The world’s preparedness for the next pandemic is “perilously fragile”, with gaps that “leave us dangerously exposed to a future threat”, according to the Global Preparedness Monitoring Board (GPMB) in its 2023 annual report released on Monday.

“We lack the solid foundations needed to ensure current efforts for preparedness can be brought together to build an enduring bridge to a state of security. This is made more fragile by lack of trust both between and within countries,” said Kolinda Grabar-Kitarovic, co-chair of the GPMB.

“To counter a mistrust, we need to address its root causes, which is why this GPMB report places great emphasis on equity, accountability, leadership and coherence as underpinning factors for preparedness,” said Grabar-Kitarovic, former President of Croatia, at the launch of the report at the World Health Organization (WHO) headquarters in Geneva.

The GPMB is an independent body convened by the WHO and the World Bank in 2018 to ensure preparedness for global health crises.

Areas of decline from “already low levels of preparedness” include the global coordination of research and development (R&D); efforts to address misinformation; the participation of low and middle-income countries (LMIC) in the governance of pandemic preparedness; the lack of financing, and lack of independent monitoring. 

“Equity is not a ‘nice to have’ embellishment of global preparedness, it is its beating heart. Global security will be reached only when everyone regardless of geography is valued and assured equal access,” the report stresses.

‘Canary in the coal mine’

“We call these shortcomings ‘canary in the coal mine issues’ because these are the earliest signals of systematic problems. Without concrete commitments for financing and monitoring, preparedness capacities are likely to regress further over the coming years,” warned Grabar-Kitarovic.

However, the report identifies the negotiations to establish a WHO pandemic agreement, improved One Health surveillance capacity, community engagement and regional laboratory capacity as areas of progress. 

“The key takeaways are that our ability to deal with a potential new pandemic threat remains inadequate, and the world has insufficient capacities to guarantee our safety,” concluded Grabar-Kitarovic.

Co-chair Joy Phumaphi said that the report, the fourth produced by the GPMB since its establishment shortly before the COVID-19 pandemic, is the first to use a new monitoring framework. The board assessed 30 indicators using a stop light grading system – yet not a single indicator scored “green” (full preparedness).

Phumaphi, Botswana’s former health minister, characterised as “deeply troubling” the global failures to increase preparedness financing to meet the needs identified since COVID-19 and to integrate independent monitoring into reforms to health sector architecture.

Geopolitical tensions and competing demands for resources are also weakening countries’ resolve needed to close the pandemic response gaps, according to the board.

The report identifies four key priorities to repair the weaknesses in global preparedness, namely: strengthening monitoring and accountability; reforming the global financing system for pandemic prevention, preparedness and response (PPPR),  more comprehensive, equitable and robust R&D and supply chains; and stronger multi-sectoral, multi-stakeholder engagement.

Tedros agrees with independent monitoring 

“Our assessment reveals that current mechanisms for PPPR monitoring and accountability do not provide a complete picture,” said GPMB member Bente Angell-Hansen. 

“They tend to focus on systems and capacities and give less attention to important aspects of leadership, effectiveness and equity. They are mostly based on self-assessment with limited independent monitoring.”

Angell-Hansen added that a “critical weakness” in the current drafts of the pandemic agreement and the amendments to the International Health Regulations (IHR) was their lack of provisions for independent monitoring.

To address this shortcoming, the board proposes “independent monitoring to complement self-assessment and peer review, at all levels, nationally, regionally and globally” – as well as in the pandemic agreement and IHR amendments.

Speaking at the launch, WHO Director-General Dr Tedros Adhanom Ghebreyesus agreed with the board’s call for “independent monitoring and accountability mechanisms to be embedded in the ongoing reforms including the WHO pandemic agreement”. 

“In fact, it was the need for independent monitoring that impelled then-World Bank President Jim Kim and I to set up the GPMB in 2018. You cannot have accountability without monitoring, which provides accurate and timely information for turning commitments into effective action,” Tedros told the launch.

There has been furious lobbying for independent PPPR monitoring from a number of groups, including the Independent Panel for Pandemic Preparedness and Response. 

Financing needs ‘fundamental reform’

Board member Naoko Ishii outlined the world’s failure to raise adequate. sustainable financing as a key finding, with global research financing and global common goods financing being the worst resourced.

”Only 40% of countries have domestic contingency funds that could be used for health emergencies across the board,” said Ishii.

The report also highlights that global PPPR financing is “inefficient, uncoordinated, and insufficiently aligned to country needs and processes” and that the Pandemic Fund is far short of its aim of $10 billion.

“PPPR financing requires fundamental reform to free it from the limitations of development assistance and place it on a sustainable footing, based on burden-sharing,” recommends the report. “Strengthening PPPR requires ensuring sustainable financing for WHO and other international organisations working on PPPR.”

The report also proposes that the immediate funding gaps be addressed “to enable greater national investments and bolster international financing through new modalities and sources of financing”.

Governance: ‘Everything, everywhere all at once’

“Global health has become more crowded – much too crowded probably – and the governance of PPPR is deeply fragmented and lacks coherence. Some of us feel like in the Hollywood movie, ‘Everything Everywhere All at Once’,” said board member Ilona Kickbusch, chair of the Global Health Centre at Geneva’s Graduate Institute of International and Development Studies.

“None of the capacities we assess this year are adequate,” added Kickbusch. “And this after so many decades of work in this issue. There are multiple parallel efforts, some of which overlap but which still leave gaps, particularly in relation to equity, research and development and access to medical countermeasures.”

Furthermore, “there is no strategic plan to coordinate the whole of UN, whole-of-society response to health emergencies and our governance structures struggle to provide the necessary leadership and unity to guide us through the pandemic”, she added.

While the pandemic agreement may address these gaps, the GPMB expressed concern about the slow pace of negotiations and “the challenges and divides that are holding back progress”. 

“Member states must redouble efforts to finalise the agreement before May 2024 when the World Health Assembly meets. Our collective preparedness against the next pandemic depends on it,” stressed Kickbusch.

Tedros agreed with her: “I think you know, I have made clear to our member states that there is no time to waste. Another pandemic or global health emergency could come at any time, just as it did in 2019.”

Describing the pandemic agreement as “a generational agreement that must be written by the generation with the lived experience of a pandemic”, he urged the board to “continue your advocacy with, and for, member states to work with a greater sense of urgency, with a particular focus on the most difficult issues”.

On a positive note, Kickbusch said that during the course of the COVID-19 response, member states had come to recognise the central and vital role of the WHO in health emergencies. 

“They have demonstrated their renewed trust in WHO by increasing their assessed contributions to correct the incoherence that has plagued PPPR governance. This empowerment of WHO at the centre of global health is essential, complemented with efforts to strengthen the whole of UN multi-sectoral response to pandemics,” said Kickbusch.

More equitable R&D

The board’s Victor Dzau said that, while global R&D spending overall is “at a record high of almost $1.7 trillion per year, 80% of spending is concentrated in 10 countries – most of which are high income”. 

No “effective global mechanism to set priorities and coordinate pandemic R&D means that the world cannot prioritise countermeasures development” for the most harmful pathogens or deliver pandemic products according to need, said Dzau.

“Low and middle-income countries are inadequately represented in decision-making and coordination processes. This means that their needs are fully met in resource allocation,” he added.

To address this, the GPMB proposes “strengthening regional capacities for R&D, manufacturing and supply” which will help to address “the inequities in global access to medical countermeasures”.

Finally, the board calls on global, regional and national leaders to “fully institutionalise preparedness measures that work in the collective interests of all”, and to address the four key priorities it has identified to “repair the weaknesses in global preparedness”.