Financing of international collective action for epidemic and pandemic preparedness

/in ,

The Lancet Global Health

May 18, 2017

The global pandemic response has typically followed cycles of panic followed by neglect. We are now, once again, in a phase of neglect, leaving the world highly vulnerable to massive loss of life and economic shocks from natural or human-made epidemics and pandemics. Quantifying the size of the losses caused by large-scale outbreaks is challenging because the epidemiological and economic research in this field is still at an early stage. Research on the 1918 influenza H1N1 pandemic and recent epidemics and pandemics has shown a range of estimated losses (See full report here).

 A limitation in assessing the economic costs of outbreaks is that they only capture the impact on income. Fan and colleagues recently addressed this limitation by estimating the “inclusive” cost of pandemics: the sum of the cost in lost income and a dollar valuation of the cost of early death. They found that for Ebola and severe acute respiratory syndrome (SARS), the true (“inclusive”) costs are two to three times the income loss. For extremely serious pandemics such as that of influenza in 1918, the inclusive costs are over five times income loss. The inclusive costs of the next severe influenza pandemic could be US$570 billion each year or 0·7% of global income (range 0·4–1·0%)—an economic threat similar to that of global warming, which is expected to cost 0·2–2·0% of global income annually. Given the magnitude of the threat, we call for scaled-up financing of international collective action for epidemic and pandemic preparedness.

Two planks of preparedness must be strengthened. The first is public health capacity—including human and animal disease surveillance—as a first line of defence. Animal surveillance is important since most emerging infectious diseases with outbreak potential originate in animals. Rigorous external assessment of national capabilities is critical; WHO developed the Joint External Evaluation (JEE) tool specifically for this purpose. Financing for this first plank will largely be through domestic resources, but supplementary donor financing to low-income, high-risk countries is also needed.

The second plank is financing global efforts to accelerate research and development (R&D) of vaccines, drugs, and diagnostics for outbreak control, and to strengthen the global and regional outbreak preparedness and response system. These two international collective action activities are underfunded.

Medical countermeasures against many emerging infectious diseases are currently missing. We need greater investment in development of vaccines, therapeutics, and diagnostics to prevent potential outbreaks from becoming humanitarian crises. The new Coalition for Epidemic Preparedness Innovations (CEPI), which aims to mobilise $1 billion over 5 years, is developing vaccines against known emerging infectious diseases as well as platforms for rapid development of vaccines against outbreaks of unknown origin. The WHO R&D Blueprint for Action to Prevent Epidemics is a new mechanism for coordinating and prioritising the development of drugs and diagnostics for emerging infectious diseases. Consolidating and enhancing donor support for these new initiatives would be an efficient way to channel resources aimed at improving global outbreak preparedness and response.

Crucial components of the global and regional system for outbreak control include surge capacity (eg, the ability to urgently deploy human resources); providing technical guidance to countries in the event of an outbreak; and establishing a coordinated, interlinked global, regional, and national surveillance system. These activities are the remit of several essential WHO financing envelopes that all face major funding shortfalls. The Contingency Fund for Emergencies finances surge outbreak response for up to 3 months. The fund has a capitalisation target of $100 million of flexible voluntary contributions, which needs to be replenished with about $25–50 million annually, depending on the extent of the outbreak in any given year. However, as of April 30, 2017, only $37·65 million had been contributed, with an additional $4 million in pledges. The WHO Health Emergencies and Health Systems Preparedness Programmes face an annual shortfall of $225 million in funding their epidemic and pandemic prevention and control activities.

Previous health emergencies have shown that it can take time to organise global collective action and provide financing to the national and local level. In such situations, a global mechanism should offer a rapid injection of liquidity to affected countries. The World Bank’s Pandemic Emergency Financing Facility (PEF) is a proposed global insurance mechanism for pandemic emergencies. It aims to provide surge funding for response efforts to help respond to rare, high-burden disease outbreaks, preventing them from becoming more deadly and costly pandemics. The PEF currently proposes a coverage of $500 million for the insurance window; increasing the current coverage will require additional donor commitments. In addition, the PEF has a $50–100 million replenishable cash window.

As the world’s health ministers meet this month for the World Health Assembly, we propose five key ways to help prevent mortality and economic shocks from disease outbreaks. First, to accelerate development of new technologies to control outbreaks, donors should expand their financing for CEPI and support the WHO R&D Blueprint for Action to Prevent Epidemics. Second, funding gaps in the WHO Contingency Fund for Emergencies and the WHO Health Emergencies Programme should be urgently filled and the PEF should be fully financed. Third, all nations should support their own and other countries’ national preparedness efforts, including committing to the JEE process. Fourth, we believe it would be valuable to create and maintain a regional and country-level pandemic risk and preparedness index. This index could potentially be used as a way to review preparedness in International Monetary Fund article IV consultations (regular country reports by staff to its Board). Finally, we call for a new global effort to develop long-term national, regional, and global investment plans to create a world secure from the threat of devastation from outbreaks.

Gavin Yamey, Marco Schäferhoff, Ole Kristian Aars, Barry Bloom, Dennis Carroll, Mukesh Chawla, Victor Dzau, Ricardo Echalar, Indermit Singh Gill, Tore Godal, Sanjeev Gupta, Dean Jamison, Patrick Kelley, Frederik Kristensen, Ceci Mundaca-Shah, Ben Oppenheim, Julie Pavlin, Rodrigo Salvado, Peter Sands, Rocio Schmunis, Agnes Soucat, Lawrence H Summers, Anas El Turabi, Ron Waldman, Ed Whiting

The Future of Aid for Health

/in , ,

In a keynote address on November 30, 2016 at the World Innovation Summit for Health (WISH) in Doha, Qatar, Summers talked about the Future of Aid for Health. Summers said, “I have always believed that economics is a moral science because it is so centrally involved with choices that directly affect human well being.  And cancer at age 30 reinforced for me that no choices centrally affect human well being as those involving health. Economics is defined as ‘the study of the allocation of scarce resources among competing ends.’  Few if any resources allocation choices are as consequencial as those involved with health care. I have become convinced  that even as we fight for increases in global health aid, there is a need for a major reorientation of the global aid for health effort away from financing service delivery in individual countries and towards global priorities.”

The Fusion of Civilizations

/in , , ,

In the May/June 2016 issue of Foreign Affairs, Summers and Mahbubani explore the case for global optimism.  The essay states, “Historians looking back on this age from the vantage point of later generations, however, are likely to be puzzled by the widespread contemporary feelings of gloom and doom. By most objective measures of human well-being, the past three decades have been the best in history. More and more people in more and more places are enjoying better lives than ever before.” Read more

The Inclusive Cost of Pandemic Influenza Risk

/in ,

In an NBER working paper published in March 2016, Summers, Fan and Jamison explore how each year a small likelihood exists that the world will again suffer an influenza pandemic akin to the catastrophic one of 1918. Even a moderately severe pandemic could lead to 2 million or more excess deaths. Read more

Declaration on Universal Health Coverage

/in , ,

On September 18, 2015, The Lancet published a declaration endorsing universal health coverage, signed by 267 economists in 44 countries. With the United Nations set to launch the bold sustainable development agenda, this is a crucial moment for global leaders to reflect on the financial investments needed to maximize progress by 2030. Read more

Lancet: Can one turn an aspiration into reality?

/in ,

By Richard Horton

The Lancet Vol. 385 February 7, 2015

The idea of a “grand convergence” in health, achievable
within our lifetimes, might seem a naive idea. Chronic
confl icts, unpredictable humanitarian disasters, and
the persistent fragility of some nation states makes
the notion of ending preventable mortality within a
generation little more than a pipe-dream. But these
ambitious goals have inspired wide support for the core
message of the Commission on Investing in Health,
known also as Global Health 2035 (published in The Lancet
in December, 2013). Why has the central argument of the
Commission, despite its utopian implications, been so
warmly embraced?

Read the full piece: Lancet Editorial on Global Health 2035

We play with fire if we skimp on public health

/in ,

November 10, 2014

Epidemics and pandemics are like earthquakes. Tragic, inevitable and unpredictable. It starts as a random event. A virus jumps species from a bird, bat, or other animal to “Patient Zero” – who passes it on to other human beings. More likely than not, over the course of this century we will face an influenza pandemic similar to the one in 1918 that killed 50m people.

President Barack Obama’s first chief of staff, Rahm Emanuel, said in the wake of the global economic meltdown that “you never let a serious crisis go to waste”. Crises are opportunities to learn. They point to measures that will prevent the collapse of institutions when they are under extreme pressure.

While the focus is understandably on responding to the Ebola crisis, it is equally important that it serves as a wake-up call with respect to inadequacies that threaten not just tragedy on an unprecedented scale but the basic security of the US and other wealthy nations. As with climate change, no part of the world can insulate itself from the consequences of epidemic and pandemic.

The report of the Global Health 2035 commission, which I co-chaired, points up three crucial lessons. First, collective action must be taken to build strong health systems in every corner of the globe. In west Africa, Ebola was a “stress test” on national health systems, and in Sierra Leone, Liberia and Guinea the systems could not cope. There were too few trained health professionals; there was also too little equipment and too few supplies, and too little capacity for public health surveillance and control.

Nigeria’s containment of the virus after the first case was diagnosed in July is instructive. Its success, hailed by the World Health Organisation as a piece of “world class epidemiological detective work”, is explained by its aggressive, co-ordinated surveillance and control response. It already had a polio surveillance system, with skilled outbreak specialists who were quickly put to work tackling Ebola. While much of Nigeria’s health system, such as primary care services, remains very weak, on Ebola the surveillance and control system worked.  Every country needs this kind of system. Prevention is cheaper than cure and leads to better outcomes.

Building these systems takes time and money. Our research, conducted with an international team of economists and health experts, and published last year in the medical journal The Lancet, suggests that the price of this “systems strengthening” would be about $30bn a year for the next two decades. The good news is that we have the financing to pay for this through a combination of aid and domestic spending. The cost represents well under 1 per cent of the additional gross domestic product that will be available to low- and lower-middle-income countries due to increased GDP growth over the next 20 years.

The second lesson is that the lack of investment in public health is a global emergency. The WHO’s slow response to Ebola was not surprising, given its recent staff cuts. For that, we all share the blame. Since 1994, the WHO’s regular budget has declined steadily in real terms. Even before the Ebola crisis, it struggled to fund basic functions. The entire budget for influenza was just $7*7m in 2013 – less than a third of what New York City alone devotes to preparing for public health emergencies.

It takes just one infected airline passenger to introduce an infection into a country. We need the WHO more than ever. It alone has the mandate and legitimacy to serve as a health protection agency for all countries, rich and poor. Starving it of funds is reckless.

The third lesson concerns scientific innovation. When it comes to discovering and developing medicines, vaccines and diagnostic tests, we have been largely ignoring the infectious diseases that disproportionately kill the world’s poor. Consequently, we still have no medicines or vaccine for Ebola. All we can do is provide basic life support, such as fluids and blood pressure treatment . For prevention, we have to rely on old-fashioned measures such as quarantine.

Margaret Chan, WHO’s director-general, has explained the reason for this neglect. Doctors were “empty-handed”, she said, because “a profit-driven industry does not invest in products for markets that cannot pay”. Ebola affects poor African nations, so drug companies see no profit in working on it. No society will allow companies to reap huge profits when disease is spreading rapidly.

Rich governments and donors need to step up. Investing several billion dollars a year, less than 0.01 per cent of global GDP, could be decisive in preventing tragedy on the scale of world war.

Some issues are more important than recessions and elections. Ebola is a tragedy. Let us hope that it will also be a spur to taking the necessary steps to prevent the far greater one that is nearly inevitable on the current policy trajectory. The next Ebola is just around the corner.
The writer is Charles W Eliot university professor at Harvard and a former US Treasury secretary. Dr Gavin Yamey, University of California contributed to this piece.

Push for Domestic Financing for Health

/in , ,

Summers spoke to the United Nations General Assembly on Monday, September 22, 2014 and called for low and middle income countries to increase their spending on health.  Summers said, “Just 1 percent of their economic growth over the next two decades would fund the grand convergence.” Read more

Global Health 2035: A World Converging within a Generation

/in

Global Health 2035: A World Converging within a Generation, published in The Lancet.

The report makes the case that:

  • The returns on investing in health are even greater than previously estimated
  • Within a generation—by 2035—the world could achieve a “grand convergence,” bringing preventable infectious, maternal and child deaths down to universally low levels
  • Taxes and subsidies are a powerful and underused lever for curbing non-communicable diseases and injuries
  • Progressive universalism, a pathway to universal health coverage (UHC) that targets the poor from the outset, is an efficient way to achieve health and financial protection.