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preparedness, governments continue to neglect it. World Bank and WHO analyses indicate that most countries would need to spend on average between US$ 1-US$ 2 per person per year to reach an acceptable level of pandemic preparedness (44,45). Considering the benefits to economic growth (not counting the enormous cost to human life), investing in health systems to implement the IHR (2005) would yield a positive return on investment in all plausible scenarios (46). A yearly investment of US$ 1.9–3.4 billion to strengthen animal and human health systems would yield an estimated global public benefit of more than US$ 30 billion annually (47), a return on investment of 10 to 1 or higher (48). Preparedness capacities and systems are global public goods–all countries benefit from every country’s investment. Not investing is a high-risk gamble, given the potential economic and response costs. Financing 21 5 6 PROGRESS, CHALLENGES, ACTIONS: FINANCING Some countries and parts of the international community are increasingly recognizing preparedness capacity as a critical part of wider public health systems strengthening and the universal health coverage agenda (49). For example: Senegal created a budget line to support the operating costs of its emergency operations centre; and The Greater Mekong Sub-region Health Security Project began working with the governments of Cambodia, the Lao People’s Democratic Republic, Myanmar and Vietnam to improve preparedness for infectious diseases and other health threats. Regional initiatives have also increased funding for preparedness, including the following: - the Africa Centres for Disease Control and Prevention (US$ 35 million, 2017- 2018) developed a five-year strategic plan that provides the rationale for external funders to consider significant direct or parallel financial support; - the West Africa Regional Disease Surveillance Systems Enhancement Project (US$ 390.8 million, 2016-2018), is supporting 11 West African countries in increasing national, regional and cross-sectoral capacity for integrated disease surveillance and response; - the Indo-Pacific Health Security Initiative invested in product development partnerships to accelerate research on new drugs and diagnostics and applied health systems. Ten countries conducted cross-cutting mapping of NAPHS and other health plans and domestic and bilateral/multilateral aid flows, identifying synergies and funding: for example, in Sierra Leone, the exercise identified US$ 47.7 million across eight Ministries and external donors for two-year implementation of the NAPHS (50). International financial institutions have begun to prioritize preparedness: - WHO established the Contingency Fund for Emergencies (CFE) to respond immediately, within the critical first 24-48 hours, to a disease outbreak and humanitarian crises; since its launch in 2015; the CFE has enabled WHO to respond rapidly to 70 separate events in 48 countries (51); - the World Bank developed the Pandemic Emergency Financing Facility (PEF) to make pay-outs early during an outbreak cycle–before it becomes a pandemic–through two windows, insurance and cash; funding requests are assessed based on three criteria–pathogen type, epidemiological thresholds and a technical assessment (52); - the World Bank Group, including IDA, has taken steps to develop not only financing, but the political support and coordination needed to build clinical research capacity in developing countries as a crucial component of global epidemic preparedness (53). Progress to date PROGRESS, CHALLENGES, ACTIONS: FINANCING 22 More and better-targeted funding is required at all levels starting with national governments. Too many national leaders have not prioritized spending on health systems overall and on preparedness in particular. Preparedness investments is also poorly differentiated from other aspects of health system strengthening. Success in national preparedness rests upon the ability of countries to identify systems gaps, develop their plans and finance them. Despite significant progress in assessing deficiencies and developing plans, not a single NAPHS has been fully financed (54). Without domestic resources,