Executive Summary

Pandemics and epidemics have killed countless millions throughout human history. Highly virulent infectious diseases, such as the plague, cholera, and influenza, have repeatedly swept through human societies, causing death, economic chaos, and, as a consequence, political and social disorder. In the past 100 years, the 1918 influenza pandemic killed approximately 50 million (CDC, 2014); HIV/AIDS took the lives of more than 35 million (CDC, 2013). Although more recently-emerging epidemics, such as severe acute respiratory syndrome (SARS) in 2003, H1N1 in 2009—and, most recently, the Ebola epidemic in West Africa—have had lower death tolls, they have nevertheless had a huge impact in terms of both social and economic disruption.

It is clear that, despite extraordinary advances in medical science, we cannot be complacent about the threat of infectious diseases. The underlying rate of emergence of infectious diseases appears to be increasing, most likely due to the growing human population and consequent greater food production and animal–human interaction. Contagion risks are also larger as globalization and urbanization drive travel and trade, creating ever-increasing personal interaction and interdependence.

Infectious diseases remain one of the biggest risks facing humankind. Few events are capable of equal damage to human lives and livelihoods. Yet the global community spends relatively little to protect populations from the risks of pandemics. Compared with other high-profile threats to human and economic security—such as war, terrorism, nuclear disasters, and financial crises—we are underinvested and underprepared. This is the neglected dimension of global security.

The Ebola epidemic was both a tragedy and a wake-up call. The outbreak revealed deficiencies in almost every aspect of global defenses against potential pandemics. Disease surveillance proved inadequate. Alerts were escalated too slowly. Local health systems were quickly overwhelmed. Communities lost trust. Governments elsewhere in the world reacted haphazardly to the threat of contagion. The international response was sluggish, ill-coordinated, and clumsy.

Eventually, we made great progress toward containing Ebola, thanks to the courage and determination of health care workers and community leaders on the ground and a massive deployment of resources by the international community. But more lives were lost than should have been, and the economic costs were far greater than they could have been.

Before the memories of Ebola fade, we should heed this call. Global health security is a global public good—making each of us safer depends on making all of us safer; holes in one community’s defenses are holes in all of our defenses. Global leaders must therefore commit to creating and resourcing a comprehensive global framework to counter infectious disease crises. We cannot afford to continue to neglect this risk to global security.

THE CASE FOR INVESTING IN PANDEMIC PREPAREDNESS

There is a strong case for investing more to make the world safer from the threat of potential pandemics. Although there are enormous uncertainties in modeling the risks and potential impact of infectious disease crises, the case is compelling no matter how it is calculated. The po-

tential losses in terms of human lives and livelihoods are immense. The economic costs alone can be catastrophic. By our calculation, the annualized expected loss from potential pandemics is more than $60 billion.¹ Against this, we propose incremental spending of about $4.5 billion per year—a fraction of what we spend on other risks to humankind. Framed as a risk to human security, this is a compelling investment. Framed as a risk to economic growth and stability, it is equally convincing.

Moreover, the risks of spending too much or too little are asymmetric. Even if we have overestimated the risks of potential pandemics, money invested to mitigate them will still be money well spent. Most of the investments we recommend will help achieve other high-priority health goals, such as countering antimicrobial resistance and containing endemic diseases like tuberculosis and malaria. Yet if we spend too little, we open the door to a disaster of terrifying magnitude. The Commission therefore recommends the following:

The G7, G20, and United Nations (UN), under the leadership of the UN Secretary General, should reinforce and sustain international focus and actions to protect human lives and livelihoods from the threat of infectious diseases by:

Recommendation A.1: Committing to implementing the framework set out in the report The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises and embodied in Recommendations B.1–D.3.

Recommendation A.2: Committing and mobilizing the incremental financial resources required to implement the framework, as set out in the report The Neglected Dimension of Global Security: A Framework to Counter Infectious Disease Crises, which amount to about $4.5 billion per year.

Recommendation A.3: Monitoring progress of implementation by commissioning an independent assessment in 2017 and every 3 years thereafter.

STRENGTHENING PUBLIC HEALTH AS THE FOUNDATION OF THE HEALTH SYSTEM AND FIRST LINE OF DEFENSE

Robust public health infrastructure and capabilities are the foundation of resilient health systems and the first line of defense against infectious disease outbreaks that could become pandemics. Yet far too many countries have failed to build the necessary capabilities and infrastructure. Even by their own internal assessments, 67 percent of the World Health Organization (WHO) member states fail to meet the requirements of the 2005 International Health Regulations (IHR) (WHO, 2015); objective external evaluations would almost certainly reveal even lower rates of compliance.

Previous international efforts to galvanize greater commitment to building resilient public health systems have largely failed. After every outbreak of infectious disease, there is a flurry of activity and reports, but political interest quickly wanes and other priorities dominate.

Building and sustaining strong health systems is achievable with leadership and commitment, at the national, provincial, and local levels, even in relatively poor countries. Countries like Uganda have demonstrated that creating resilient and effective public health systems that can identify and contain infectious disease outbreaks is not beyond reach. What is required is leadership. Governments must recognize that protecting against the threat of infectious disease is a fundamental part of their basic duty to protect their citizens.

Building effective public health systems requires more than surveillance systems, laboratory networks, and clinical capabilities. Engaging and communicating with communities is critical. Community awareness enhances surveillance. Trust and cooperation of the local population is a vital component of any response strategy.

Also essential is clarity about the benchmark attributes of a highly-functioning public health system and transparency about actual achievement against these benchmarks. Therefore, we need a clear definition of the core capacities required to deliver according to the IHR requirement—plus regular, rigorous, and objective assessments of delivery against these benchmarks. Publication of such assessments will enable civil society to hold governments accountable and facilitate prioritization and the monitoring of progress.

We make 10 recommendations about building more effective public health infrastructure and capabilities at

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¹ All monetary figures in U.S. dollars.

the national level as the foundation of a more resilient health system and the first line of defense against potential pandemics.

First, we need clear definitions of the required infrastructure, capabilities, and benchmarks for effective functioning for a national public health system.

Recommendation B.1: The World Health Organization, in collaboration with member states, should develop an agreed-on, precise definition and benchmarks for national core capabilities and functioning, based on, and implemented through, the International Health Regulations and building on the experiences of other efforts, including the Global Health Security Agenda and the World Organization for Animal Health Terrestrial Animal Health Code by the end of 2016. Benchmarks should be designed to provide metrics against which countries will be independently assessed (see Recommendation B.2).

Second, we also need a regular, independent, and objective mechanism to evaluate country performance and to ensure publication of the results. This is essential for prioritization, progress monitoring, and accountability.

Recommendation B.2: The World Health Organization should devise a regular, independent, transparent, and objective assessment mechanism to evaluate country performance against the benchmarks defined in Recommendation B.1, building on current International Health Regulations monitoring tools and Global Health Security Agenda assessment pilots, by the end of 2016.

Third, all countries must agree to participate. Otherwise, we will encounter adverse selection, with those most needing evaluation declining to participate.

Recommendation B.3: By the end of 2016, all countries should commit to participate in the external assessment process as outlined in Recommendation B.2, including publication of results.

Fourth, to reinforce the incentive to participate in the assessment mechanism, international partners should make clear to countries needing assistance that support is subject to participation in this mechanism. For countries in need of external support to reinforce their core capacities, the assessment process will establish a clear starting point and enable prioritization of actions to fill gaps.

Recommendation B.4: The World Bank, bilateral, and other multilateral donors should declare that funding related to health system strengthening will be conditional upon a country’s participation in the external assessment process.

To underscore the importance of pandemic preparedness as a way of protecting economic growth and stability, the International Monetary Fund (IMF) should routinely incorporate the results of the external assessment of national core capacities in its economic evaluations of individual countries. The IMF should also consider non-participation in the assessment process a signal of a country’s lack of commitment to managing economic risk.

Recommendation B.5: The International Monetary Fund should include pandemic preparedness in its economic and policy assessments of individual countries, based on outcomes of the external assessment of national core capacities as outlined in Recommendation B.2.

The primary responsibility for achieving and sustaining public health infrastructure and capabilities of the required standard rests with national governments. We therefore call on national governments to develop and publish plans by mid-2017 (where plans do not already exist) to achieve benchmark status in the required core capacities by 2020. Plans should be comprehensive and realistic, addressing the challenges of sustainable financing and skills building.

Recommendation B.6: Countries should develop plans to achieve and maintain benchmark core capacities (as defined in Recommendations B.1). These plans should be published by mid-2017, with a target to achieve full compliance with the benchmarks by 2020. These plans should include sustainable resourcing components, including both financing and skills.

WHO should provide technical assistance to national governments seeking to rectify deficiencies in

their public health core capacities by building skills and transferring best practices.

Recommendation B.7: The World Health Organization (WHO) should provide technical support to countries to fill gaps in their core capacities and achieve benchmark performance. (Technical support will be coordinated through a WHO Center for Health Emergency Preparedness and Response; see Recommendation C.1.)

Because national governments must take responsibility for protecting their citizens from the threat of infectious disease, the primary source of funding for building and maintaining public health core capacities must be their own domestic budgets. This is also the best way of ensuring the funding is stable and sustained.

We therefore call on the governments of upper- and upper-middle-income countries to ensure that sufficient funding for public health systems is incorporated in their national budgets. Lower-middle- and low-income countries need to adequately invest in domestic core capacities. In addition, there may be a need for external assistance to rectify deficiencies and build capabilities. Importantly, even lower-income governments should seek to devise pathways to full domestic resourcing.

Recommendation B.8: National governments should develop domestic resourcing plans to finance improvement and maintenance of core capacities as set out in the country-specific plans described in Recommendation B.6. For upper- and upper-middle-income countries, these plans should cover all financing requirements. For lower-middle- and low-income countries, these plans should seek to develop a pathway to full domestic resourcing, with a clear timetable for achieving the core capacity benchmarks.

Given that lower-middle- and low-income countries are likely to need financial assistance in filling gaps and strengthening their public health systems, the World Bank should convene other multilateral donors, bilateral donors, and other philanthropic sources to cultivate financial support for such plans. This support should be contingent on (1) the plan’s inclusion of a pathway to full domestic resourcing and (2) the recipient country’s cooperation with the external assessment process (see Recommendation B.2).

Recommendation B.9: The World Bank should convene other multilateral donors (including the African Development Bank, Asian Development Bank, New Development Bank, United Nations Development Program, and Asian Infrastructure Investment Bank) and development partners by mid-2017 to secure financial support for lower-middle- and low-income countries in delivering the plans outlined in Recommendation B.6.

Fragile states, failed states, and warzones pose a particular problem for the maintenance of basic public health infrastructure and capabilities. For these situations, we recommend that the UN Secretary General takes the lead, working with WHO and other parts of the UN system to sustain at least minimal public health capacities within the context of the broader UN strategy for each particular circumstance.

Recommendation B.10: The United Nations (UN) Secretary General should work with the World Health Organization and other parts of the UN system to develop strategies for sustaining health system capabilities and infrastructure in fragile and failed states and in warzones, to the extent possible.

STRENGTHENING GLOBAL COORDINATION AND CAPABILITIES

While reinforcing the first line of defense at the country level is the foundation of a more effective global framework for countering the threat of infectious diseases, strengthening international coordination and capabilities is the next most vital component. Pandemics know no borders, so international cooperation is essential. Global health security is a global public good requiring collective action.

Ebola revealed significant shortcomings in the functioning and performance of the international public health system. Neither WHO, the UN system, nor regional entities escaped criticism. There were failures of execution, coordination, and leadership at multiple levels.

The Commission believes that an empowered WHO must take the lead in the global system to identify, prevent, and respond to potential pandemics. There is no realistic alternative. However, we believe that WHO must make significant changes in order to play this role effectively. It needs more capability and more resources, and it must demonstrate more leadership.

First, WHO needs to establish a dedicated and well-resourced operational center for coordinating preparedness and response. This should be a dedicated center, not a program—reflecting its status as a permanent and critical component of WHO’s role. Furthermore, this center should be guided and overseen by a Technical Governing Board (TGB). The TGB should be chaired by the Director-General, but otherwise its composition should comprise members who are independent of and drawn from outside WHO on the basis of technical expertise.

Recommendation C.1: By the end of 2016, the World Health Organization should create a Center for Health Emergency Preparedness and Response—integrating action at headquarters, regional, and country office levels—to lead the global effort toward outbreak preparedness and response. This center should be governed by an independent Technical Governing Board.

The WHO Center for Health Emergency Preparedness and Response (CHEPR) will need sustainable funding. To achieve this, there should be an appropriate increase in member states’ core contributions. These required contributions are a better resource than relying on voluntary contributions, which are often unpredictable and ultimately unsustainable, to support a core function of WHO.

Recommendation C.2: In May 2016, the World Health Assembly should agree to an appropriate increase in the World Health Organization member states’ core contributions to provide sustainable financing for the Center for Health Emergency Preparedness and Response.

We support the World Health Assembly’s resolution to create a $100 million contingency fund to enable rapid response to health emergencies, including infectious disease outbreaks. We believe one-off contributions or binding contingent commitments proportional to member state core contributions are the most efficient way to finance this fund.

Recommendation C.3: By the end of 2016, the World Health Organization should create and fund a sustainable contingency fund of $100 million to support rapid deployment of emergency response capabilities through one-off contributions or commitments proportional to assessed contributions from member states.

Ebola revealed weaknesses in WHO’s coordination with other parts of the UN system. WHO and the UN should address the need for coordination, agreeing on effective mechanisms for crises that are primarily health-driven as well as those that pose broader humanitarian challenges. The composition of the TGB, which will include representation from other parts of the UN system, will facilitate this. Where a potential pandemic goes beyond the capacity of WHO and/or becomes a broader humanitarian crisis—or where the health challenges are just one element of a broader crisis—there should be an agreed-on escalation process, facilitating the UN Secretary-General’s overall control of such situations.

Recommendation C.4: By the end of 2016, the United Nations (UN) and the World Health Organization should establish clear mechanisms for coordination and escalation in health crises, including those that become or are part of broader humanitarian crises requiring mobilization of the entire UN system.

Regional networks have an important role to play, complementing the regional structure of WHO. They can enhance cross-border cooperation, facilitate the sharing of scarce resources, and provide extra capacity in the event of outbreaks. WHO needs to recognize the value of such networks and improve its linkages with them.

Recommendation C.5: By the end of 2017, the World Health Organization should work with existing formal and informal regional and sub-regional networks to strengthen linkages and coordination, and thus enhance mutual support and trust, sharing of informa-

tion and laboratory resources, and joint outbreak investigations among neighboring countries.

The Ebola outbreak demonstrated the importance of non-state actors—from community leaders to international nongovernmental organizations and private-sector businesses. It also revealed many shortcomings in approaches taken at both the national and global level to engage with such players. WHO and individual national governments should proactively create mechanisms to engage with the various categories of non-state actors on preparedness and response. Waiting until the crisis hits is too late.

Recommendation C.6: By the end of 2016, the World Health Organization and national governments should enhance means of cooperation with non-state actors, including local and international civil society organizations, the private sector, and the media.

At the moment there is no formalized intermediate level of public alert below a Public Health Emergency of International Concern (PHEIC), which is an extremely rare event. The Commission believes that there would be merit in generating a daily “watch list” of outbreaks of PHEIC potential. The CHEPR should develop clear criteria to determine the outbreaks included in this list. This would raise awareness of the underlying pattern of potential threats and normalize the process of raising alerts.

Recommendation C.7: By the end of 2016, the World Health Organization (WHO) should establish a mechanism to generate a daily high-priority “watch list” of outbreaks with potential to become a Public Health Emergency of International Concern to normalize the process of reporting of outbreaks by country and encourage necessary preparedness activities. WHO should communicate this list to national focal points on a daily basis and provide a public summary on a weekly basis.

Self-interested and misguided behavior by individual countries can be an impediment to an effective international response to infectious disease threats, whether by delaying or suppressing data or alerts or by imposing excessive restrictions on travel and trade. We believe the global community should establish tougher norms and pursue greater compliance in these areas—and be prepared to “name and shame” where necessary.

Recommendation C.8: By the end of 2016, the World Health Assembly should agree on new mechanisms for holding governments publicly accountable for performance under the International Health Regulations and broader global health risk framework, as detailed in Recommendation B.2, including:

• protocols for avoiding suppression or delays in data and alerts, and
• protocols for avoiding unnecessary restrictions on trade or travel.

We support the World Bank’s proposal to create a Pandemic Emergency Financing Facility as a complement to WHO’s contingency fund. If innovative insurance and capital market mechanisms can be demonstrated to be both economically viable and practical, these could potentially represent an attractive new source of funds. While clearly politically challenging to implement, binding contingent commitments from donor governments represent an economic and flexible alternative.

Recommendation C.9: By the end of 2016, the World Bank should establish the Pandemic Emergency Financing Facility as a rapidly deployable source of funds to support pandemic response.

To ease fiscal pressure on governments that raise infectious disease outbreak alerts, and reduce the incentive to avoid doing so, the IMF should make clear that it is in a position to provide budgetary assistance when needed.

Recommendation C.10: By the end of 2016, the International Monetary Fund should ensure that it has the demonstrable capability to provide budgetary support to governments raising alerts of outbreaks, perhaps through its existing Rapid Credit Facility.

ACCELERATING RESEARCH AND DEVELOPMENT TO COUNTER INFECTIOUS DISEASES

As part of creating a more effective global framework to counter infectious disease threats, we need to strengthen our scientific and technical resources against these threats. This means accelerating research and development (R&D) in a coordinated manner across the whole range of relevant medical products, including vaccines, therapeutics, diagnostic tools, personal protective equipment, and instruments.

To ensure that incremental R&D has maximum impact in strengthening defenses against infectious diseases, we propose that WHO galvanize the creation of a Pandemic Product Development Committee (PPDC) to mobilize, prioritize, allocate, and oversee R&D resources relating to infectious diseases with pandemic potential. The chair of the PPDC should be an R&D expert appointed by the WHO Director-General, with the rest of the membership comprised of internationally recognized leaders with expertise in discovery, development, regulatory review and approval, and manufacturing of medical products. Although supported by WHO, the PPDC should operate independently and should be held accountable by the TGB. To facilitate this linkage, the chair of the PPDC should be a member of the TGB.

Recommendation D.1: By the end of 2016, the World Health Organization should establish an independent Pandemic Product Development Committee, accountable to the Technical Governing Board, to galvanize acceleration of relevant research and development, define priorities, and mobilize and allocate resources.

Accelerating R&D will require a significant financial investment. We recommend mobilization of about $1 billion per year (as part of the total investment proposed of $4.5 billion). Deployment of these funds, which we envision as being sourced from a variety of contributors, will be coordinated by the PPDC.

Recommendation D.2: By the end of 2016, the World Health Organization should work with global research and development stakeholders to catalyze the commitment of $1 billion per year to maintain a portfolio of projects in drugs, vaccines, diagnostics, personal protective equipment, and medical devices coordinated by the Pandemic Product Development Committee.

Enhancing the effectiveness of R&D requires agreement on protocols and approaches in a number of key aspects of the way R&D is conducted, including commitment to scientific standards during a crisis, engagement of communities, and harmonization of multiple aspects of development and approval, and manufacturing and distribution processes.

Recommendation D.3: By the end of 2016, the Pandemic Product Development Committee should convene regulatory agencies, industry stakeholders, and research organizations to:

• Commit to adopting research and development approaches during crises that maintain consistently high scientific standards.
• Define protocols and practical approaches to engage local scientists and community members in the conduct of research.
• Agree on ways to expedite medical product approval, manufacture, and distribution, including convergence of regulatory processes and standards; pre-approval of clinical trial designs; mechanisms for intellectual property management, data sharing and product liability; and approaches to vaccine manufacture, stockpiling, and distribution.

BUILDING A GLOBAL FRAMEWORK TO COUNTER INFECTIOUS DISEASE CRISES

For far too long, infectious disease has been the neglected dimension of global security. Few threats pose such risks to human life and well-being. Yet we have invested relatively little to counter such risks, and neither national nor global systems performed well when tested.

The Commission believes the time has come to reverse this neglect. The framework we propose has three key elements:

1. Stronger national public health capabilities, infrastructure, and processes built to a common standard and regularly assessed through an objective, transparent process fully consistent with international legal obligations under the IHR.

2. More effective global and regional capabilities, led by a reenergized WHO, through a dedicated CHEPR, coordinated effectively with the rest of the UN system, and supported by the World Bank and IMF.
3. An accelerated program of R&D, deploying $1 billion per year and coordinated by a dedicated committee.

These actions have a price tag. We estimate an incremental funding requirement of about $4.5 billion per year. This comprises:

• The upper end of the World Bank’s 2012 estimated range of $1.9–$3.4 billion per year for the cost of upgrading national pandemic preparedness capabilities (World Bank, 2012).
• Our proposed figure of $1 billion per year for infectious disease prevention and response R&D (see Chapter 5).
• High-level preliminary estimates of costs for the establishment of WHO’s CHEPR ($25 million), WHO’s Contingency Fund for Emergencies ($25–$30 million) and the World Bank’s Pandemic Emergency Financing Facility ($80–$100 million), which amount together to about $130–$155 million per year (see Chapter 4).

$4.5 billion is not a small sum, but neither is it beyond reach. In the context of estimated expected economic losses from pandemics of more than $60 billion per year, it is very good investment. Considering the potential threat to human lives, the case is even stronger.

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