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. 2023 Mar;11(3):e385-e413.
doi: 10.1016/S2214-109X(23)00007-4. Epub 2023 Jan 24.

Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026

Global Burden of Disease 2021 Health Financing Collaborator Network
Collaborators

Global investments in pandemic preparedness and COVID-19: development assistance and domestic spending on health between 1990 and 2026

Global Burden of Disease 2021 Health Financing Collaborator Network. Lancet Glob Health. 2023 Mar.

Abstract

Background: The COVID-19 pandemic highlighted gaps in health surveillance systems, disease prevention, and treatment globally. Among the many factors that might have led to these gaps is the issue of the financing of national health systems, especially in low-income and middle-income countries (LMICs), as well as a robust global system for pandemic preparedness. We aimed to provide a comparative assessment of global health spending at the onset of the pandemic; characterise the amount of development assistance for pandemic preparedness and response disbursed in the first 2 years of the COVID-19 pandemic; and examine expectations for future health spending and put into context the expected need for investment in pandemic preparedness.

Methods: In this analysis of global health spending between 1990 and 2021, and prediction from 2021 to 2026, we estimated four sources of health spending: development assistance for health (DAH), government spending, out-of-pocket spending, and prepaid private spending across 204 countries and territories. We used the Organisation for Economic Co-operation and Development (OECD)'s Creditor Reporting System (CRS) and the WHO Global Health Expenditure Database (GHED) to estimate spending. We estimated development assistance for general health, COVID-19 response, and pandemic preparedness and response using a keyword search. Health spending estimates were combined with estimates of resources needed for pandemic prevention and preparedness to analyse future health spending patterns, relative to need.

Findings: In 2019, at the onset of the COVID-19 pandemic, US$9·2 trillion (95% uncertainty interval [UI] 9·1-9·3) was spent on health worldwide. We found great disparities in the amount of resources devoted to health, with high-income countries spending $7·3 trillion (95% UI 7·2-7·4) in 2019; 293·7 times the $24·8 billion (95% UI 24·3-25·3) spent by low-income countries in 2019. That same year, $43·1 billion in development assistance was provided to maintain or improve health. The pandemic led to an unprecedented increase in development assistance targeted towards health; in 2020 and 2021, $1·8 billion in DAH contributions was provided towards pandemic preparedness in LMICs, and $37·8 billion was provided for the health-related COVID-19 response. Although the support for pandemic preparedness is 12·2% of the recommended target by the High-Level Independent Panel (HLIP), the support provided for the health-related COVID-19 response is 252·2% of the recommended target. Additionally, projected spending estimates suggest that between 2022 and 2026, governments in 17 (95% UI 11-21) of the 137 LMICs will observe an increase in national government health spending equivalent to an addition of 1% of GDP, as recommended by the HLIP.

Interpretation: There was an unprecedented scale-up in DAH in 2020 and 2021. We have a unique opportunity at this time to sustain funding for crucial global health functions, including pandemic preparedness. However, historical patterns of underfunding of pandemic preparedness suggest that deliberate effort must be made to ensure funding is maintained.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests S Bhaskar reports support for the present manuscript from leadership or fiduciary roles in board, society, committee or advocacy groups, paid or unpaid with the Rotary Club of Sydney and Global Health and Migration Hub Community, Global Health Hub Germany as a Board Director and Co-Manager. N Fullman reports funding from Gates Ventures, outside of the submitted work. D Holinelli reports grants or contracts from Ministero dell'Università e della Ricerca (Italian Ministry of University and Research, MUR), outside the submitted work. A Guha reports being the recipient of the American Heart Association Strategically Focused Research Network Grant, consulting fees from Myovant and Pfizer, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from the Association of Community Cancer Centers, Ohio State University, and the University of Kentucky, outside the submitted work. C Herteliu reports grants or contracts from Romanian Ministry of Research Innovation and Digitalization and MCID, outside the submitted work. J J Jozwiak reports personal fees from Novartis and Adamed, outside the submitted work. K Krishan is supported by the UGC Centre of Advanced Study (phase II), awarded to the Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. L G Mantovani reports support from the Italian Ministry of Health for the present manuscript. L Monasta received support for the present manuscript from the Italian Ministry of Health (Ricerca Corrente 34/2017), payments made to the Institute for Maternal and Child Health IRCCS Burlo Garofolo. F Obi is an unpaid board member of Health Systems Global, outside the submitted work. J Sanabria reports a patent for a synthetic peptide active on ATP1A1 signalosome for hepatocellular carcinoma and is a member of multiple scientific and clinical societies and associations, outside the submitted work. L R Silva supported by the project code CENTRO-04-3559-FSE-000162, Fundo Social Europeu. J A Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs, Adept Field Solutions, Clinical Care options, Clearview Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM, Trio Health, Medscape, WebMD, Practice Point Communications, the US National Institutes of Health, and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Simply Speaking; support for attending meetings or travel from the steering committee of OMERACT; unpaid participation on a data safety monitoring board or advisory board with the US Food and Drug Administration Arthritis Advisory Committee; leadership or fiduciary role in board, society, committee or advocacy group, paid or unpaid, with OMERACT as a steering committee member, as Chair of the Veterans Affairs Rheumatology Field Advisory Committee, and as Editor and Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis; stock or stock options in TPT Global Tech, Vaxart Pharmaceuticals, Atyu Biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics, Seres Therapeutics, Tonix Pharmaceuticals, and Charlotte's Web Holdings; and previously owning stock options in Amarin, Viking, and Moderna pharmaceuticals. L Zühlke receives support from the National Research Foundation of South Africa, as well as the UK Medical Research Council and the UK Department for International Development under the MRC/DFID Concordat agreement, via the African Research Leader Award (MR/S005242/1). All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Per-person development assistance for health (A), per-person development assistance for pandemic preparedness (B), and per-person COVID-19 development assistance for health spending (C), by World Bank income groups Spending reported in 2021 inflation-adjusted US$.
Figure 2
Figure 2
Development assistance for health, by health focus area, 1990–2021 (A), and percentage of development assistance for COVID-19, 2020–21 (B) In A, Other health focus areas captures development assistance for health for which we have health focus area information but is not identified as being allocated to any of the health focus areas listed. Health assistance for which we have no health focus area information is designated as Unassigned. In B, Other sources captures development assistance for health for which we have source information but which is not identified as originating within any of the sources listed. Other governments includes Afghanistan, Angola, Argentina, Austria, Azerbaijan, Bangladesh, Belgium, Bhutan, Brazil, Brunei, Bulgaria, Côte d'Ivoire, Cameroon, Central African Republic, Chad, Colombia, Croatia, Czechia, DR Congo, Denmark, Egypt, Estonia, Ethiopia, Finland, Gabon, Greece, Guinea, Hungary, Iceland, India, Indonesia, Iran, Iraq, Ireland, Italy, Jamaica, Jordan, Kenya, Kuwait, Latvia, Lebanon, Libya, Lithuania, Luxembourg, Madagascar, Malaysia, Malta, Monaco, Myanmar, New Zealand, Nigeria, Oman, Pakistan, Palestine, Peru, Poland, Portugal, Qatar, Romania, Russia, São Tomé and Príncipe, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, South Africa, South Korea, South Sudan, Sudan, Sweden, Switzerland, Syria, Taiwan (province of China), Thailand, Togo, Türkiye, Uganda, Ukraine, United Arab Emirates, Yemen, and Zimbabwe. Health assistance for which we have no source information is designated as Unidentified. Regional development banks include the African Development Bank, the Asian Development Bank, and the Inter-American Development Bank. Other bilateral development agencies include Austria, Belgium, Denmark, Finland, Greece, Ireland, Italy, Luxembourg, Netherlands, New Zealand, Norway, South Korea, Spain, Sweden, Switzerland, United Arab Emirates, the European Commission, and the European Economic Area. Argentina is included in the Global Burden of Disease high-income classification but has been included in Latin America and Caribbean because Argentina was considered a middle-income country by the World Bank in 2020 and 2021. Health assistance for which no recipient country of regional information is available is designated as Unallocable. CEPI=Coalition for Epidemic Preparedness Innovations. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. HSS/SWAps=health system strengthening and sector-wide approaches. IBRD=International Bank for Reconstruction and Development. NGOs=non-governmental organisations. PAHO=Pan American Health Organization. UNFPA=United Nations Population Fund. Global refers to donor resources that were contributed towards goods or activities that are of benefit to the world; these types of goods or activities are more commonly referred to as global public goods. Spending reported in 2021 inflation-adjusted US$. *2021 disbursement estimates are preliminary.
Figure 3
Figure 3
Development assistance for pandemic preparedness by source of funding (A) and disbursing entity (B), 1990–21 Other sources captures development assistance for health for which we have source information but which is not identified as originating within any of the sources listed. Other governments includes Afghanistan, Angola, Argentina, Austria, Azerbaijan, Bangladesh, Belgium, Bhutan, Brazil, Brunei, Bulgaria, Côte d'Ivoire, Cameroon, Central African Republic, Chad, Colombia, Croatia, Czechia, DR Congo, Denmark, Egypt, Estonia, Ethiopia, Finland, Gabon, Greece, Guinea, Hungary, Iceland, India, Indonesia, Iran, Iraq, Ireland, Italy, Jamaica, Jordan, Kenya, Kuwait, Latvia, Lebanon, Libya, Lithuania, Luxembourg, Madagascar, Malaysia, Malta, Monaco, Myanmar, New Zealand, Nigeria, Oman, Pakistan, Palestine, Peru, Poland, Portugal, Qatar, Romania, Russia, São Tomé and Príncipe, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, South Africa, South Korea, South Sudan, Sudan, Sweden, Switzerland, Syria, Taiwan (province of China), Thailand, Togo, Türkiye, Uganda, Ukraine, United Arab Emirates, Yemen, and Zimbabwe. Health assistance for which we have no source information is designated as Unidentified. Regional development banks include the African Development Bank, the Asian Development Bank, and the Inter-American Development Bank. Other bilateral development agencies include Austria, Belgium, Denmark, Finland, Greece, Ireland, Italy, Luxembourg, Netherlands, New Zealand, Norway, South Korea, Spain, Sweden, Switzerland, United Arab Emirates, the European Commission, and the European Economic Area. CEPI=Coalition for Epidemic Preparedness Innovations. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. HSS/SWAps=health system strengthening and sector-wide approaches. IBRD=International Bank for Reconstruction and Development. NGO=non-governmental organisation. PAHO=Pan American Health Organization. UNFPA=United Nations Population Fund. Spending reported in 2021 inflation-adjusted USD. *2021 disbursement estimates are preliminary.
Figure 4
Figure 4
Development assistance for pandemic preparedness and COVID-19, 1995–2026 Projected future pandemic preparedness needs come from the report Financing the Global Commons for Pandemic Preparedness and Response. Spending reported in 2021 inflation-adjusted US$. DAH=development assistance for health. HLIP=High-Level Independent Panel. LMIC=low-income or middle-income country.
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