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countries cannot redress the gaps, and momentum in national planning may stall or reverse. Resource-constrained countries are unlikely to finance their NAPHS fully from domestic resources alone. With US$ 75 billion available, the current IDA18 replenishment has met its target of supporting preparedness plans in 25 countries, yet most poor countries will not elect to use their finite IDA envelopes for preparedness given the trade-offs with other development priorities. Existing financing mechanisms are inadequate for prolonged outbreaks and would not suffice for a fast-moving global pandemic, particularly one involving a respiratory pathogen. WHO lacks the predictable, flexible and sustainable funding it needs to play its critical role in coordinating preparedness and response and supporting country health systems. Nearly 80% of the WHO budget is voluntary and highly earmarked, precluding holistic preparedness efforts and hindering WHO’s ability to provide a global safety net. Following its use in early response to the current outbreak of Ebola in eastern DRC, the CFE is now depleted (55). A review of the intended purpose and use of expenditure from the CFE, along with lessons for its maximum efficiency and focus, would be useful. To date, the PEF model is not working because of key design issues; notably its parametric criteria for the diseases covered were set too high for the release of the insurance mechanism (56,57). The World Bank is redesigning the PEF and expects a new model to be ready in mid-2020. This will need to allow greater flexibility and agility so that financing can be made available earlier in a broader range of outbreak situations. Although businesses rely on economic and social stability and have valuable systems, including logistics and supply chains, that could contribute to preparedness efforts, the private sector has not been sufficiently engaged. A multipronged effort is required to create an environment where policy-makers and communities demand the planning and resources necessary for effective preparedness. There is a lack of long-term, holistic, costed resource mobilization plans for supporting preparedness. Decision-makers must engage the private sector and create investment cases showing preparedness for health emergencies in health systems, human health, animal health, disaster management and the environment. Persistent challenges and obstacles Financing systems for preparedness are broken, particularly at the national level National action plans for health security lack domestic financing International financing to the poorest countries is insufficient, and available funds are not well utilized Insufficient rapid financing is available for preparedness and rapid response surge capacity WHO is underfunded The Pandemic Emergency Financing Facility is in need of reform Private-sector resources remain largely untapped Need for investment cases and building donor confidence PROGRESS, CHALLENGES, ACTIONS: FINANCING 23 Progress indicator(s) by September 2020 • The IMF and the World Bank integrate preparedness into their systematic country risk, policy and institutional assessments, including in Article IV staff reports and for IDA credits/cgrants/respectively. • International funding mechanisms expand their scope and envelopes to include health emergency preparedness, including the IDA19 replenishment, the Central Emergency Response Fund, Gavi, the Global Fund and others. Required actions Financing institutions must link preparedness with economic risk planning. To mitigate the severe economic impacts of a national, regional epidemic and/or a global pandemic, the IMF and the World Bank must urgently renew their efforts to integrate preparedness into economic risk and institutional assessments, such as the IMF’s next cycle of Article IV consultations with countries, and the World Bank’s next Systematic Country Diagnostics for IDA credits and grants. The funding replenishments of the IDA, Global Fund to Fight AIDS, TB and Malaria, and the Gavi Alliance should include explicit commitments regarding preparedness. 24 Development assistance funders must create incentives and increase funding for preparedness. Donors,