Ebola again: Preparedness is still underfinanced, but new opportunities are in play

By Amanda Glassman, Liesl Schnabel, and Rebecca Forman

On May 8, the Democratic Republic of the Congo (DRC) declared a new Ebola outbreak. To date, the DRC’s Ministry of Health has reported 34 cases of Ebola. And reports suggest the outbreak could spread from its current, remote location to more densely populated areas. While new tools are in place, it’s past time to recognize the need to adequately finance preparedness at home and abroad, and to act on existing opportunities to deploy funding and link tightly to progress on preparedness metrics.

Preparedness is still underfinanced and ad hoc

An infectious disease outbreak in the DRC—or anywhere in the world for that matter—poses a threat everywhere. Pathogens don’t respect borders and can travel quickly from even the most remote places to major cities around the globe. Population growth and urbanization in the last several decades have forced people and animals into tighter living quarters, increasing opportunities for zoonotic disease transmission. Meanwhile, synthetic disease creation raises risks of bioterrorism or accidental pathogen release from a laboratory.

A widespread pandemic could lead to a devastating loss of lives and have damaging economic consequences. Conservative estimates suggest the 2003 SARS outbreak cost the global economy between $30 and $40 billion in a six-month timespan. And experts project a moderately severe to severe pandemic could cause a global economic loss of $570 billion, or roughly 0.7 percent of the world’s income.

The Global Health Security Agenda’s Joint External Evaluation (JEE), launched in 2016, is used as an evaluation tool to help countries systematically evaluate their preparedness capacity for pandemics—helping to identify gaps and target areas for improvement. As of today, only 27 of 199 countries have completed their JEEs.

Of the 27 countries with completed JEEs, only 2 have used the results generated to develop costed plans. One immediate priority is to estimate the cost of filling the highest-priority gaps.

Though all agree that domestic resources should be deployed to fill gaps once they are identified, allocating these monies has proven extremely difficult. The challenge is particularly great in low- and middle-income countries with limited budgets and many competing health priorities.

New funding and incentives for preparedness are in place, but we need to assess their fit for purpose and use them

There are at least three new funding mechanisms that might be deployed for preparedness, but they require adjustments—their total amounts, their incentives, and their allocation and focus on results need further attention:

1. A US emergency reserve fund exists, but it is small and only for use at home. The very same day the new outbreak was declared, the White House submitted a rescission package to Congress that proposed returning to the Treasury $252 million in unspent funding previously appropriated for Ebola response in FY 2015, draining the remainder of that emergency account. This is exactly the wrong approach. In fact, the United States should be reinvesting this money into bilateral or multilateral preparedness efforts or setting it aside for the next disease threat. During the 2014 Ebola outbreak, precious time was wasted waiting for Congress to allocate appropriate funding to the outbreak, and we can’t afford to repeat this mistake. Congress deserves credit for creating an “Emergency Reserve Fund” for contagious infectious disease outbreaks with a domestic focus, but the account only has $105 million—which could be rapidly exhausted in the face of a pandemic. The fund should be at least $500 million, a small share of the likely economic costs of faster spread in the absence of response. 
    
2. The poorest countries have insurance, but there is still weak incentive to prepare. For IDA-eligible countries, the World Bank’s Pandemic Emergency Financing Facility (PEF) has created an incentive to invest in preparedness. The financing facility is a form of indemnity insurance that disburses a set amount when activation criteria associated with an outbreak are met, creating a modest incentive for countries to minimize expenses associated with an outbreak by being prepared ahead of time. However, there is still work to be done: as is, the incentive is not universally understood, the activation criteria are not well defined, and the fund is not complete. IDA countries insured by the facility still need to be persuaded that the potential of outbreak-related “savings” is an adequate incentive to invest domestically in preparedness. 
    
3. There’s new money for global public goods, but will it go towards preparedness? The World Bank’s recent announcement of a general capital increase includes up to $100 million of IBRD annual income for programs addressing global public goods (GPG). There’s an indication that the Bank’s Board of Governors could increase the amount in the future. GPG includes pandemic preparedness and antimicrobial resistance. This funding could be used to buy down the cost of IBRD lending in low- and middle-income countries for this use or could be provided as a straight grant. This opportunity may require some demand creation efforts from the World Bank’s HNP practice, and has the potential to be co-funded with philanthropic monies.

In addition to resources and incentives, leadership itself is a critical component of pandemic preparedness. The recent news that Tim Ziemer, the head of global health security on the White House’s National Security Council, has left the administration—and that he will not be replaced—is incredibly worrisome. The current administration has a real opportunity to lead on the global health security agenda, but it won’t be able to without smart people in critical positions leading the way.

As news of the most recent Ebola outbreak in the DRC develops, it will be important for us to not only stop the spread of infection, but also for the United States and other key development actors to invest directly in preparedness—watch for more on this issue from CGD soon.