-standing lack of funding for its core responsibilities.

The COVID-19 pandemic has shown us that we need a surge in support for these global functions. Funding for pandemic response and preparedness temporarily rises whenever a major outbreak occurs, but then falls once the outbreak is contained; such fluctuations in funding are known as “cycles of panic and neglect”. Modernizing the global health system for improved pandemic preparedness will require stepped-up investments in: (i) research and development (R&D) to develop medicines, vaccines and diagnostics against emerging infectious diseases; (ii) stockpiling pandemic control tools, including personal protective equipment for health workers; (iii) establishing global “surge capacity” to allow urgent manufacturing of vaccines; and (iv) funding WHO to be able to perform its key duties.

The “price tag” for modernization

The modernization outlined above will of course require new investments at national, regional and global levels, over and above current levels of spending:

  • The Commission on a Global Health Risk Framework estimates that an additional $3.4 billion per year is needed to strengthen national health system preparedness specifically against pandemics. This figure does not include the costs of strengthening primary care systems more broadly.
  • The Global Preparedness Monitoring Board estimates that $0.25 billion is needed annually to strengthen regional surveillance.
  • CIH estimates that about $7 billion annually is needed to strengthen a range of critical global functions, including R&D for neglected and emerging infections and strengthening WHO core activities.

This price tag of around $11 billion annually is tiny compared to the devastating health, social and economic consequences of COVID-19, including the estimated global economic loss of $1 trillion in 2020 alone. The return on this $11 billion annual investment is likely to be one of the highest in the history of global development.


4 May 2020

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