Any strategic or funding decision on pandemic prevention, preparedness and response (PPPR) needs to be grounded in a critical reflection on the failures of our earlier understanding of effective PPPR, and build on our understanding of how to achieve success in global health. Since 2020, we have seen in sequence our pandemic prevention systems fail, our understanding of pandemic preparedness proven wrong – JEE and GHS scores held no predictive power on COVID-19 outcomes – and our pandemic response shown to be inadequate and inequitable. The WHO estimates that across 2020 and 2021, over 14 million people lost their lives, directly or indirectly, because of the pandemic. We cannot afford to repeat the mistakes of 2020. To prepare, we have to accept for what they are the grim outcomes of our past models and efforts. We need to reform our approach to pandemic prevention, preparedness and response, and bring it closer to models we know are creating more resilient and equitable societies.
The obvious model to emulate for a dedicated global pandemic preparedness infrastructure is the Global Fund to Fight AIDS, Tuberculosis and Malaria. In twenty years, the Global Fund has grown to become the largest mechanism for investing in Global Health, and has saved over 44 millions lives. Much of the success of the Global Fund came from its innovative and top-to-bottom commitment to partnership. Donor countries, implementing countries, civil society and community representatives sit on the Board of the Global Fund, and are all meaningfully engaged in dialogues on the strategic orientation of the fund. This is in large part thanks to the way voting seats are allocated to ensure that donor countries cannot alone outvote other groups, forcing delegations to reach consensus. The Global Fund Secretariat has dedicated staff for civil society and community engagement who work to maintain open channels with the grassroot. In implementation countries, grants are designed through a consultative process that includes governments alongside technical partners, civil society and community. In times of emergency, this inclusive and decentralized structure is able to quickly adapt its priorities and scale up efforts – as we saw through the COVID-19 Response Mechanism, thanks to which the Global Fund was able to rapidly allocate surge funding during the pandemic, and in the aftermath of the attack on Ukraine by Russia.
The way the Global Fund is structured is informed by a commitment to transparency and inclusivity, but also by an understanding that investment in health cannot be impactful without trust, at all levels. When fighting infectious diseases, no one is safe until everyone is safe – but reaching everyone is not easy, and is not just a matter of funding. The IPPPR expects that the United States, by far the world richest country, will miss the target of vaccinating 70% of its population by the end of 2022. The Global Fund has 20 years of experience reaching out to marginalized and criminalized populations in over a hundred countries – populations where distrust of governments and institutions is deeply rooted. In rethinking our approach to pandemic preparedness, we do not have to start from scratch. And yet, the PPPR FIF is being constructed in apparent ignorance of these lessons: behind closed door, and on a timeline that gives no room for meaningful consultation with anyone beside a handful of early pledging countries.
As representatives of civil society, we demand that the governance of the PPPR FIF be rethought, to integrate as equal partners implementing countries and civil society – through integration throughout the design process, and the granting of voting seats on the Board once created.
We believe that only through a reform of the PPPR FIF creation process will we be able to make the right kind of investment in pandemic preparedness and response. As representatives of civil society, we demand that we learn the right lessons from COVID-19 and our history of successful investment in Global Health:
- Invest in people – With the benefit of hindsight, we can see that investment in specialized equipment is not sufficient. In the case of a highly contagious pathogen like COVID-19, hospitals and laboratories will be overwhelmed if transmission is not controlled. Investments need to increase the numbers and strengthen the capacity of primary health care workers, who bear the brunt of any pandemic and are key to slowing down transmission by implementing response measures.
- Invest in communities – COVID-19 showed us the limits of our current model of public health communication, with in each country a sizable share of the population actively resisting public health measures. There is a clear need to rebuild trust between citizens and our health infrastructures. Investment needs to support community health workers and peer networks. They need to be the basis of an effective and decentralized surveillance net, embedded in and trusted by local communities. This localized infrastructure will allow for the effective dispersing of public health messaging, and rapid mobilization to support the broader health system in case of emergency.
- Invest in equity – The speed of development and production of a vaccine against COVID-19 was unprecedented, and could have been the crowning achievement of our pandemic response infrastructure – if only vaccine access had been equitable. The world’s failure to prioritize equity in vaccination not only translated into the disease being allowed to find unprotected and vulnerable populations, but also gave it time to mutate again and again, gaining second, third, fourth winds and hitting the world in waves. Investment in local production capacity and publicly funded R&D, able to produce IP-free treatments and vaccines, has to be central to pandemic preparedness.
- Invest in rights – The pandemic created new inequalities, but also widened existing ones. Inequalities on the basis of gender, race and class have in turn fueled the pandemic by creating reservoirs of population made vulnerable by increased exposure and reduced access to services. They also created fertile ground for mistrust and disinformation. Investments must include funding for advocacy, strive to be gender transformative, and further human rights. Interventions promoting digital literacy must be prioritized to empower citizens to make informed decisions regarding the information they receive online, and independent watch dogs must be supported to limit the reach and dominance of disinformation, including coming from official sources.
- Invest in sustainability – The past two years proved that pandemic preparedness is not only a question of means, but one of planning and will at the national level. COVID-19 outcomes were only loosely influenced by a country’s wealth, as measured by GDP per capita. Investment must foster and promote domestic investment in the health system, in particular primary care, and fund community monitoring to ensure that governments are kept accountable and fulfill their promises.
‘The next pandemic’ is already here. By not hearing the calls of fixing the blatant inequities of our pandemic preparedness and response mechanisms, we have already let vulnerable groups be exposed to a new pathogen. It might not be too late yet to stop monkeypox in its tracks, but its emergence as the world still struggles against COVID-19 makes clear the urgency of the situation, and the cost of the status quo. The sense of urgency that surrounds the creation of the new PPPR FIF is justified, but by thinking that closed doors are the key to a rapid response, its founders are on their way to repeat the errors of the past and waste badly needed money. The PPR that we want is the PPR that the world needs.
Find all of our resources on the new PPPR FIF here.
 Issues with our measures of pandemic preparedness were raised by the IPPPR in their first report, and reiterated since. From their May 2022 assessment report: “The systems for assessing or measuring preparedness and assessing the robustness of those systems were shown to have low predictive value for how well countries were able to respond to the COVID-19 emergency.”
 The WHO estimates the excess mortality over 2020-2021 for the United States (GDP per capita: over $65,000) at 140 per 100,000; the United Kingdom ($43,000) at 109; Thailand ($7800) at 11; Vietnam ($2700) at -3; and Cambodia ($1643, or almost 40 times lower than the US) at 37. See WHO Excess Death Data.