July 25, 2022
Friends along with several U.S. based advocacy organizations sent a statement to Janet Yellen, Secretary of the Treasury, Xavier Becerra, Secretary of Health and Human Services, Jake Sullivan, National Security Advisor, National Security Council, Antony Blinken, Secretary of State urging them to adhere to four lessons learned in pandemic preparedness and response. Read the statement below or download the PDF here.
We represent organizations based in the United States working on simultaneous pandemics and deeply interconnected issues of pandemic preparedness. Creating a Financial Intermediary Fund (FIF) for pandemic preparedness and response (PPR) at the World Bank could serve as an important step toward greater global health security – but only if it builds on important lessons learned about what works, and what doesn’t, in preparing for and responding to pandemics.
Now that a FIF has been established, the U.S. will play a central role in working with partners to design the governance, priorities and operating modalities of the fund. Based on our diverse experience, we urge the U.S. Government to ensure all of the following are included in the FIF. We consider these non-negotiables for a successful FIF. A FIF needs to:
- Establish broad, transparent and inclusive representation in its governance, including by integrating civil society and low- and middle-income countries as full voting members.
- Invest in existing multilateral implementers with proven track records in PPR particularly the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and Gavi, the Vaccine Alliance (Gavi).
- Implement a clear strategy to expand global health investments with additional funding rather than competing with existing organizations and funding mechanisms for resources.
- Prioritize investments in health systems and community systems that strengthen and sustain services today and are better prepared for new disease threats.
Having responded to pandemics for more than 40 years, the global health field has learned that international solidarity, fair, equal representation, and shared responsibility and accountability are essential to success in responding to pandemics. We are deeply concerned that the World Bank’s white paper outlining a new FIF for PPR  ignores central lessons of the last half-century, opting instead for an outmoded donor-driven, IFI-centric model. The following four specific recommendations are not merely long-term ideals, but prerequisites for impact. Without them, the initiative would be a step backward rather than forward.
1. Governance of any new PPR funding mechanism must include robust representation of the global South and civil society.
An array of innovative funding organizations emerging in the last two decades are widely acknowledged as being among the most successful global health initiatives in history – including the Global Fund; the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and Gavi. Key to the success of these initiatives is their inclusive approach, with decisions made jointly by donor and recipient countries, with the meaningful involvement of civil society and affected communities.
Although some World Bank FIFs include recipient countries on their governing boards, others do not, and the white paper suggests the possibility that the new FIF’s governing board might exclude governments from the global South altogether. Governments from the global South must be robustly represented and have voting seats on the new FIF’s governing board. Meaningful participation in decision-making is essential for ensuring their ownership of actions needed to bolster vigilance and resilience of their health systems. To address PPR, a genuinely global challenge, decision-making rules that are globally inclusive are critical.
It is similarly vital to ensure that civil society and affected communities are robustly represented and have voting seats on the new FIF’s governing board. Formally including civil society in global health governance has driven transformative innovation, cultivated constituencies that can effectively advocate for health investments, promoted accountability for results, and informed health investments with the lived experiences of communities most heavily affected. 
Despite the clear trend in the global health field toward meaningful inclusion of civil society in governance, the World Bank’s white paper envisions civil society solely as observers to the governing board, not voting members. The choice articulated in the Bank’s white paper between inclusion and efficiency is a false one. Both the Global Fund and Gavi – two large and enormously successful health programs – have managed to develop governance rules that enable timely and efficient decision-making while ensuring that communities affected by these decisions are part of the process.
The governance model of the Global Fund (that includes donor and implementing countries, civil society, affected communities and the private sector) must be used as a template for the new FIF. This would balance representation of donor and recipient governments, with broad representation of civil society and affected communities.
2. The new FIF should prioritize funding for existing global health initiatives that are already making clear contributions to PPR in low- and middle-income countries.
After the World Bank’s original white paper draft attracted considerable criticism for its limited spectrum of eligible funding recipients, the paper was amended to state that the Global Fund and Gavi would be eligible for FIF funding, contingent on obtaining a waiver. Far from being after-thoughts, the inclusion of these essential global health initiatives from the outset as eligible funding recipients leverages these initiatives’ concrete, substantive contributions to PPR and broader health systems strengthening. In the case of the Global Fund, for example, one-third of its investments support programs to strengthen health security.
Global Fund and Gavi are among institutions that should be foundational to pandemic preparedness and should not require a waiver or special review in order to play a central role in a pandemic fund.
3. Funding for the FIF must be new money and not borrow or detract funding from other global health and development initiatives.
The white paper pledges that the FIF will “add to, and not substitute for, existing” official development assistance (ODA). Although we appreciate this commitment, translating this aspiration into reality will demand far more international solidarity than what donor countries displayed during the COVID-19 pandemic, when global investments in vaccination, therapeutics, diagnostics and mitigation measures in low- and middle-income countries amounted to a mere fraction of what the global crisis warranted. Responding to one health priority by undercutting other priorities is not a sound global health strategy.
Supporters of the FIF must commit to increasing overall investments in health and ensure that PPR funding is additive, not replacement. A successful Global Fund replenishment now underway is a critical part of real pandemic preparedness, as a third of these resources go toward strengthening preparedness, and investments in the FIF must not detract from this essential goal.
There will never be genuine health security if we allow AIDS, TB and malaria to continue to kill millions per year.
Moreover, the FIF should mobilize new sources of donor funding so that it does not compete with current ODA investments. This commitment to additionality must be measurable, and be explicitly outlined in the FIF’s governance framework.
4. Effective PPR investments must prioritize strengthening essential health and community systems through existing mechanisms that are bolstering systems.
The way to ensure PPR tools and personnel are ready to respond quickly and effectively in a crisis is not to leave them “on the shelf” and separated from functioning health systems, but rather integrate them in health services. Therefore, a new FIF should not be limited to the functions in the International Health Regulations. It must also support the functions of health systems related to pandemic preparedness, including community health workers, primary care and community systems of delivery, surveillance and lab capacity alongside new technological solutions to effectively get ahead of emerging pandemics. To that end, new resources dedicated to strengthening health systems should flow through the existing systems already designed to support community-led work (Gavi, Global Fund, PEPFAR, UNAIDS, etc.) rather than duplicate these systems.
Thank you for your consideration of these points. We welcome a discussion with you about U.S. engagement in designing the FIF.
Elizabeth Glaser Pediatric AIDS Foundation
Friends of the Global Fight Against AIDS, Tuberculosis and Malara
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