Keywords

FormalPara Learning Objectives

This chapter will help readers understand and describe:

  • The role of international financial institutions (IFIs) in financing preparedness and response for emerging infectious diseases

  • How IFIs can support emergency response research

  • How IFI initiatives complement other global efforts to strengthen disease surveillance and response systems

  • How IFIs effectively contribute to partnerships

  • How IFIs have used development lending to bolster core capacity of health systems and clinical research

  • Constraints faced by IFIs in financing clinical research

  • Examples of lessons learned in recent pandemics

  • The potential for IFIs to further improve investment in emergency research preparedness and response

1 Introduction: International Financial Institution Investments in Health Security

International financial institutions (IFIs) began to play an increasingly crucial role in health security financing after the 2014–2016 West Africa Ebola virus disease (EVD) epidemic. Since then, diverse actors in the global health field, including large foundations, regional players, and IFIs have increasingly assumed major roles in global health, health security, and integrating research into emergency response.

During and after the West Africa EVD outbreak, several commissions and task forces offered recommendations on how the global community could better prepare for crises. They included investing more in preparedness, leveraging new funding mechanisms for emergency response, such as an insurance model, and establishing a global research and development (R&D) facility to develop drugs for outbreaks (Gostin et al. 2016; GPMB 2019; Moon et al. 2015). In response, the international development community took several steps to strengthen the capacity to prevent, detect, and respond to outbreaks (GPMB 2019). They included establishing the World Health Emergencies (WHE) Programme and Contingency Fund for Emergencies (CFE) at the World Health Organization (WHO), the African Union’s Africa Centres for Disease Control and Prevention (Africa CDC), the African Risk Capacity (ARC) Group, and the Coalition for Epidemic Preparedness Initiatives (CEPI). These changes include initiatives by the World Bank Group and other IFIs to strengthen both preparedness and response aspects of health security (African Risk Capacity (ARC) Group 2022; CEPI 2020; Nkengasong et al. 2017; WHO 2017).

2 International Financial Institution Initiatives to Strengthen Emergency Response: Leveraging Insurance, Contingency Financing, and Institutional Changes

IFIs were heavily engaged in financing the emergency response to the EVD outbreak. For example, AfDB was among the first to support EVD-affected countries, with a grant of US$3 million in April 2014 and overall financing of US$223 million. During the epidemic, IFIs distributed over US$1 billion to affected countries for outbreak response (Office of the UN Special Envoy on Ebola 2016). The WBG provided US$518 million for immediate response and US$650 million in International Development Association (IDA) grants and loans (Reynolds 2015; World Bank 2019c). However, delays in detection of Ebola cases, resource mobilization, and financing hindered a swift and effective response.

Since then, there has been notable progress in creating new financing mechanisms, approaches, and funding commitments for response. These include the World Bank’s expansion of the eligibility criteria for its Crisis Response Window (CRW) and adoption and adaptation of the Contingent Emergency Response Component (CERC) and the Catastrophic Demand Drawdown Option (Cat-DDO), which permits access to funds within WBG-financed projects and budget support during crises, respectively.Footnote 1 Further, in 2016 the World Bank launched its Pandemic Emergency Financing Facility (PEF), in consultation with WHO and other partners, to rapidly finance surge response (World Bank 2019c). When the coronavirus disease 2019 (COVID-19) pandemic struck, several IFIs responded early and vigorously to support Ministries of Health (MoHs).

On March 17, 2020, the World Bank approved the COVID-19 Fast-Track Facility to help countries prevent, detect, and respond to the rapid viral spread of severe acute respiratory coronavirus-2 (SARS-CoV-2). On April 2, 2020, the World Bank approved the global COVID-19 Strategic Preparedness and Response Program, using the multi-programmatic approach (MPA) to provide up to US$6 billion for response from its International Bank for Reconstruction and Development (IBRD) and IDA funds to focus on the COVID-19 health response. Up to US$4.4 billion of these funds have been committed across all seven World Bank regions. In October 2020, additional financing of US$12 billion was approved for COVID-19 vaccine acquisition and deployment. As of January 17, 2022, the Bank had approved 83 operations totaling US$7.6 billion to support vaccine procurement and rollout in 69 countries.

Similarly, other IFIs provided crucial support for country response. For example, AfDB created a US$10.2 billion Crisis Response Facility (CRF) to provide a flexible range of support to African countries to help manage pandemic impacts (African Development Bank 2021). A US$3 billion “Fight COVID-19” social bond was successfully marketed to make resources available immediately. The Islamic Development Bank (IsDB) also approved five health-sector projects with an overall allocation of US$172.3 million in Benin, Chad, Côte d’Ivoire, Guinea, and Pakistan to help mitigate COVID-19. The Bank also contributed US$72.5 million toward the International Vaccine Access Center (IVAC) Covid-19 Vaccine Support for Pakistan (Islamic Development Bank 2021). In 2021, ADB committed US$4.9 billion through rapid-disbursing operations, including policy-based lending (US$4.6 billion) and the COVID-19 Pandemic Response Option (US$250 million), to help countries fight COVID-19 (ADB 2021). To address gaps in continuity of essential health services and enhance resilience to future pandemics, ADB provided US$1.3 billion for programs and projects supporting COVID-19 response in education, public health, and social protection (ADB 2021).

IFI financing during recent health emergencies, including COVID-19, has focused on curbing the impact of health crises while also leveraging response efforts and strengthening pandemic preparedness. Given the speed with which countries needed to mount a response and the long-standing fragility of many health systems, the focus was on supporting countries in delivering COVID-19 interventions.

3 Mobilizing International Financial Institution Investment to Bolster Preparedness

In 2016, the World Bank, in partnership with the Wellcome Trust, launched the International Working Group (IWG) for Financing Preparedness to recommend innovative measures for development partners and governments to finance preparedness (WBG 2017). To monitor the state of global preparedness, WHO and the World Bank also launched the Global Preparedness Monitoring Board (GPMB) in 2018 (GPMB 2021) (◘ Fig. 1).

Fig. 1
figure 1

The Money & Microbes report, supported and published by the World Bank, was an important step in recognition of the need for financing research as an integral element of infectious disease response. (International Vaccines Task Force 2018)

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IFIs are increasingly contributing to country preparedness. For example, World Bank-funded emergency response projects have often embedded health-system strengthening and preparedness activities together. Between 2020 and 2022, the World Bank committed more than US$15 billion in the health sector towards the Strategic Preparedness and Response Program (SPRP) using the multi-programmatic approach (MPA). Many of these COVID-19 health response operations also include a focus on longer-term prevention and preparedness (World Bank 2023). Even prior the COVID-19 pandemic, the World Bank committed an average of US$133 million per year to strengthen preparedness in the period from FY2015 to FY2019. During the COVID-19 pandemic (FY2020 to FY2022), the World Bank’s financing for preparedness increased more than six-fold, reaching US$882.2 million per fiscal year on average—representing an increase in commitment to support preparedness. Through their core funding mechanisms, IFIs have become the largest source of external financing for pandemic prevention, preparedness, and response (PPPR). For example, in Ghana, the US$35 million World Bank operation includes support for strengthening national laboratories to provide real-time disease surveillance and outbreak reporting systems.

Furthermore, multi-donor trust fund (MDTF) programs, such as the World Bank’s Health Emergency Preparedness and Response (HEPR) Umbrella Program, can serve as critical tools in the arsenal of IFIs for promoting PPR. The World Bank launched HEPR in 2021 to provide financing and technical assistance for pandemic preparedness in low-income countries with weak health emergency preparedness and response capabilities, including countries that are unable to access regular World Bank financing because they are in arrears with their payments to the IDA (World Bank 2021).

IFIs have also supported regional investments in preparedness, such as the East Africa Public Health Laboratory Network, the Southern Africa Tuberculosis Health Systems project, the Regional Disease Surveillance Systems Enhancement (REDISSE) Program, Africa CDC, and ADB’s Greater Mekong Sub-region Health Security project and Pacific Regional Systems Strengthening project.

3.1 Emergency Research for Emerging or Re-emerging Infectious Diseases (EIDs) Limited by Weak Country Research Capacity

Research is a crucial building block for emergency response. It spans epidemiological, virological, and disease course research on pathogens and the diseases they cause to development and assessment of medical countermeasures (MCMs). It includes fundamental research for development of diagnostics, vaccines, and therapeutics, and applied research, such as emergency response implementation research, evaluations, and social research. These research domains are critical to understanding and stopping epidemics (Hall et al. 2019).

The 2014–2016 Ebola epidemic in West Africa underscored the urgent need to strengthen the mobilization of rapid, robust research during epidemics and the importance of access to effective therapeutics, vaccines, and personal protective equipment (PPE) (NASEM 2017). Ebola had not been identified in West Africa previously, and reliable systems for sharing epidemiological, genomic, and clinical data were absent. Multiple analyses of the Ebola response highlighted the need to develop a framework of norms and rules for conducting research during epidemics, ensure equitable benefit, and develop a global R&D financing facility for drugs, diagnostics, and PPE.

Since then, some strengthening of epidemic response research has occurred. These include WHO’s R&D Blueprint, a global strategy that includes 10 prioritized EIDs, a roadmap of action, and a structure for coordinating research during emergencies. The R&D Blueprint was instrumental in supporting the deployment of rVSV-ZEBOV vaccine for Ebola, prioritization of R&D activities for Zika virus vector control interventions, and the use of GeneXpert to augment diagnostic capacity during the ninth and tenth EVD epidemics in the Democratic Republic of the Congo (DRC) (WHO 2019).

Another major milestone has been the launch of the Coalition for Epidemic Preparedness Innovations (CEPI)—a partnership of bilateral donors, philanthropy, civil organizations, and IFIs such as the World Bank—to stimulate, finance, and coordinate vaccine development against prioritized diseases with epidemic potential (► Chap. 13). CEPI was launched in January 2017, with US$500 million initial funding from the Bill and Melinda Gates Foundation, Wellcome Trust, Norway, Japan, and Germany (Hatchett and Lurie 2019; Leigh et al. 2018). CEPI raised US$800 million to invest in vaccine candidates for diseases like Lassa fever, Middle East respiratory syndrome (MERS), Nipah, chikungunya, and Rift valley fever.

Other R&D initiatives include the Global Research Collaboration for Infectious Diseases Research (GloPID-R), European and Developing Countries Clinical Trial Partnership (EDCTP), U.S. Biomedical Advanced Research and Development Authority (BARDA), U.S. National Institutes of Health (NIH) R&D investments, and several new networks for research collaboration (e.g., the Joint West Africa Research Group and the African Coalition for Epidemic Research, Response, and Training). Recently, the Global Virome Project was established to find and sequence viruses circulating in wildlife that could spill over to humans.

COVID-19 further underscores the importance of R&D and innovation as key enablers of response not only to the COVID-19 pandemic as such, but also to its health, economic, and social disruptions. Research has progressed during the pandemic at an unprecedented speed and scale, and gains in understanding the virus and developing and assessing countermeasures have been impressive. When the SARS-CoV-2 virus was identified in early 2020, researchers shared its entire genetic sequence online within 42 days. Rapid research and dissemination of results were vital to vaccine development. Research on related coronaviruses and mRNA vaccine platforms underway long before COVID-19 appeared was instrumental in speeding up trials and developing timely interventions (Bloom et al. 2021).

Vaccine development often takes many years, but during COVID-19 there were nearly 100 vaccines in development and eight in clinical trials within 6 months, with the first emergency use authorizations coming from the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) in December 2020. In the first weeks of the outbreak, WHO activated the R&D Blueprint and established the Solidarity international clinical trials aimed at rapidly assessing the relative effectiveness of COVID-19 treatments (WHO 2022b, c). As the need for strengthened international coordination of the COVID-19 R&D effort became evident, major global health organizations—WHO; CEPI; the Foundation for Innovative New Diagnostics, a global alliance for diagnostics; Gavi, the Vaccine Alliance; the Global Fund; Unitaid; the Wellcome Trust; and the World Bank—established the Access to COVID-19 Tools Accelerator (ACT-A) with additional support from governments, manufacturers, and other funders (WHO 2022a).

Despite such efforts to improve coordination of R&D during the pandemic, progress has still been ad hoc at best. GPMB reports in 2020 and 2021 have called on countries to invest in R&D, enable data sharing (especially genome sequences), and create an “end-to-end mechanism for research, development, and equitable access to common goods” (GPMB 2021). The momentum created by the pandemic is an opportunity to establish effective and sustainable mechanisms to support the R&D necessary to confront health emergencies.

3.2 The Market Is Failing to Support R&D for Emerging or Re-emerging Infectious Diseases

Without the prospect of profit, it is difficult to find private-sector partners to fund the research, including clinical trials, required for licensing vaccines, therapeutics, and diagnostics (VTDs) to fight epidemics (Leigh et al. 2018). Despite a large potential market, there is a market failure for pharmaceutical investment in innovation for EID VTD: the development process is risky; lengthy (typically up to 10 years); and costly (on the order of US$1 billion or more until licensure, with the success rate of interventions that enter trials historically less than 12% (NASEM 2017). Given profit maximization driving the private sector, investments in R&D tend to go to diseases with a high potential return on investment—often those prevalent in high-income countries (HICs), especially chronic diseases for which patients need to take medications over the long term.

This suggests that market mechanisms do not generate sufficient incentives for companies to invest in drug discovery or development for EIDs or diseases prevalent in low- and middle-income countries (LMICs). Despite the high social impact, vaccines and point-of-care diagnostics are also less profitable than drugs and laboratory assays, resulting in lower incentive to invest in R&D to prevent EIDs. As a result, few companies invest in emergency response research, particularly for VTD (Perkins et al. 2017). Reliable incentives are lacking for mechanisms that incentivize international collaboration to develop VTD outside of emergencies.

3.3 Rationale for Public Investment in Emergency Response Research

Given the high social impact, research on EIDs (including the development of VTD and research on delivery and acceptance of countermeasures) is considered a global public good (GPG). As a general rule, public goods are considered to be non-rival (one person’s consumption of the good does not diminish another person’s access to it) and non-excludable (a person must not be denied access to that good). While the knowledge generated by medical research could be considered a GPG, even access to that knowledge comes with a price and a delay (e.g., payment to a journal for access to an article that has taken time to write and review). GPGs are items available to all (air and water), abstractions like knowledge or human rights, or services like national defense or (in many developed countries) health care (Reiss 2021). In this context, actions aimed at improving health, including (1) knowledge generation, (2) fostering global health leadership and stewardship, and (3) activities controlling negative and regional externalities, such as pandemic preparedness, can be viewed as global public goods (McDade et al. 2019). While the rationale for public investment in emergency response research is strong, the results of that research, for example in the form of VTD, are often distributed based on ability to pay and thus not non-excludable and are in limited supply and thus not non-rivalrous (Lie and Miller 2020).

Gaps in health research capacity, VTD production, and distribution networks impact not only the availability of VTD to lower income countries, but they directly affect decision-making and may undermine public trust, both of which are integral to an effective emergency response. A lack of information and evidence during a health shock can generate misinformation, as with the promotion of hydroxychloroquine, an anti-malarial drug, for COVID-19 treatment without sound clinical evidence—the drug turned out be non-beneficial for COVID-19 and appeared to be associated with heart arrhythmias (Infante et al. 2021). Evidence-based decision-making is critical to public trust and hinges on well-designed research during emergencies, including biomedical and epidemiological research, data modeling, R&D, and clinical trials. In the aftermath of recent epidemics, including Ebola outbreaks in West Africa, DRC, and Uganda, Zika largely in South America, and of course during the COVID-19 pandemic, investment in emergency response research as a GPG has been recognized as essential to attain SDGs and health security (Lurie et al. 2021).

3.4 Research During Emergencies Requires Prior Investment in Research Systems

In addition to insufficiently focusing on R&D, several LMICs have weak research and regulatory systems. An analysis of global health security capacity in all countries found that 76% have limited capacity to test and approve new medical countermeasures (MCMs), and 50% and 80% have low capacity to acquire MCMs and to dispense MCMs during emergencies, respectively (GHS Index 2021).

Striking gaps in R&D investments and capacities persist between HICs and LMICS, which are more vulnerable to the threat of epidemics in part because of weaker health systems. Lack of adequate research infrastructure and equipment, coupled with limited research capacity, results in a significant research disparity. For example, less than 0.5% of global publications in health research comes from Africa. Analysis by WHO reveals that the number of research grants for health research in the United States in 2016 was 53,114, with only 450 and 122 for Africa and Southeast Asia, respectively (Ralaidovy et al. 2020).

Research is essential not only for developing VTD but also for understanding their effects, both desired and undesired, in diverse populations. In addition to fundamental research—required for pathogen detection, identification, and development of diagnostics, therapeutics, and vaccines—there is also a need to strengthen applied research capabilities. This includes implementation research, evaluation methods, and social research during emergencies to understand attitudes, barriers, and enablers for interventions. Research for understanding population differences and disparities in access to and demand for vaccines proved critical in the response to COVID-19. Research during COVID-19 also highlighted the issue of mistrust in governments and pharmaceutical companies, hindering the uptake of vaccines and leading to defiance of physical distancing guidelines and masking mandates. Research on new SARS-CoV-2 strains via genome sequencing also informed decisions on MCM composition and administration, on physical distancing, travel guidelines, and isolation periods for patients and community.

3.5 International Financial Institutions and Research Financing

While IFIs are among the largest multilateral funders of global health and GPGs (Sridhar et al. 2017), they were not established with research financing as a primary goal and have not been much involved in financing research until recently. Direct investments by IFIs are subject to demand generation by countries and regions, requiring high-level political commitment by the ministry of finance (MoF) and often the head of government. Strong advocacy has often been needed to ensure research investments are high on their agenda. Further, given the risks of MCM development, investing in research can have reputational risks for both governments and IFIs, which often raise funds on capital markets through issuance of bonds and from member states. Additionally, governance of research directly supported by IFIs (there are often no ethical review boards set up for IFIs) can be challenging as the IFIs would have to rely on national institutions.

While IFIs typically are not set up to directly fund R&D for EIDs, they still have a strong comparative advantage and role in supporting emergency response research (McDade et al. 2019). First, IFIs such as the World Bank are well placed to deliver on GPGs (Sridhar et al. 2017). With their strong convening power, IFIs can steer global and regional agendas by bringing donors together for consensus-building, harmonization of priorities, and resource mobilization. This includes regional data sharing, harmonization of regulatory processes, and investments in centers of excellence for cutting edge research.

Second, the comparative advantage of IFIs includes knowledge sharing and technical assistance for policy advice. For example, the World Bank in its role as a “knowledge bank” can strengthen knowledge generation and exchange to support emergency response research.

Third, IFIs have longstanding relationships with MoFs and other ministries, such as agriculture and education, which can strengthen cross-sectoral advocacy and collaboration for investments in emergency response research. IFIs can further make an investment case for preparedness for emergency response research.

Fourth, global public-private financing partnerships, such as the Global Fund and Gavi, and to some extent IFIs, can shape markets to incentivize research on MCMs for EIDs through advanced market commitments (AMC). For example, Gavi provided US$5 million to develop Ebola vaccines. During COVID-19, IFIs helped LMICs finance and distribute vaccines. The World Bank partnered with COVAX, the vaccine distribution arm of WHO’s COVID-19 response, and the African Union (through the Africa Vaccine Acquisition Task Team) to help countries purchase and deploy vaccines, thus helping shape the market for COVID-19 vaccines.

Fifth, IFIs have a strong comparative advantage in fund management, including trust funds, for major global private-public partnerships that invest in emergency response research. For example, the World Bank serves as the trustee for CEPI.

Finally, IFIs support emergency response research through their routine approach to lending for projects that strengthen research systems and policy lending that provides budgetary support to countries contingent on policy reforms. Transport and electricity are as necessary to clinical research efforts as experimental medicinal products (► Chap. 39).

Consequentially, although IFIs are not structured to finance research, there are innovative examples wherein IFIs financing can be leveraged to strengthen research capacity by integrating investments in research capabilities and research systems in projects. For example, for the COVID-19 multiprogrammatic approach (MPA), the template used by projects included components for monitoring and evaluation as well as learning agendas to support research on forecasting, social behaviors including compliance with and impact of social distancing measures under different contexts, etc. Furthermore, research requires not just direct research financing but also capabilities such as sequencing capacity, trained molecular biologists and scientists, quality laboratories, training in clinical trials and evaluations, strong public health institutions, knowledge exchange, regional hubs—all requiring long-term country investments that IFIs can support. The following section highlights some innovative examples wherein IFIs can be leveraged to promote investments in research capacity especially for health emergencies.

3.6 How International Financial Institutions Can Support Emergency Response Research: Examples from the World Bank

IFIs partner with major institutions to manage funds and can bring donors together to support R&D. As partners, IFIs can strengthen financial management, coordination, resource mobilization, and financing of emergency response research through multi-donor trust funds (MDTFs) and small trust funds, which provide targeted funding for World Bank (or other agency) implementation and supervision, and Financial Intermediary Fund (FIF) partnerships, which provide large-scale funding under independent governance (World Bank 2019a).

3.6.1 Convening Global Partnerships During Emergencies

IFIs, in their role as convenors, can advocate for investments in GPGs. For example, the World Bank co-convened the Access to COVID-19 Tools Accelerator (ACT-A)’s Health System Connector (HSC) as a time-limited global collaboration to accelerate the development, production, and equitable access to COVID-19 tests, treatments, and vaccines to expedite the end of the acute phase of the pandemic. ACT-A brought together diverse stakeholders, including multilateral institutions and IFIs, academic researchers, and the private sector to speed development and delivery of COVID-19 interventions.

3.6.2 Leveraging Trust Funds for R&D

IFIs can leverage trust funds to support research. For example, the International AIDS Vaccine Initiative (IAVI) was among the first product development partnerships for R&D. IAVI aimed to accelerate R&D for HIV vaccines while supporting affordability and access to data, and the World Bank supported IAVI in developing its investment case. The partnership with the World Bank enabled IAVI to facilitate a conference on R&D for global health research,Footnote 2 where participants shared lessons on vaccine development and galvanized efforts to mobilize private-sector financing for vaccine development for high-priority, epidemic-prone diseases (World Bank 2019b). Japanese government funding, coupled with management of internal and external expectations, helped minimize reputational risk: it had to be clear to stakeholders that supporting basic science research might or might not result in a viable vaccine, but would still yield significant knowledge.

IAVI provides a successful model of how IFI partnership and co-financing can help leverage small trust funds by reducing transactional costs for supervision, knowledge sharing, and financial management. This model can be replicated to improve cost effectiveness of other official development assistance (ODA) through small or multi-donor trust funds for emergency response research with reduced transactional costs.

It is important to recognize that successful development of COVID-19 vaccines in record time was largely possible because of decades of HIV research, vaccine development and clinical research capacity building. Investment in HIV research also informed strategies on how to reach the most impacted communities, with the most widely used guidance for community engagement, Good Participatory Practice, growing out of HIV/AIDS research (UNAIDS and AVAC 2007; UNAIDS and WHO 2021).

3.6.3 Multi-Donor Trust Funds Strengthening Research Systems

Multi-donor trust funds (MDTF) focused on pandemic preparedness and response (PPR) can also strengthen research systems. For example, the Health Emergency Preparedness and Response (HEPR) Multi-Donor Fund, supported by Japan, Australia, and Germany, brings together different sectors to support preparedness activities in the health sector (e.g., expanding surveillance efforts, training health and laboratory staff, developing contingency plans, and strengthening laboratory networks) and preparedness support activities in other sectors (World Bank 2022a). HEPR has strengthened research systems in several countries and regions, including Africa. For example, it is advancing Africa’s genomics surveillance network, coordinated by Africa CDC, through grant support for the Centre for Epidemic Response and Innovation in South Africa and the African Centre of Excellence for Genomics of Infectious Disease (ACEGID) (World Bank 2022a). In Zimbabwe and São Tomé and Príncipe, the HEPR Umbrella Program is supporting training of laboratory technicians, availability of climate-friendly cold chain equipment, and installation and maintenance of solar systems in health facilities—all activities that also support a broader research system (World Bank 2022a).

3.7 Leveraging Routine Lending to Accelerate Research

IFIs can use routine development assistance lending to build core country capacities for prevention, detection, and response as well as research on outbreaks. Mobilizing rapid, robust research during outbreaks depends on investments during non-crisis periods. However, there continue to be major gaps even in funding core capacities required of all countries under the International Health Regulations (2005), which are less demanding than research capacity requirements (WHO 2016). IFIs can also use development lending to accelerate innovation of infectious disease VTD when countries prioritize commitment to research.

3.7.1 Financing Research on Emerging or Re-emerging Infectious Diseases by Strengthening Public Health

The following six major capacity challenges hindered research during the West Africa EVD epidemic

  1. 1.

    Lack of clinical experience with Ebola

  2. 2.

    Poor surveillance and laboratory capacity

  3. 3.

    Deficiency of crucial health system infrastructure and health care workers

  4. 4.

    Small pool of clinical research experts and very limited prior experience in the conduct of clinical research

  5. 5.

    Ethics review boards lacking the resources, experience, and information management systems needed to evaluate an unprecedented number of clinical research proposals

  6. 6.

    Lack of experience and expertise on complex legal and bureaucratic steps in clinical trial conduct, e.g., contract negotiations (NASEM 2017)

Multiple studies have emphasized the importance of knowledge sharing, specimen transport, infrastructure (e.g., cold chain), a functional health care system, and a qualified health and epidemiology workforce as cornerstones for accelerating response research and clinical trials (Hatchett and Lurie 2019; NASEM 2019). For example, the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE) faced grave challenges, including a lack of −80 °C freezers, cold chain, basic equipment (e.g., centrifuges), Good Clinical Practice (GCP) training, and laboratories in smaller towns (Widdowson et al. 2016). A lack of laboratory infrastructure also undermined initial clinical trials in Liberia by fueling mistrust when investigational Ebola virus vaccines had to be stored in the U.S. Embassy in Monrovia due to lack of cold storage capacity elsewhere (NASEM 2017). Strengthening research capacity for epidemic threats cuts across many aspects of preparedness and requires a legal framework, strong country and regional systems for scientific, ethical, and regulatory review, good laboratories, human resources, and equipment.

The development of sustainable disease surveillance and response capacities during inter-epidemic periods is essential for countries to conduct foundational research and prepare for future threats. IFIs can provide financing to build core capacity for health-system research, including surveillance, diagnostic capacity, rehabilitation of facilities, laboratory equipment for clinical and epidemiological research, and research supplies. The World Bank finances multiple regional and country projects to

  • Strengthen regional and country assets and infrastructure by improving surveillance systems, laboratory networks, and regional biobanks.

  • Strengthen regional and national institutions for project management and public-health research.

  • Improve capacity building through interdisciplinary training opportunities, such as field epidemiology training programs (FETP).

  • Foster knowledge sharing between countries.

World Bank lending projects that have strengthened key elements of emergency response research include:

3.7.2 The East Africa Public Health Laboratory Network

The East Africa Public Health Laboratory Network shows how an IFI-funded project on laboratory strengthening for tuberculosis can support overall research systems strengthening and anti-microbial resistance (AMR) surveillance. Launched in 2010, the US$129 million project established a network of efficient, high-quality, accessible public-health laboratories in Burundi, Kenya, Rwanda, Tanzania, and Uganda (World Bank 2017). The project has helped 32 laboratories become centers of excellence and increased access to laboratories for poor and vulnerable populations. The project strengthened diagnostic and surveillance capacity, laboratory worker training, and operational research. These included multi-country research on patterns of drug resistance to newly prescribed antibiotics, renovation and construction of laboratories, roll-out of molecular technology for multi-drug resistant tuberculosis (MDR-TB), financing to support certification of the Uganda National TB Reference Lab as a WHO supranational reference lab, training over 10,000 health personnel, strengthening cross-border disease surveillance, and emergency response gap analysis, which enabled swift response to Marburg and EVD outbreaks.

3.7.3 The Southern Africa Tuberculosis Health Systems Support Project

The Southern Africa Tuberculosis Health Systems Support (SATBHSS) project was conceptualized as a disease-specific projectFootnote 3 to address tuberculosis (TB), including antimicrobial resistant or multi-drug resistant TB [AMR or MDR-TB]), as well as TB/HIV coinfection, in Southern Africa. SATBHSS also supports investments in health systems, strengthening disease surveillance, response to infectious disease outbreaks in cross-border areas, and occupational health interventions in the mining and labor sectors. MDR-TB is one of the world’s biggest AMR challenges, and the project systematically supports coordinated regional investment to control MDR-TB. The project also supports pilot programs for health care worker screening and strengthening laboratories. SATBHSS has also coordinated simulations for EVD preparedness and response, which helped contain a 2018 cholera outbreak in six Southern Africa Development Community countries. The project has supported key innovations in TB care and control and proven to be a valuable resource for countries in responding to public health threats (◘ Fig. 2).

Fig. 2
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Southern Africa TB and Health Systems Support Project summary. (SATBHSS Project Brochure 2021)

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3.7.4 The Regional Disease Surveillance Systems Enhancement Program

The Regional Disease Surveillance Systems Enhancement (REDISSE) program is a series of projects established after the 2014–2016 West Africa Ebola outbreak to address systemic weaknesses in national and regional capacity for disease surveillance and response. Developed jointly by the Health, Nutrition, and Population and Agriculture Global Practices of the World Bank, REDISSE is a flagship regional One Health program focusing on the human-animal-environment interface where many novel diseases arise (► Chap. 10). REDISSE supports 16 countries in West Africa, the West African Health Organization (WAHO), and the Economic Community of Central African States, and has helped establish regional and multisectoral partnerships to

  1. 1.

    Promote collaboration.

  2. 2.

    Reduce the economic burden caused by epidemics.

  3. 3.

    Extend efficiency gains through resource sharing.

  4. 4.

    Bolster health security as a global public good.

  5. 5.

    Address common research needs.

  6. 6.

    Improve rapid response.

3.7.5 The Africa CDC Project

The Africa CDC project strengthened the all-Africa CDC and public-health assets in Ethiopia and Zambia. The project supports transnational surveillance networks, emergency-response mechanisms, training for laboratory workers and field epidemiologists, equipment maintenance, and other health functions to manage epidemic risks across the continent, including sentinel and reference laboratories in Ethiopia and Zambia which can be utilized regionally. Reference laboratories, including bio-safety level (BSL) 2+ laboratories, are crucial for emergency research on pathogens that pose risks to laboratory personnel and surrounding communities. In many countries, lack of adequate BSL-2 and BSL-3 laboratories limits research on such pathogens, or samples may be handled with limited biosecurity measures, posing a risk to workers and communities. Establishment of regional facilities will facilitate research, buttress biosafety, and speed detection of outbreaks. Support of institutions such as Africa CDC can facilitate IFI financing for development of broad capacities and policies for research, such as continent-wide material transfer agreements (MTAs) for expedited sample identification and sequencing, development of research priorities, etc.

3.8 Financing Academic Capacity Building for Research

Lack of research capacity, including high-quality laboratories, is among the most critical challenges to emergency response research. Investments by IFIs in programs such as REDISSE are strengthening regional knowledge exchange and capacity building and enhancing country capacity to conduct health research. Among the needs is training in budget management, grant acquisition, and procurement to make capacity sustainable. Sustainable research capacity also requires strong scientific talent, high-quality universities, and career paths for researchers. Despite being hotspots for emerging epidemics, Southeast Asia and Africa have proportionately very low levels of health research. For example, Africa represents 15% of the global population and 25% of global disease burden but only 2% of global research output and 0.1% of patents (Lan et al. 2014; Schemm 2013; Simpkin et al. 2019). As highlighted by severe acute respiratory syndrome coronavirus (SARS-CoV), Ebola virus, and SARS-CoV-2, strengthening international collaboration between universities can facilitate the development of diagnostics and MCMs during epidemics.Footnote 4 Private-sector collaboration with universities also increases the propensity of firms to introduce new products (Marotta et al. 2007).

IFIs have been able to provide development financing for strengthening academic research, research partnerships, and innovation. The African Higher Education Centers of Excellence (ACE) Program provides financing to strengthen the quality of post-graduate education and build collaborative research capacity across Africa (ACE 2022). Under ACE, IFIs have encouraged regional specialization, so participating universities can deliver better specialized training and research support. Subject areas have been selected through a competitive process in key priority disciplines, including health.Footnote 5 These centers address development challenges in infectious disease management, public health, and drug development by providing postgraduate training and research experience in molecular biology, analytical epidemiology, traditional medicine, and pharma-biotechnology. They also provide a regional platform for innovative drug development, including exploring the use of traditional medicine, and support equitable access to medications and diagnostics in the region. Since 2014, ACE Health Centers have been leaders in applied research, with the Africa Center for Infectious Genomics and Diseases (ACEGID) playing a central role in the 2014 Ebola response by leading the diagnostics and testing of the first Ebola sample collected in Lagos, Nigeria, and more recently the first genomic sequencing of SARS-CoV-2 in Africa.

The ACE project has led to international accreditation of several health-related programs, increased enrollment in health postgraduate programs across Africa, and several memoranda of understanding (MoUs) on research and training collaborations between ACE centers and other regional and international universities and research institutions.

3.9 Lending for Innovation, and R&D for Public Health

IFIs support emergency response research by leveraging development financing for co-financing innovative R&D for MCMs in LMICs. The pharmaceutical sector is critical in R&D for EIDs. However, market failures and the long-standing disconnect between R&D investments and needs in LMICs result in limited research on public-health priorities for LMICs, particularly on neglected tropical diseases and emerging infectious diseases, though there have been several recent partnerships established to remedy the situation (Chatelain and Ioset 2011; Ioset and Chang 2011; Sunyoto 2020). A mix of regulatory and financial barriers to commercialization, lack of capacity for product design and clinical trials, weak intellectual property rights, lack of basic infrastructure, and a shortage of experienced researchers disincentivize private-sector investment in R&D in LMICs. Despite growing capacity for Phase III clinical trials, the production and manufacturing phase of the value chain also remains weak (Simpkin et al. 2019). These inequalities are reflected in the mismatch of R&D outputs with needs. For example, between 1975 and 1999, just over 1% of the 1393 new chemical entities marketed by the pharmaceutical industry were for use in tropical diseases and TB, despite these diseases accounting for 12% of the global disease burden (Torreele et al. 2004; Trouiller et al. 2002). Incentivizing investment in R&D through collaborative financing mechanisms is crucial to stimulate research capacity and future research output in LMICs.

An example is the World Bank’s Innovate in India for Inclusiveness project, a US$250 million project established in 2017 and co-financed by the World Bank and government of India (World Bank 2022b). The project helped unlock India’s potential for R&D by facilitating innovation in biopharmaceutical products and medical devices to address India’s public-health priorities. India has displayed immense growth and capacity for manufacturing generic drugs and vaccines, but research on diseases that largely affect people with lower incomes remains limited. Innovate in India for Inclusiveness was established to promote innovative, early development of biopharmaceuticals and medical devices to address India’s public health priorities according to disease burden rather than commercialization potential. The project targets critical gaps in infrastructure, human capital and skills, and technology transfer with the goal of strengthening the pilot-to-market innovation ecosystem. Grant funding is provided to support centers of excellence for validation, early-stage bio-manufacturing, clinical development, training, and technology transfer. Grantees are selected from among top institutions in both the public and private sectors, those that already have a successful track record in the biotechnology space but may lack specific capabilities to enable faster, lower-cost validation through preclinical and clinical development and early-stage manufacturing. It provides grant funding to consortia of private, public, and academic institutions to accelerate development of low-cost vaccines, biopharmaceuticals, diagnostics and medical devices targeted to public health priorities in India (World Bank 2018).

By extending financing to consortia, the project seeks to foster a more collaborative R&D environment and link micro, small, and medium enterprises with larger companies. By engaging vaccine development ethicists from its early stages, the project has minimized reputational risks associated with clinical trial failures. Further, a partnership with NIH has facilitated capacity building for clinical trials and a collaborative environment for R&D investment in India. Two COVID-19 vaccines supported by the project during Phase I/II clinical trials received emergency authorization in 2021 (World Bank 2022b). The project has surpassed its goal of creating a more robust pipeline for affordable products and spurred greater public-private collaboration for research, and is also supporting development of vaccines for other diseases including influenza, dengue, chikungunya, and cholera (Swarup et al. 2019).

3.10 The World Bank’s Comparative Advantage in Financial Management

IFIs often partner with other parts of the international community to support large initiatives that are not sufficiently supported by existing funds or mechanisms. Apart from MDTF or single-donor trust funds, IFIs can use their financial and administrative management advantage with financial intermediary funds (FIFs). These are independently governed financial partnership platforms that fund projects implemented by multiple entities, such as other multilateral banks or UN agencies. In FIFs, the World Bank acts as a limited trustee, providing well-established financial, investment management, and accounting platforms, along with specialized legal and treasury services (WBG 2019). In some instances, the Bank also acts as the secretariat or serves as an implementing entity for FIF. While their governance structures vary, all FIFs have external governing bodies responsible for funding decisions. FIFs can incorporate innovative financing and governance arrangements and flexible designs, allowing funds to come through multiple channels and from the private sector, bilateral donors, and foundations (WBG 2014).

Examples of such partnerships include the Onchocerciasis Control Program, which was the first FIF-type partnership, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, CEPI, and PEF. At the end of the financial year 2018 (FY18), there were 27 FIF-type partnerships in operation with cumulative funding of US$97.4 billion. These FIF partnerships transferred US$6.7 billion for development projects in FY2018 (WBG 2019).

FIFs particularly add value when a global call for collective action for GPGs requires long-term, large-scale funding, closely coordinated decision-making, and joint implementation across several multilateral organizations. FIF partnerships allow the World Bank to use its advantage in financial services, including receiving, holding, and investing funds; transferring funds as directed by the FIF governing body; and providing treasury management. Beyond its trustee role, the World Bank can provide secretariat services, donate to a FIF, provide advisory support, or serve as an implementing entity for FIF funds. Engagement of the World Bank in such partnerships raises their profile, ensures due diligence, and increases trust by donors, which helps mobilize resources. Partnership with the World Bank also reduces transactional costs for holding, investing, and disbursing funds.

As a partner, the World Bank has leveraged several of the following FIF-type partnerships (◘ Table 1) that have facilitated research or shaped markets to advance research.

Table 1 Examples of Financial Intermediary Fund-type partnerships. In the latter half of 2022, the World Bank launched the Financial Intermediary Fund for Pandemic Prevention, Preparedness, and Response to improve preparedness and response for future pandemics (WBG 2022) (authors)
Full size table

3.10.1 Coalition for Epidemic Preparedness Innovations (CEPI)

The World Bank helped launch CEPI and facilitate resource mobilization for vaccine development to combat emerging infectious disease, including identified pathogens with pandemic potential and the unknown pathogen X—of which the first turned out to be SARS-CoV-2. The Bank also serves as a trustee for CEPI. CEPI’s goal is to move new vaccines through late pre-clinical studies to proof of concept and safety in humans before epidemics happen or very rapidly after they are identified. Its current aspiration is to develop and assess vaccines for initial use within 100 days after a new pathogen is sequenced (Pandemic Preparedness Partnership 2021).

CEPI also supports vaccine platforms that can be readily adapted and deployed against known and unknown pathogens. As a trustee, the World Bank manages contributions, investments, cash transfers, accounting, and financial reporting. When CEPI was in its start-up phase, partnership with the World Bank facilitated swift resource mobilization, so that CEPI had already raised US$800 million of its US$1 billion target before COVID-19 struck, enabling it to invest in vaccine candidates for Lassa fever, MERS, Nipah, and more recently chikungunya, Rift Valley fever, and COVID-19.

3.10.2 Gavi, the Vaccine Alliance

The World Bank’s partnership in FIFs for the International Finance Facility for Immunization (IFFIm) and Advance Market Commitments (AMC) enabled the establishment of Gavi as the largest contributor to childhood immunization in lower-income countries, and now as an important actor in emergency response. IFFIm, the frontloading mechanism that supports Gavi, has received over US$6.3 billion in pledges from nine donors over a period of 23 years. These commitments were used to issue vaccine bonds in capital markets, which helped raise US$4.5 billion from investors to provide Gavi with greater flexibility beyond donor funding. The AMC partnership helps accelerate the global rollout of vaccines against pneumococcal diseases, a leading cause of child mortality in 60 of the poorest countries. AMC financial commitments provide vaccine manufacturers with incentives to invest in vaccine research and expand manufacturing capacity for affordable vaccines. Donors commit funds to guarantee a low price for vaccines to qualifying countries. The World Bank assumed financial risk for AMC and reputational risk for both AMC and IFFIm.

Gavi has played a key role in advancing emergency response research though its efforts in market shaping, surge response, and implementation research (Gavi 2019; Malhame et al. 2019). For example, Gavi supports diagnostic development for yellow fever through provision of market pull incentives for test kits and maintains diagnostics stockpiles for yellow fever, meningitis, and cholera (Johnson 2018; Zerhouni 2019). In 2016, with a global shortage of yellow fever vaccine, Gavi and WHO pioneered fractional dosing of yellow fever vaccine.Footnote 6 Further, Gavi provided US$5 million in AMC to the private sector for the development of the first licensed Ebola vaccine (rVSV-ZEBOV), which was used during the 2018–2020 Ebola epidemic in DRC (Oroxom and Glassman 2019; Schnabel and Glassman 2019). Gavi also supports malaria vaccine development and implementation research on MCM delivery.

3.10.3 The Global Fund to Fight AIDS, Tuberculosis, and Malaria

The Global Fund to Fight AIDS, Tuberculosis, and Malaria is an innovative financing partnership among governments, the private sector, civil society, and communities that provides funding for programs to prevent and treat people with HIV/AIDS, tuberculosis, and malaria. The Global Fund is funded by 55 donor countries, the Bill & Melinda Gates Foundation, European Commission, UN Foundation, WHO, and the private sector. The World Bank serves as its trustee and is a non-voting ex-officio member of its Board. The Global Fund raises and invests nearly US$4 billion annually in its 3-year replenishment cycles to support its programs, including emergency response research, by providing catalytic investments for facilitating market entry of new MCMs through a revolving fund that makes advanced commitments to manufacturers to reduce market entry risk (Global Fund 2019).

4 Lessons Learned

4.1 Develop Emergency Research Capacity in Synergy with Capacity for Ongoing Health Research

Building research capacity is an essential component of preparedness. Clinical research (particularly during epidemics) requires strong laboratory infrastructure and systems, human resources, information technology, project and financial management, bio-banking, and ethical review board and regulatory capacity (Gostin et al. 2016; Moon et al. 2015; World Bank 2018). To maximize the impact of emergency research, International Health Regulations (IHR)-required capacities must be strengthened in LMICs, which are often most vulnerable to epidemics. Unfortunately, many LMICs lack adequately trained workforces, laboratory facilities and research infrastructure, and regulatory and ethical review capacities. Strong laboratory systems assist in detection and contribute to critical research, and investments in human resources (including field epidemiology training) support local capacity building for epidemiological research (Beyeler et al. 2019; Carpenter and Bhadelia 2019). Limited access to public health infrastructure and facilities, such as laboratories, research institutions, and advanced training, poses a critical challenge to emergency research and requires upfront investments. By investing in core IHR capacities and disease surveillance and detection systems during non-crisis periods, IFIs can strengthen surge capacity for emergency research response. IFI investments in laboratories and human resources can be optimized for research by integrating applied and clinical research training with field epidemiology training, by conducting clinical research on locally endemic diseases when there is not an outbreak emergency, and by bringing laboratories into the research endeavor. A service model with the private sector can also be explored where laboratories have partnership with the pharmaceutical sector for conducting clinical trials.

4.2 Promote Research Collaboration Among Countries and Stakeholders

Lack of coordination and formal governance, absence of priority setting, insufficient information sharing, and transparency issues are major challenges that can hinder resource mobilization and implementation of emergency response research (Beyeler et al. 2019). Despite new initiatives, resources for research remain fragmented, and there is information asymmetry and insufficient transparency on sources of funding and results of clinical trials, which can lead to duplication of efforts. In such scenarios, the World Bank (or other IFIs) are strategically well placed to bring together countries, regional partners, and developmental partners and use its consensus-building processes and coordination and advocacy functions to enable prioritization and resource mobilization for research. IFIs also typically have fewer challenges working regionally than bilateral players and demonstrate greater legitimacy to ensure trust for resource mobilization.

4.3 Countries Can Leverage International Financial Institution Financing for Research by Ensuring Demand for Investment in Research Is Voiced at the Highest Levels of Government

Policy commitments to preparedness, including research, facilitate emergency response and require advocacy and macroeconomic justifications at the highest levels. Through regular efforts to make the investment case with country leadership, it is possible to ensure research financing is prioritized in the national agenda and subsequently in IFI financed projects. The World Bank’s internal processes of Country Policy Institutional Assessment, Systematic Country Diagnosis, and Country Partnership Framework can also be used to encourage such investments. Mainstreaming the importance of research, innovation, and PPR into these country-specific processes can help make research funding a greater priority and generate demand for research investment to unlock financing for research. In addition to IFI investment projects, countries can also request financing from the Pandemic Fund to strengthen investments in surveillance, laboratory systems, human resources—all of which strengthen research systems as well.

4.4 Provide Incentives for Investing in Preparedness and Regional Collaboration

The World Bank’s Regional Program for the International Development Association (IDA) provides regional funds along with country IDA allocations for projects that meet regional criteria.Footnote 7 Incentives to countries for using IFI financing or domestic financing for regional approaches to health security and research, such as via matching funds or schemes like the Regional Program for IDA, can facilitate establishment of regional assets and promote cross-border collaboration essential to EID research in emergencies. Further, regional partnerships and programs can enable efficiency gains in research through sharing assets.

4.5 Include Research-Related Indicators in Monitoring and Evaluation

Tracking progress in R&D at a global systems level and project level can guide efforts to strengthen emergency response research. The Global Preparedness Monitoring Board (GPMB), established jointly by the World Bank and WHO, regularly monitors system-wide progress on research and development for EIDs, thereby ensuring accountability. Including research-specific indicators in development projects that report detailed results more systematically helps to ensure research needs are prioritized in preparedness projects. Without such research-linked indicators, investments in research capacity are not likely to meet emergency needs.

4.6 Share Information and Investment Plans Between Epidemics

Preparedness for emergencies can become more robust with planning; pre-approved clinical trial designs; prepositioned MTAs, ethical review protocols and procedures; and regional platforms for vaccine research (Gobat et al. 2019; Gostin et al. 2016). An example is the regional Partnership for Research on Ebola Vaccines in Liberia (PREVAIL), which was set up for ZMapp and vaccine trials during the West Africa Ebola epidemic and enabled swift trials (Kennedy et al. 2016). Similarly, swiftly sharing information stimulates collaboration and implementation of emergency response research, as was seen during the COVID-19 outbreak, where sharing of the genomic sequence and open-access publication of research findings were instrumental in the development of diagnostic tests, vaccines, and therapeutics.

4.7 Develop Additional Incentives to Encourage Investment in R&D

Accelerating development of MCMs, especially in LMICs, requires technical and financial support to successfully navigate the development process and clinical trials. Engagement with the pharmaceutical industry and institutions such as U.S. National Institutes of Health (NIH) can improve sustainability of initiatives and provide technical support needed to stimulate R&D for MCMs.

IFIs can help mobilize investments in clinical research by incorporating components and indicators for research into development assistance lending operations and health security investments. Research-sensitive investments in preparedness that both bolster research systems and regional research networking (including in countries experiencing fragility, conflict, and violence) and favor regional and country-level investments in clinical research for MCMs can stimulate emergency response research. Greater investments in regional institutions, such as West African Health Organization (WAHO) and Africa CDC, would build the capacity of the research institutions to be competitive for research financing.

The IAVI project provides a successful model in which IFI partnership and co-financing can help leverage small trust funds by reducing transactional costs for supervision, knowledge sharing, and financial management. This model can be replicated to enable utilization of other Official Development Assistance (ODA) through small trust funds or MDTF for emergency response research with reduced transactional costs. The World Bank’s HEPR Program and the new FIF for PPR can also be leveraged to strengthen research systems and provide catalytic investments for generating demand for greater investment in research. A trust fund can facilitate consultations and country mechanisms to strengthen prioritization and resource alignment for research, provide technical assistance to invest in research for PPR, and subsidize country investments in research through concessional financing and buy-downs.

World Bank innovative financing mechanisms and FIFs (including CEPI) can be used to stimulate R&D, enable tech transfer, and build capacity. These FIFs can be leveraged to finance clinical trials and scale up MCM production during emergencies (Yamey et al. 2020). Use of FIFs to finance R&D would mitigate fragmentation of resources and improve reaction time, reduce transaction costs, and speed resource mobilization for research during emergencies.

Discussion Questions

  1. 1.

    Discuss the IFI role in financing preparedness and response for EIDs and how IFIs can more effectively contribute.

  2. 2.

    IFIs are not traditionally purpose-built to finance research but have a strong comparative advantage in strengthening systems and coordinating research. Provide examples from the World Bank of how IFIs can support emergency response research.

  3. 3.

    The development of sustainable disease surveillance and response capacities during inter-epidemic periods is essential for countries to conduct ongoing research and prepare for future threats. How do IFI initiatives complement other global efforts to strengthen disease surveillance and response systems?

  4. 4.

    IFIs often partner with other organizations to respond to pressing needs that are not sufficiently addressed by existing funds or mechanisms. What are IFIs especially good at contributing to such partnerships or consortia?

  5. 5.

    How have IFIs used development lending to bolster core capacity at the intersection of health systems and clinical research? How does this contribute to research during emergencies?

  6. 6.

    What are some constraints faced by IFIs in financing clinical research?

  7. 7.

    Briefly list and discuss some lessons we have learned in recent outbreaks and pandemics. In light of this experience, what opportunities can you identify for IFIs to improve their investments in emergency research preparedness and response?