5. The Independent Panel’s recommendations for transforming the international system for pandemic preparedness and response

The Panel believes that system-level change is needed to overcome the manifest failure of the international system to prevent, contain, and mitigate the impact of a pandemic. Pandemic preparedness and response have to function at national, regional and global levels, across different sectors of social and economic life, and include government, business and community.

The current pandemic needs to be stopped as quickly as possible. Then measures in the recovery phase must be taken to ensure that such a pandemic never happens again, by building forward better. The lost ground in progress towards the Sustainable Development Goals needs to be made up by redressing the interlocking impacts of the pandemic on health, livelihoods, and inequality.

The Panel’s recommendations follow from the diagnosis we have made of what went wrong at each stage of the pandemic, in preparedness, surveillance and alert and early and sustained response and from our view of the leadership required to transform the system.

There is a need for:

The Panel calls on Member States to request the United Nations Secretary-General to convene a special session of the United Nations General Assembly to reach agreement on the reforms needed to ensure that the world can prevent the next outbreak of a new pathogen becoming another pandemic.

1. Elevate leadership to prepare for and respond to global health threats to the highest levels to ensure just, accountable and multisectoral action

The COVID-19 pandemic has laid bare the lack of high-level political leadership in coordinated global action against the pandemic, with resultant failures in securing agreement between governments in support of common goals and alignment of efforts to tackle health, social and economic challenges. As a result, coherent global strategic directions in pandemic response have not been set and linked to international agencies and regional institutions. Nor have the private sector and civil society organizations been able to contribute to strategic direction setting in an effective way.

The organic evolution of the international health system over recent decades in order to address particular health problems has resulted in pockets of major progress but also created inefficiencies resulting from unclear roles and responsibilities and an inability to leverage effectively the comparative advantages of different actors. Global health crises have whole-of-system impacts and require coordinated leadership from WHO, the International Monetary Fund (IMF), World Bank, and the United Nations Secretary-General. Similar coordination is required regionally. At country level where there is a United Nations presence the Resident Coordinator system provides United Nations system coordination in support of countries.

The international system for pandemic preparedness and response requires fundamental transformation, catalyzed by political leadership at the highest level. That transformation needs to deliver synergies between international, regional and national organizations, increased pandemic preparedness and response capacities at all levels, and effective monitoring and compliance systems.

The Panel is convinced that a Global Health Threats Council at the most senior level is vital to success in the future. The pandemic shows such a body is long overdue. It would help secure high-level political leadership and ensure attention to pandemic prevention, preparedness and response is sustained over time in the service of a vision of a world without pandemics. The Council should be an inclusive and legitimate voice of authority with the ability to utilise both accountability mechanisms and provide access to financing to ensure preparedness as well as response at the national, regional and global levels.

Any transformation of the international system will require more robust international governance for pandemic preparedness and response. International legal instruments should support that goal. The Panel believes that a Framework Convention would be an opportunity to address gaps in the international response, clarify responsibilities between States and international organizations, and establish and reinforce legal obligations and norms. Mechanisms for financing, research and development, technology transfer, and capacity building could also be enshrined in the Convention. Expeditious adoption of a Pandemic Framework Convention should capitalize on political will at the peak of global determination to avoid future pandemics and serve to accelerate governance reforms.

The commitment of Heads of State and Government to transform the international system for pandemic preparedness and response must go together with their commitment to lead strong and effective national implementation. It will dovetail with continued and enhanced implementation of the 2030 Agenda and the Sustainable Development Goals.

The Panel Recommends

  1. Establish a Global Health Threats Council. The membership should be endorsed by a United Nations General Assembly resolution (see below recommendations for a Special Session of the General Assembly and Annex A). The Council should be led at Head of State and Government level and the membership should include state and relevant non-state actors, ensuring equitable regional, gender and generational representation, with the following functions:
    • Maintain political commitment to pandemic preparedness between emergencies and to response during emergencies.
    • Ensure maximum complementarity, cooperation and collective action across the international system at all levels.
    • Monitor progress towards the goals and targets set by WHO, as well as against potentially new scientific evidence and international legal frameworks, and report on a regular basis to the United Nations General Assembly and the World Health Assembly.
    • Guide the allocation of resources by the proposed new finance modality according to an ability to pay formula.
    • Hold actors accountable including through peer recognition and/or scrutiny and the publishing of analytical progress status reports.
  2. Adopt a Pandemic Framework Convention within the next 6 months, using the powers under Article 19 of the WHO Constitution, and complementary to the IHR, to be facilitated by WHO and with the clear involvement of the highest levels of government, scientific experts and civil society.
  3. Adopt a political declaration by Heads of State and Government at a global summit under the auspices of the United Nations General Assembly through a Special Session convened for the purpose and committing to transforming pandemic preparedness and response in line with the recommendations made in this report.

2. Focus and strengthen the independence, authority and financing of the WHO

The WHO has an indispensable leadership role in the international system for prevention, preparedness and response to a global health emergency such as a pandemic. The work of WHO during the COVID-19 pandemic has been at a substantively different scale and level compared for example to the initial period of the response to Ebola in west Africa in 2014. WHO must be central to the global health system. For many years, it has been given new tasks without sufficient authority or resources to undertake them fully. In this pandemic, the efforts of its leadership and staff have been unstinting but structural problems have been exposed.

WHO is and should be the lead health organization in the international system, but it cannot do everything. It is imperative that the international preparedness and response system works together at the global, regional, and country levels as a well-defined and well-coordinated system in support of countries where different actors’ comparative advantages are maximized.

WHO should in its support to national governments be the convener, but also in cases of emergencies it should strengthen its role as the coordinator without, in most circumstances, also taking on delivery functions (such as procurement and supply). WHO should focus on providing strategic direction and analysis, and formulating norms, standards and technical advice to ensure that countries have resilient health systems that are prepared with the required response capacities for health emergencies. In the case of emergencies WHO has an important operational role to play providing technical advice and support.

The quality, timing and clarity of the technical advice and direction WHO provides to the world are of the utmost importance. Programmes should be staffed with up-to-date, relevant, high quality experts, supported by the necessary financial, organizational, and management systems. Regional offices can play a key role in tailoring global advice more specifically to local contexts. A core technical function of WHO is the translation of models of successful national response into strategies that can be applied elsewhere.

The way that WHO is financed today has serious impacts on the quality of the organization’s performance. Its precarious financing is a major risk to the integrity and independence of its work. Incremental attempts in recent decades to improve the present funding model have not been successful.

While the WHO Director-General nominally has the necessary formal and legal authority to make decisions, and guide and communicate with the world concerning pandemics and health at large, in practice there are challenges to the use of that authority. Global health is inevitably a politically charged domain and it is vital that WHO as an institution is strong enough to be able to perform with maximum independence. The same degree of independence is also desirable for other institutions across the multilateral system.

Governance needs to align with the expectations laid on the organization, especially when it comes under the extreme stress of dealing with a pandemic. Reform attempts directed towards the role of the Executive Board have met with little success. The failure of the Board to perform as an executive body, closely supporting and guiding the work of the organization, has been evident during the current pandemic.

The Panel Recommends

  1. Establish WHO´s financial independence, based on fully unearmarked resources, increase Member States fees to 2/3 of the budget for the WHO base programme and have an organized replenishment process for the remainder of the budget.
  2. Strengthen the authority and independence of the Director-General, including by having a single term of office of seven years with no option for re-election. The same rule should be adopted for Regional Directors.
  3. Strengthen the governance capacity of the Executive Board, including by establishing a Standing Committee for Emergencies.
  4. Focus WHO’s mandate on normative, policy, and technical guidance, including supporting countries and regions to build capacity for pandemic preparedness and response and for resilient and equitable health systems.
  5. Empower WHO to take a leading, convening, and coordinating role in operational aspects of an emergency response to a pandemic, without, in most circumstances, taking on responsibility for procurement and supplies, while also ensuring other key functions of WHO do not suffer including providing technical advice and support in operational settings.
  6. Resource and equip WHO Country Offices sufficiently to respond to technical requests from national governments to support pandemic preparedness and response, including support to build resilient equitable and accessible health systems, UHC and healthier populations.
  7. Prioritize the quality and performance of staff at each WHO level, and de-politicize recruitment (especially at senior levels) by adhering to criteria of merit and relevant competencies.

3. Invest in preparedness now to create fully functional capacities at the national, regional and global level

Pandemic preparedness has received insufficient political priority. It has been largely confined to the health sector. The extent of pandemic risk has not been appreciated in financial decision-making or in whole-of-government or organizational priority-setting at national, regional or global levels.

An immediate opportunity to integrate pandemic risk awareness and pandemic preparedness with economic development would be to incorporate relevant pandemic considerations into existing instruments used by the IMF and World Bank.

Multisectoral coordination of preparedness has been lacking. While the Sendai Framework for Disaster Risk Reduction includes pandemic risk in its purview, disaster risk reduction capacity-building has largely been separated from health-sector pandemic preparedness efforts.

One consequence of the lack of priority given to pandemic preparedness is a financing gap to support national preparedness planning and capacity-building and global support functions. National pandemic response plans have often not been strategic and have lacked realistic financial mobilization plans.

The funding gap for preparedness exists globally and in countries at all income brackets. While low- and middle-income countries may need international support to supplement their domestic resources for pandemic preparedness, high-income countries can meet all the required costs from domestic resources.

Preparedness assessments were not robust, and in practice they failed to predict actual performance in COVID-19 responses. The use of simulation exercises was at best patchy and not systematically followed up with remedial action. Animal and environmental health systems were largely not integrated with human health protection systems. Explicit One Health planning was not adopted at the top governance level nationally, regionally or globally.

There was a lack of surge plans, rapidly deployable human resources, stockpiles, and pre-positioning of essential supplies.

A new pathogen with pandemic potential could emerge at any time. These gaps in preparedness need urgent rectification. While many governments and regional and international organizations are focused on the ongoing COVID-19 crisis, they may find it challenging to pay attention to the measures needed to prepare better for future outbreaks. Those future outbreaks may also be of very different pathogens with different implications. So, the shared learnings about the successes in responding to COVID-19, and the hard-won lessons from failings, represent a once-in-a-lifetime opportunity to get preparedness right to prevent a catastrophic pandemic from arising again.

The Panel recommends

  1. WHO to set new and measurable targets and benchmarks for pandemic preparedness and response capacities.
  2. All national governments to update their national preparedness plans against the targets and benchmarks set by WHO within six months, ensuring that whole-of-government and whole-of-society coordination is in place and that there are appropriate and relevant skills, logistics and funding available to cope with future health crises.
  3. WHO to formalize universal periodic peer reviews of national pandemic preparedness and response capacities against the targets set by WHO as a means of accountability and learning between countries.
  4. As part of the Article IV consultation with member countries, the IMF should routinely include a pandemic preparedness assessment, including an evaluation of the economic policy response plans. The IMF should consider the public health policy evaluations undertaken by other organizations. Five-yearly Pandemic Preparedness Assessment Programs should also be instituted in each member country, in the same spirit as the Financial Sector Assessment Programs, jointly conducted by the IMF and the World Bank.

4. Establish a new international system for surveillance, validation and alert

Epidemic intelligence is increasingly based on a constant process of surveying tens of thousands of signals from open sources and identifying and verifying potential public health threats. Advances in real-time digitally based surveillance, supported by machine learning, have created an always-on system that rapidly identifies information of concern. In contrast, the alert, verification and notification processes integral to the IHR (2005) require information to be methodically relayed through the machinery of government nationally and then to WHO. The methodical IHR-based process is not equipped to respond at a speed commensurate with surveillance systems, and the lag between the two is a critical point of system failure. This failure is especially evident if containment of a fast-moving respiratory pathogen is at issue.

WHO Member States have been reluctant to give the organization and its Director-General the power to investigate and report immediately on potential outbreaks. Technical expert missions can be dispatched to individual countries only with their permission, and a system of pre-authorization of missions has not been established. Often lengthy negotiations with governments for access by missions are required after an outbreak has been notified.

The bias of the current system of pandemic alert is towards inaction – steps may only be taken if the weight of evidence requires them. This bias should be reversed – precautionary action should be taken on a presumptive basis, unless evidence shows it is not necessary.

A PHEIC should serve as a clarion call for emergency pandemic response across the world, with countries being attentive to the precise nature of the emergency and the potential threat it contains. Instead, the processes around a PHEIC declaration are more oriented to ensuring that unwarranted trade and travel restrictions are not imposed. The IHR (2005) establish no obligations on States for action following declaration of a PHEIC.

In changing the system of alert to orient it towards speedy action, the incentive structures need to be addressed. At present, from local up to international level, public health actors only see downsides from drawing attention to an outbreak that has the potential to spread. Incentives must be created to reward early response action and recognize that precautionary and containment efforts are an invaluable protection which benefits all humanity.

Explicit performance standards should be attached to outbreak alert and response. These performance standards have to address different classes of emerging pathogen. Each of the steps leading up to and following the alert should be predictable and trigger requisite response action without delay.

The Panel Recommends

  1. WHO to establish a new global system for surveillance, based on full transparency by all parties, using state-of-the-art digital tools to connect information centres around the world and including animal and environmental health surveillance, with appropriate protections of people’s rights.
  2. WHO to be given the explicit authority by the World Health Assembly to publish information about outbreaks with pandemic potential on an immediate basis, without requiring the prior approval of national governments.
  3. WHO to be empowered by the World Health Assembly to investigate pathogens with pandemic potential in all countries with short-notice access to relevant sites, provision of samples and standing multi-entry visas for international epidemic experts to outbreak locations.
  4. Future declarations of a PHEIC by the WHO Director-General should be based on the precautionary principle where warranted, as in the case of respiratory infections. PHEIC declarations should be based on clear, objective, and published criteria. The Emergency Committee advising the WHO Director-General must be fully transparent in its membership and working methods. On the same day that a PHEIC is declared, WHO must provide countries with clear guidance on what action should to be taken and by whom to contain the health threat.

5. Establish a pre-negotiated platform for tools and supplies

ACT-A was launched on 24 April 2020 and evolved organically. Its vaccines, diagnostics, therapeutics pillars, and health systems connector are intended to be agile, collaborative partnerships rather than hierarchical structures. While ACT-A was able to establish a successful platform in many respects, the fact that it did not exist before the COVID-19 pandemic and had to be created for that purpose is reflected in its shortcomings. Not all pillars of the initiative have been equally successful, and a coherent, strategic, inclusive, and fully funded framework has not been achieved, to this day. ACT-A is seen by some countries and civil society as supply-driven and not sufficiently inclusive, with large donor countries and institutions having an asymmetrical influence on decision-making.

There is a lack of shared vision among all stakeholders, including both countries and manufacturers, that the therapeutics, vaccines and diagnostics needed to counter pandemics are global health commons. Without that shared vision, the “business-as-usual” approach prevails dominated by the development and sale by global corporations of proprietary products designed for wealthy countries, leaving the rest of the world dependent on the goodwill of donors, development assistance and charity to gain access – eventually – to life-saving health technologies. 

The alignment of international instruments should support such a shared vision, for example, by including the open licensing of vaccines, therapeutics and diagnostics in the United Nations Educational, Scientific and Cultural Organization’s forthcoming Recommendation on Open Science, an international standard-setting instrument that is currently being negotiated with Member States for adoption in 2021.

Concentration of manufacturing capacity, and of trials and knowledge generation, for vaccines, therapeutics, diagnostics and other essential supplies in a small number of countries has been a major contributor to inequity. While vaccine product development has been the most successful, there was a lack of end-to-end planning with R&D, clinical trials and manufacturing processes guided by a goal and strategy for equitable and effective access.

A pre-negotiated system to accelerate R&D and achieve equitable access is vital to pandemic response and the development and delivery of vaccines, therapeutics, diagnostics, and essential supplies. ACT-A provides a valuable model. Lessons drawn from both its strengths and weaknesses should guide the establishment of a permanent platform which can stand in readiness for any future pandemic.

The Panel believes that a comprehensive review of the achievements, financing, and governance of ACT-A should be conducted to make it more robust and fit for the extended purpose it should assume. The current model of high-income-country dominated systems must be transformed to a global, inclusive approach, because it is the morally right thing to do and because it is the only way to manage a global pandemic.

Critically, such a system needs to be able coordinate decision-making globally; maintain effective relationships with vaccine and other product manufacturers from both the public and the private sector and from all regions; strengthen global and local manufacturing capacity, including long-term and sustained investment in technology transfer; and incorporate a financing mechanism that invests early in the development cycle in order to support rapid and equitable development, manufacturing, and access.

The Panel Recommends

  1. Transform the current ACT-A into a truly global end-to-end platform for vaccines, diagnostics, therapeutics, and essential supplies, shifting from a model where innovation is left to the market to a model aimed at delivering global public goods. Governance to include representatives of countries across income levels and regions, civil society and the private sector. R&D and all other relevant processes to be driven by a goal and strategy to achieve equitable and effective access.
  2. Ensure technology transfer and commitment to voluntary licensing are included in all agreements where public funding is invested in research and development.
  3. Establish strong financing and regional capacities for manufacturing, regulation, and procurement of tools for equitable and effective access to vaccines, therapeutics, diagnostics and essential supplies, and for clinical trials:
    • based on plans jointly developed by WHO, regional institutions, and the private sector;
    • with commitments and processes for technology transfer, including to and among larger manufacturing hubs in each region; and
    • supported financially by International Financial Institutions and Regional Development Banks and other public and private financing organizations.

6. Raise new international financing for the global public goods of pandemic preparedness and response

“More money” is an easy response to any problem. But the Panel’s call is for specific financing for specific purposes.  In addition to funding needed for the current response, and more and different funding for WHO, the COVID-19 crisis has revealed two particular challenges in respect of the global public good of effective pandemic preparedness and response: insufficient funding of pandemic preparedness at national, regional and global levels before the pandemic, and the slow flow of funding for response once the PHEIC was declared.

It is a vital function of the international system for pandemic preparedness and response to bridge two specific gaps that exist in poorer countries for the delivery of the global public good of regular funding for pandemic preparedness and fast funding for early response. Examples of preparedness funding of this kind include helping countries and regions run simulation exercises and set up genomic sequencing facilities. Examples of response funding would be expediting the purchase of therapeutics and diagnostics or expanding testing.

It is necessary to think beyond aid and official development assistance (ODA) to finance global public goods. Pandemic preparedness and early response capacity should be thought of as critical infrastructure elements which cannot be allowed to fail, requiring stable and reliable financing in the same way as other critical international systems such as finance and banking, or security and peacekeeping.

The present international system for raising, channelling and spending international resources for pandemic preparedness and response has a diversity of actors, mandates, and financing tools. We do not recommend creating new implementing agencies. But we do believe that existing implementing agencies need additional funding, directed towards the vital public goods they deliver.

Already there are successful examples in COVID-19 financing which are a starting point for the comprehensive overhaul of financing which is needed; for example the mobilisation and reallocation by the Global Fund to Fight AIDS, TB and Malaria of US$ 1 billion to meet urgent COVID-19 needs early in the pandemic and its recent addition of US$ 3.5 billion to support COVID-19 responses, including testing, PPE and oxygen supplies. Our determination is to ensure that these efforts are proactive and planned, not reactive and rushed.

The Panel Recommends

  1. Create an International Pandemic Financing Facility to raise additional reliable funding for pandemic preparedness and for rapid surge financing for response in the event of a pandemic.
    • The facility should have the capacity to mobilize long-term (10–15 year) contributions of approximately US$ 5–10 billion annually to finance ongoing preparedness functions. It will have the ability to disburse up to US$ 50 –100 billion at short notice by front-loading future commitments in the event of declaration of a pandemic. The resources should fill gaps in funding for global public goods at national, regional and global level in order to ensure comprehensive and inclusive pandemic preparedness and response.
    • There should be an ability-to-pay formula adopted whereby larger and wealthier economies will pay the most, preferably from non-ODA budget lines and additional to established ODA budget levels.
    • The Global Health Threats Council will have the task of allocating and monitoring funding from this instrument to existing regional and global institutions, which can support development of pandemic preparedness and response capacities.
    • Funding for preparedness could be pre-allocated according to function and institution. Surge financing for response in the event of a new pandemic declaration should be guided by prearranged response plans for the most likely scenarios, although flexibility would be retained to adapt based on the threat.
    • The Secretariat for the facility should be a very lean structure, with a focus on working with and through existing global and regional organizations.

7. Countries to establish highest level national coordination for pandemic preparedness and response

National responses in a significant number of countries failed to get ahead of the pandemic. Measures that were taken too late had all of the costs but none of the benefits of early containment, resulting in a negative feedback loop in which the economy was pitted against health.

Countries which successfully managed the disease took whole-of-government and whole-of-society approaches, sought scientific guidance, engaged with community health workers and community leaders, involved vulnerable and marginalized populations, also in conflict-affected countries, and worked closely with subnational governments. But where scientific advice was side-lined, and national approaches were characterized by denial, delay, and distrust, the result was uncoordinated and confused national efforts that were ineffective in curbing community transmission.

Building resilient and equitable societies requires a serious shift in mindsets. The extent to which the COVID-19 pandemic has exacerbated inequalities is an emphatic demonstration of the interconnectedness of social, economic, environmental and political factors in society. Health programmes and COVID-19 responses need to recognize and act upon gender, ethnic, and other inequalities. Both community and private-sector actors have been viewed as conduits for resources to supplement the core business of health systems, rather than as actors with a vital stake in pandemic outcomes and a right to a seat at the decision-making table.

Accomplishing a change of paradigm to a resilient, equitable and inclusive system for pandemic preparedness and response is an inevitably political exercise because it demands that respect for human rights and promotion of equality are brought to the foreground. Health and well-being require the intersectional nature of disadvantage and exclusion to be tackled.

The Panel Recommends

  1. Ensure that **national and subnational public health institutions have multidisciplinary capacities and** multisectoral reach and the engagement of the private sector and civil society. Evidence-based decision-making should draw on inputs from across society.
  2. Heads of State and Government to appoint national pandemic coordinators accountable to the highest levels of government, with the mandate to drive whole-of-government coordination for both preparedness and response.
  3. Conduct multisectoral active simulation exercises on a yearly basis as a means of ensuring continuous risk assessment and follow-up action to mitigate risks, cross-country learning and accountability and establish independent, impartial and regular evaluation mechanisms.
  4. Strengthen the engagement of local communities as key actors in pandemic preparedness and response and as active promoters of pandemic literacy, through the ability of people to identify, understand, analyse, interpret, and communicate about pandemics.
  5. Increase the threshold of national health and social investments to build resilient health and social protection systems, grounded in high-quality primary and community health services, universal health coverage and a strong and **well-supported health workforce,** including community health workers.
  6. Invest in and coordinate risk communication policies and strategies that ensure timeliness, transparency, and accountability, and work with marginalized communities, including those who are digitally excluded, in the co-creation of plans that promote health and well-being at all times, and build enduring trust.

Actions that together will transform the international system for pandemic preparedness and response

The transformation of the international system for pandemic preparedness and response which the Panel recommends will fail if it is approached piecemeal. The lesson from previous recommendations for change following earlier pandemics is that change will only result from the adoption and implementation of inter-linked and interdependent measures. Just as pandemic preparedness itself is undone by failure in the weakest link in the chain, so too recommendations for change will fail if the hardest problems are set aside.

The Panel has assessed the set of recommendations it has proposed against one criterion only: if they had been in place, would they have stopped the COVID-19 pandemic? We believe the answer is yes, and therefore urge their implementation as a whole and in a timely manner.

The Panel’s recommendations aim to equip countries and the international system to prevent an outbreak from becoming a pandemic and, if a pandemic does occur, to prevent it becoming a global health and socioeconomic crisis.

The Panel's recommendation framework for transforming the international  system for pandemic preparedness and response.
A groups of people smiling without masks. Credit: Christine McNab
Endnotes