Putting Pandemics Behind Us Investing in One Health to Reduce Risks of Emerging Infectious Diseases © 2022 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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Table of Contents Preface................................................................................................................. 3 Abbreviations and acronyms........................................................................... 5 Glossary............................................................................................................... 6 Putting Pandemics Executive summary........................................................................................... 9 Behind Us Introduction...................................................................................................... 13 Investing in One Health to Reduce Risks of Emerging Addressing pandemic risk at the source......................................................17 Infectious Diseases 1. A cautionary tale—the story of Nipah virus disease....................................... 17 2. Understanding the drivers of spillover to reduce pandemic risk...............18 October, 2022 3. One Health as a necessary foundation of pandemic prevention..............20 Guiding investments towards prevention of pandemics........................24 1. Adopting One Health.................................................................................................24 2. Shifting to pandemic prevention...........................................................................26 3. Complying with countries’ obligations and minimum standards............. 27 4. Focusing on hotspots.................................................................................................29 5. De-risking farms, forests, and urban sprawl.....................................................30 Overcoming the lack of incentives to invest in prevention.....................33 1. Removing the obstacles to prevention............................................................... 33 2. Financing prevention as a shared responsibility............................................ 36 3. Ensuring country ownerships and enabling institutional arrangements.....38 Moving forward............................................................................................... 43 References........................................................................................................ 45 One Health is an investment in humanity’s future. Page 1 ACKNOWLEDGEMENTS This report was written by a World Bank team co-led by Sulzhan Bali, Garo Batmanian and Franck Berthe, with contributions from Juan David Alduncin, Lucia Patricia Avila Bedregal, Marco Boggero, Luis Constantino, Felipe F. Dizon, Luis Diego Herrera Garcia, Kenan Karakulah, Catherine Machalaba, Simmy Martin Jain, Lisa Li Xi Lau, Samantha Elizabeth Power, Gayatri Rao Sanku, Geeta Sethi, Sarah Louise Shanks, Hina Khan Sherwani, Shweta Sinha, Yurie Tanimichi Hoberg, Eva Teekens, Aditya Babu Upadhyaula, Alex Vaval Pierre Charles, and Leonardo Viotti. The team benefited from regular interactions with the One Health extended team of the World Bank including Mark E. Cackler, Ana Cristina Canales Gomez, Claire Chase, Gina Cosentino, Stephen Geoffrey Dorey, Sambe Duale, Lisa Farroway, Pierre Gerber, Artavazd Hakobyan, Hikuepi Katjiuongua, Anna Elisabeth Larsen, Sitaramachandra Machiraju, Daniel Mira-Salama, Tamer Samah Rabie, Yoshini Naomi Rupasinghe, Tahira Syed, Dipti Thapa, Mariela Huelden Varas, and Shiyong Wang. The team is grateful for the peer review provided by Priya Basu, Richard Damania, Benoit Bosquet, and Magnus Lindelow. The team is also grateful for the guidance and advice of the External Advisory Panel: Bernice Dahn (former Minister of Health, Republic of Liberia), Victor Dzau (President, National Academy of Medicine), Catherine Geslain-Laneelle (Director, Council of the European Union), Amanda Glassman (Vice-President, Center for Global Development), and Cecilia Mundaca Shah (Director, Global Health, United Nations Foundation). The authors received helpful advice and comments from Gaël Giraud (Georgetown university), William B. Karesh, Noam Ross and Emma Mendelsohn (EcoHealth Alliance), Ben Oppenheim (Metabiota) and Richard Seifman. In addition, the team is greatly indebted to colleagues from the Quadripartite alliance, Emily Tagliaro and Chadia Wannous (World Organisation for Animal Health), Katrin Taylor and Katinka DeBalogh (Food and Agriculture Organization of the UN), Margarita Meldon (United Nations Environment Programme) as well as Leen Meulenbergs and Stephane de la Rocque (World Health Organization) for their advice and helpful comments during this research. Martien van Nieuwkoop and Juergen Voegele provided strategic guidance and substantive input throughout the preparation of the report, with support from Geeta Sethi, Mark E. Cackler, William Sutton, and Julian Lampietti. Finally, Venkatakrishnan Ramachandran, Pawan Sachdeva, Michelle Rebosio, and Beaulah Noble provided impeccable administrative support for which the team is grateful. The report was funded by the Federal Ministry for Economic Cooperation and Development (BMZ, Germany) as part of the World Bank’s FoodSystems2030 Trust Fund program on One Health. The authors thank Karen Schneider for editing and Jay Groff for publication layout and design. They provided invaluable support for turning a manuscript into a finalized report. Page 2 Preface The COVID-19 crisis brought home the high costs of pandemics, triggering a historic setback in the fight against poverty. It also reinforced the interconnections between people, planet and economy, calling attention to the zoonotic nature of pathogens spilling over from animals to people. We publish this report with a sense of urgency. As damaging as COVID-19 has been, the number of infectious disease outbreaks—from avian influenza to Middle East respiratory syndrome to Ebola—has been increasing dramatically. Every year, zoonoses cause more than a billion human infections and a million deaths —a trend that we must put an end to because it jeopardizes human development and breeds larger outbreaks such as COVID-19, bringing much higher death tolls. To decrease their burden, we must focus on prevention. The One Health approach proposes a way forward to reduce risk of spillover. Recognizing that the health and well-being of humans, animals, and their shared ecosystems are interdependent, One Health is designed as an integrated, practical, multisectoral framework for pandemic prevention. By stopping infectious diseases from spilling over to people and spreading to become pandemics, One Health provides a solid foundation for global health security and improved development outcomes at much lower societal and economic costs. Despite these benefits, there has been far too little attention paid to prevention and the upstream drivers of emerging infectious diseases. Unlike spending on disaster response and recovery, there are few political incentives to invest in prevention because it is invisible: a pandemic prevented is a pandemic that is not seen. This report aims to shed light on the benefits of prevention to serve as a wake-up call for policymakers and finance ministers alike. The report also outlines an investment framework and One Health architecture for zoonotic disease prevention. As you will read on these pages, compared to the sky-high cost of bringing pandemics under control, relatively modest investments in prevention will pay huge dividends. After major tragedies, countries often make large investments to prevent recurring disasters. We hope that this “Titanic effect” holds true today. The twentieth cycle of the International Development Association (IDA20), our fund for the poorest, includes a strong commitment to support countries to mainstream One Health approaches. The new Financial Intermediary Fund for Pandemic Prevention, Preparedness, and Response, and ongoing efforts toward the global accord on Page 3 pandemics are among positive signs that we may be close to breaking the cycle of panic and neglect. It is up to the leaders of today to make the investments needed to avert the pandemics of tomorrow. We hope that this report will make a useful contribution to save lives, and create a safer, more prosperous world for future generations. Axel van Trotsenburg Mari Pangestu Managing Director of Operations, Managing Director of Development World Bank Policy and Partnerships, World Bank Page 4 ABBREVIATIONS AND ACRONYMS AMR Antimicrobial Resistance EID Emerging infectious disease FAO Food and Agriculture Organization of the United Nations GAHP Good animal husbandry practices GDP Gross Domestic Product GHG Greenhouse gas emissions GHSA Global Health Security Agenda GPAI Global Program for Avian Influenza GPG Global Public Good HLIP High Level Independent Panel HPAI Highly Pathogenic Avian Influenza IDA International Development Association IEG Independent Evaluation Group IFI International financial institutions IHR International Health Regulations IMF International Monetary Fund INB International Negotiating Body IUCN International Union for the Conservation of Nature JEE Joint External Evaluation (IHR Monitoring and Evaluation Framework) MDB Multilateral Development Bank MERS-CoV Middle East Respiratory Syndrome—Coronavirus MOF Minister of Finance NBWs National Bridging Workshops ODA Official Development Assistance OECD Organisation for Economic Co-operation and Development OH One Health PPR Pandemic Prevention, Preparedness, and Response PVS Performance of Veterinary Services REDISSE Regional Disease Surveillance Systems Enhancement REDD+ Reducing Emissions from Deforestation and forest Degradation Plus RVF Rift Valley Fever SARS Severe Acute Respiratory Syndrome SCD Systematic Country Diagnostic SDG Sustainable Development Goals UN United Nations UNEP United Nations Environment Programme WHO World Health Organization WOAH World Organisation for Animal Health, founded as OIE Page 5 Glossary An epidemic refers to an increase, often sudden, in the number of cases of a disease in a particular area. Epidemics start as local outbreaks. A pandemic is defined as an epidemic occurring over a very wide area, or worldwide, crossing international boundaries and usually affecting many people. Zoonoses (or zoonotic diseases) are infectious diseases transmissible between animals and humans. Most disease outbreaks Human health is not only about absence with pandemic potential have a zoonotic of disease or disability but is also a state of origin, caused by a pathogen spillover event. physical, mental, and social well-being and a Spillover occurs when a pathogen host or fundamental human right. Public health reservoir population encounters a concerns the collective management of the susceptible host population and causes health of a population, whether this involves infection. The pathogen is transmitted from treatment, prevention, education, or social the original population and may or may not hygiene. Global health is a field of study, be further transmitted within the new host research, and practice that prioritizes population. improving health and achieving health equity Emerging infectious diseases are for everyone in the world. Environmental infections associated with new or health covers aspects of human health, significantly expanded geographic scope or including quality of life, which are determined spread of zoonotic, vector-borne, or drug- by physical, chemical, biological, social, resistant pathogens. psychosocial, and aesthetic factors of the environment. Ecosystem health is a broad term that typically refers to the condition and resilience of an ecosystem, including in relation to the array of services that are expected from it (such as disease Page 6 regulation). Animal health concerns both domesticated animals (pets and livestock) and wild animals. It is at once an ethical, economic, and health issue, as many diseases are zoonotic (e.g., can be transmitted to and from humans). The area of veterinary public health covers all activities directly or indirectly related to animals (or animal products or by-products) that contribute to the protection, preservation, and improvement of human health. Health security means protecting people from threats to their health. Health security One Health is an integrated approach that means protecting everybody, not only aims to sustainably balance and optimize the because it is an equitable thing to do, but health of people, animals, and ecosystems. It because with infectious diseases true health mobilizes multiple sectors, disciplines, and security can only be achieved if everyone is communities at varying levels of society to protected. Prevention is a global health work together to foster well-being and tackle security pillar characterized by systems, threats to health and ecosystems, while policies, and procedures to determine, addressing the collective need for clean water, assess, avoid, mitigate, and reduce threats energy and air, and safe and nutritious food; and risks by reducing vulnerability and acting on climate change; and contributing to exposure. Preparedness is the knowledge sustainable development. One Health is and capacities developed by governments, typically guided by systems thinking and response and recovery organizations, transdisciplinary working. communities, and individuals to effectively anticipate, respond to, and recover from, the impacts of likely, imminent, or current disasters. Page 7 Page 8 Executive summary The next pandemic may already be on the horizon. There is however nothing inevitable about the pace of outbreaks and emergence of infectious diseases, a growing number of which become pandemics. They are mainly the result of human activity, which is shaping the interactions among humans, animals, and the environment. Seventy-five percent of emerging infectious diseases (EIDs), and almost all recent pandemics, are zoonoses—diseases having their origin in animals. These diseases stem from increased contact between wildlife, livestock, and people, which allows microbes to ‘spill over’ from animals into human populations. The most important reservoirs of pathogens with pandemic potential are wild animals (especially mammals, particularly bats, rodents, and primates), some birds (especially water fowl), and livestock (e.g., pigs, poultry, cattle, and camels). Effectively addressing the challenges posed by pandemics requires a departure from the old cycle of panic and neglect. Even after experiencing this cycle for recent diseases such as SARS, avian influenza, and Ebola and the enormous health, economic, and societal impacts caused by COVID-19, few leaders recognize the critical importance of pandemic prevention, which means stemming a local outbreak before it becomes a pandemic. The business-as-usual approach to pandemics has been based on containment and control after a disease has emerged. It relies primarily on reductionist approaches to vaccine and therapeutic development rather than on reducing the drivers of pandemic risk to prevent them before they emerge. This has proven to be enormously expensive and insufficient to protect people from serious economic and social consequences of large outbreaks or pandemics. Yet, prevention is almost always underfinanced relative to preparedness and especially to response. Pandemic prevention is a global public good. It is non-excludable (no country can prevent others from benefitting) and non-rival (one country benefitting does not limit the extent to which other countries can benefit). Therefore, One Health, which sustainably balances and optimizes the health of people, animals, and ecosystems, is the quintessential global public good, which may explain underinvestment as countries hope to benefit without contributing (the classic ‘free-rider’ problem). Investment in pandemic prevention also has remained low because the benefits are largely invisible and uncounted, in the form of crises that do not occur. Furthermore, some drivers of pandemics (e.g., forest exploitation, extractive industry, livestock farming, and urbanization) are closely tied to income generation and livelihoods, which can hinder necessary changes. This report articulates an alternative approach that addresses pandemic risk at its source and is grounded in One Health strategies of systems thinking, whole-of-society planning, and collaboration across disciplines at the human-animal-ecosystem interfaces as a central path to global health security. The report highlights three main entry points to transition to this more effective approach. First, timing. Now is the opportune time to push for this transition, when the ravages of COVID-19 are still ongoing and there are high-level discussions about designing an international accord on pandemics and a new financing mechanism for pandemic prevention, preparedness, and response. Page 9 Second, the report highlights the relatively modest cost of prevention compared to crisis response. Prevention guided by One Health principles is estimated to cost between approximately US$10.3 billion and US$11.5 billion per year. This includes $2.1 billion per year to bring public veterinary services up to international standards, US$5 billion to improve farm biosecurity, and US$3.2- to-$4.4 billion to reduce deforestation in higher risk countries. Prevention costs are less than 1 percent of the cost of responding to COVID-19 pandemic in one single year, 2020. And the fact that prevention done right would de-risk investments in preparedness and reduce the need for subsequent response related costs. Third, the report emphasizes the many co-benefits of investing in prevention and One Health for sustainable and human development. These include reduction in CO2 emissions, climate adaptation, improved food safety and nutrition, reduced economic burden from animal diseases, increased access to markets, and strengthening resilience of health systems by boosting awareness and multisectoral action. For example, low- and middle-income countries could reap substantial benefits for their agricultural sectors (specifically livestock), driven by reduced frequency and scale of costly disease control measures such as culling and expanded access to international and higher-margin markets for producers. From a health security perspective, investments in prevention can improve the resilience of health systems, make investments in preparedness more effective, drastically reduce the need for response, and lessen the broader economic and social impacts of pandemics. Such investments must be tailored to the country context, considering national risk profiles and circumstances. One Health is an investment in humanity’s future. The co-benefits are high but so, too, is the cost of inaction. To break the cycle of panic and neglect, within the broader PPR agenda, the report proposes a One Health Investment Framework for national, regional and global stakeholders to adopt. This investment should be guided by five core principles of: (i) adopting an integrated One Health multisectoral approach that aims to sustainably balance the health of people, animals, and ecosystems, (ii) prioritizing prevention, a most overlooked component of health security, (iii) complying with existing minimum standards that are relevant for One Health, (iv) focusing on geographical locations with higher risks of spillover at the human-animal-ecosystem interfaces, and (v) reducing risks of spillovers in forests (or wildlife habitat), farms (livestock), and sprawling urban areas. One Health is a coordination-heavy agenda that requires strong champions, to mobilize finance as a shared responsibility, and a strong institutional arrangement backed by solid technical capacity supporting its work. Thus, to support countries, there is an important role for technical agencies and financial institutions to coordinate global, regional and local activities by the public sector (for public goods such as public health systems, public veterinary systems, ecosystem management and protection, and surveillance data systems), the private sector (for livestock farmers, loggers, forest-based communities, and land developers) and the civil society. Page 10 A One Health investment framework needs to be adopted and implemented at the country level based on alignment with each country’s prioritized national action plans, risk factors and vulnerabilities for EIDs, and existing resources and programs in areas for which there is overlap with the One Health agenda from public and private sources. Doing so successfully would require: (i) removing the obstacles to prevention; (ii) financing prevention as a shared responsibility; and (iii) ensuring country ownership and enabling institutional arrangements. Investing in One Health based prevention is the best way forward to break the cycle of panic and neglect—once and for all. If we fail to act now, we will be destined to become like Sisyphus, forever rolling a boulder uphill to manage the response to the next pandemics. Page 11 Page 12 Introduction The central argument of this report is that pandemic the pace of new, emerging, or re-emerging diseases has risk must be addressed at the source, via prevention, accelerated, and the next pandemic may already be on incorporating risk reduction and integration of human, the horizon. There should be no surprise. As humans animal, and ecosystem health, which is the basic extend their footprint on the planet, encroaching into premise of the One Health approach. natural habitats and altering them, the potential for diseases to emerge has increased exponentially. In Pandemics are large-scale infectious disease events, addition, our globalized, interconnected world makes most of which have their origin in domestic or wild societies increasingly vulnerable to the spread of animals. Before COVID-19, HIV/AIDS, Nipah virus disease, diseases and eruption of pandemics. Risk anywhere avian influenza, Ebola virus disease, severe acute becomes risk everywhere. respiratory syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Zika were among the diseases The accelerating trend of outbreaks results from our that emerged from animals in contact with humans over relationship with the planet and our relationship with the last few decades, and several of these fully realized each other.2 Because of this, crises are not inevitable— their pandemic potential. Many of the major human we have several opportunities and a set of appropriate infectious diseases, including some now confined to interventions that can prevent or mitigate adverse humans and absent from animals, such as measles, arose shocks caused by these outbreaks. from contact with animals. Every year, zoonotic diseases sicken billions of people, killing millions, with low- and Reactive strategies on their own are insufficient and middle-income countries being most vulnerable. Even overly expensive. When drawing lessons from the avian when animal diseases do not kill people, they frequently influenza crisis, the World Bank IEG recommended deepen poverty, diminish or destroy livelihoods, and moving from a response mode, which necessitates the undermine food security as livestock die prematurely or use of emergency instruments and often massive get culled for the purpose of disease control. resources, to a preemptive risk-reduction approach through cost-effective, regular country programs and The impact of pandemics has increased, as the world operations that tackle the drivers of disease has learned all too well from COVID-19. The emergence.3 International Monetary Fund (IMF)’s World Economic Outlook (IMF 2022) has projected the cumulative But most countries did not heed this recommendation, output loss from the pandemic through 2024 to be and prevention remains largely neglected. After each about US$13.8 trillion. The cost is unprecedented, and major incident, countries typically make limited the damage done to social cohesion, human capital, investments in preventing the emergence of infectious poverty, and sustainable development will be diseases and reducing pandemic risks. After the incalculable. outbreak is contained, attention begins to divert elsewhere and investments in prevention wane, feeding Decades ago, Albert Camus observed that there have a cycle of panic and neglect that leads the world to been as many plagues as wars in history, yet plagues once again become at risk for the next outbreak, as we and wars always take people equally by surprise.1 But saw in the years preceding COVID-19. 1 The Plague, a novel by Albert Camus. 1947 2 Laudato Si’: On Care for Our Common Home, encyclical by Pope Francis. 2015 3 Responding to global public bads, a report by the World Bank Independent Evaluation Group. 2014 Page 13 We can stop this cycle by implementing a One Health This report builds on One Health’s successes and approach, especially in countries with a high risk of EIDs lessons from many public health failures that did not and spillovers, and leverage the One Health approach to take an integrated approach. It calls for urgent, long- both prevention and preparedness. One Health term attention to prevention, a critically missing link in recognizes that human and animal health are our current approach to pandemic risk. It organizes interdependent and bound to the health of the knowledge and understanding of the drivers of ecosystems in which they exist. It offers a practical pandemic-prone emerging diseases and proposes to framework to reduce pandemic risks at the source and re-cast prevention to lessen the likelihood of spillover, the necessary foundation to achieve global health de-risk investments in preparedness, and reduce the security. cost of response. Finally, the report proposes a framework to mobilize finance for prevention to reduce One Health has proven successful. It combated river pandemic threats locally and globally. blindness during the 1970s, combining public health and environmental interventions, and the global Former Liberian President Ellen Johnson Sirleaf and program on avian influenza in the 2000s included some former New Zealand Prime Minister Helen Clark, essential One Health features, such as coordination co-chairs of the Independent Panel for Pandemic mechanisms between human and animal health Preparedness and Response, described COVID-19 as services. Years later, as COVID-19 still wreaks havoc on the 21st century’s “Chernobyl moment” and stressed lives and economies, as monkeypox is declared a Public that if investment doesn’t occur now, “we will condemn Health Emergency of International Concern, and as the world to successive catastrophes.”4 However, a year concerns arise from the detection of new zoonotic later, the co-chairs expressed their concern about the Langya virus, integrated approaches to prevention very slow progress on reforms. The world cannot afford based on One Health foundations have become even to ignore their stark warning or the recommendations more relevant and necessary. of this report. 4 The Independent Panel for Pandemic Preparedness and Response of the World Health Organization (WHO) published its findings in May 2021. Page 14 75% of emerging infectious diseases have their origin in animals The pace of emerging The impact of infectious diseases pandemics has has accelerated, increased, causing an increasing at an annual income loss of annual rate of 6.7% Pandemic risk US$490 billion must be addressed via prevention Pandemic risk can be reduced at the source by addressing drivers at the human-animal-ecosystem interfaces One Health is a necessary foundation for health security Page 15 Page 16 Addressing pandemic risk at the source The pace of EIDs has accelerated at an annual rate of day their brains would swell up. They couldn’t walk or 6.7 percent from 1980, with the number of outbreaks talk. About half the patients died. Within just a few growing to several hundred every year since 2000 months, nearly one in three families in Nipah had lost (Morand 2020). The richness of microbes causing someone to the disease. In the beginning, the disease diseases also increased significantly over that period was mistakenly identified as the mosquito-borne (Smith et al. 2014) and the yearly probability of an Japanese encephalitis but spraying for mosquitoes did occurrence of large outbreaks could increase up to not bring the situation under control. Soon people threefold in the coming decades (Marani et al. 2021). realized that no Muslims were getting sick, and only On average, more than five new diseases emerge in farmers raising pigs were falling ill. The outbreak had people every year, some of which have the potential to been preceded by a respiratory illness and encephalitis spread widely and become a pandemic. Diseases know in pigs in that same area. It was the pigs, not the no boundary, and the connectiveness of the world mosquitoes, that caused the outbreak. resulting from the movement of goods, vehicles, and people makes local outbreaks easier to spread globally. How did this happen? Fruit-bats have been identified as a natural reservoir of the Nipah virus. Over several About five years ago, annual loss from a pandemic was decades before the outbreak, the forest habitat of expected to be 0.6 percent of global income, or about these bats had been substantially reduced by US$490 billion per year, with losses varying by income deforestation and/or forest degradation for pulpwood group from a little over 0.3 percent in high-income or industrial palm plantations. A massive smoke haze countries to 1.6 percent in lower-middle-income occurred in 1997 and 1998 just before the outbreak, countries (Jamison 2017). This was an underestimation. the result of slash-and-burn deforestation and/or forest In 2020, the global economy contracted by 4.4 percent degradation that blanketed much of the region and was from the impacts of the COVID-19 economic shutdown. exacerbated by a drought driven by a severe El Niño That amounts to about US$3.6 trillion worth of lost oscillation. The haze and drought led to a reduction in goods, services, and other outputs. This does not the availability of forest-foraging areas for fruit-bats include the many ways people suffered in the downturn, and to an increased presence of bats into cultivated including through illness, death, loss of livelihoods, or fruit orchards, where piggeries allowed transmission of disruption of schooling. As of August 2022, more than the virus from bats to pigs and, ultimately, to humans. 6.45 million people have died from COVID-19, Pig farms themselves had changed over time. When according to official estimates (although the actual Malaysia had a massive economic boom in the 1980s death toll might be between 16 million and 20 million, and 1990s, the number of middle-class families who approximately equal to that of World War I), and the could afford to eat pork several times a week ballooned. virus continues to spread. While farmers once raised only a few pigs, now they crowded pigs into tight quarters and industrialized the 1. A CAUTIONARY TALE—THE STORY OF farms. NIPAH VIRUS DISEASE Once the outbreak became apparent, the government Events started in 1998 in Nipah, a suburb of Ipoh, ordered the culling of more than a million pigs—a Malaysia, when villagers experienced febrile hardship for pig farmers and a painful, dark episode for encephalitis for which there was no cure or treatment. the local community. Out of fear or economic despair, Young people would be healthy one day and the next some pig farmers affected by the outbreak sold pigs to Page 17 other farms across the country. In 1999, cases were systems, incubating, accelerating, or amplifying recognized in other parts of the peninsula, southward changes. They can either intensify or attenuate the from Kinta district, and were associated with magnitude or frequency of risks arising from various surreptitious movements of infected pigs. sources. The successful identification of risks at their early inception is at the heart of public health and The Nipah story inspired the 2011 movie “Contagion,”5 a environmental protection (Robinson et al. 2012). tale of viral transmission from deep forests to densely populated, globally connected areas and of spillover As humans have extended their footprint on the planet, from wildlife to humans. But the Nipah story is also a encroaching into natural habitats, altering them to tale of a changing climate, changing use of land and extract resources, globalizing trade, and moving goods food systems, lack of adequate biosecurity on farms, and people, the potential for infectious diseases to urbanization, social inequities and tensions, human emerge and spread has increased. Urbanization and activities driving disease emergence, and total climate change are reinforcing this trend by increasing blindness to prevention. pressure on land use and food systems and providing new, potentially more suitable, conditions for 2. UNDERSTANDING THE DRIVERS OF pathogens and diseases to develop and spread SPILLOVER TO REDUCE PANDEMIC RISK (Richardson et al. 2016). Human population displacements from economic, political, humanitarian, Seventy-five percent of EIDs and almost all recent and, increasingly, climatic crises are another set of pandemics are zoonotic in nature. These diseases stem drivers for emerging diseases. Human population from increased contact among wildlife, livestock, and growth coupled with larger numbers of livestock people, which allows microbes to ‘spill over’ from needed for animal protein will only increase spillovers if animals into human populations. The most important nothing is done to mitigate risks. Table 1 provides reservoirs of pathogens with pandemic potential are details on how farms, forests, cities, climate change, and wild animals (especially mammals, primarily bats, inequalities drive EIDs. rodents, and primates); some birds (especially water birds); and livestock (e.g., pigs, poultry, cattle, camels). Drivers usually influence systems in complex, non-linear, and not necessarily causal interactions (see Box 1 for an Spillover is a gradual process, with many dead-end example of drivers and the emergence of Ebola in West events or stuttering chains before sustained infection in Africa). Nearly one-third of the planet’s land area has humans happens or human-to-human transmission been transformed in the last 60 years, and nearly 90 occurs. Spillover is not a rare event or a “viral needle in a percent of deforestation between 2000 and 2018 was haystack,” but rather a pattern that suggests that a related to agriculture. Sixty percent of the drivers of the specific local ecological context is ripe for disease 100 biggest outbreaks since 1974 fall within the emergence and spread into human populations. domains of land-use change, especially related to forests and food systems, in particular livestock Human activities influence the rate of success of operations (Stephens et al. 2022). spillover events, the accelerating trend of EIDs, and increasing pandemic risk. The causal pathways leading While there is usually broad agreement about the to initial spillover, spreading to become epidemics, and critical factors driving disease emergence, there has in some cases leading to pandemics, are often complex, been little consistency on how to organize these drivers involving a mix of factors, also known as “drivers,” that and their relationships to key foci of risk. Based on our shape risk and can increase vulnerability. Drivers modify bibliographic review6, we propose to organize drivers 5 Contagion is a 2011 film directed by Steven Soderbergh. 6 See the technical report published as a companion document to this report. Page 18 TABLE 1: Examples of elements driving EIDs at the human, animal, ecosystem interfaces Farms Food systems open active interfaces among humans, animals, and the environment (Richardson et al. 2016). The production, distribution, and consumption of food can bring pathogens closer to people, and these activities channel waste back to the environment. Inadequate animal husbandry; lack of biosecurity; unsanitary conditions in farming, transport, slaughter, or marketing; and poor handling of animals and animal products have been identified as critical channels for transfer of pathogens across species and transmission of diseases. Higher concentration of farms and animals and more extensive production systems vulnerable to disease increase the risk for infectious diseases to emerge and spread, resulting in increasing threats to public health. Forests Land use change fuels the emergence of infectious diseases through agricultural encroachment, deforestation, forest degradation and fragmentation, encroachment into wildlife habitat (including for activities such as tourism), irrigation, wetland modification, mining, expansion of urban environments, pollution, and coastal zone deforestation, forest degradation and fragmentation. These activities generate cascades of factors that can modify, accelerate, or amplify the dynamics of pathogens and diseases (Patz et al. 2004). More than a third of EIDs reported since 1960 are attributed to land-use change, including deforestation, forest degradation and fragmentation, and 15 percent have been linked to forests. Deforestation, forest degradation and fragmentation, particularly in the tropics, has been associated with an increase in infectious diseases. Cities Urbanization has increased rapidly and creates another set of drivers (Alirol et al. 2011), where new cities can be incubators for epidemics, and zoonotic diseases can spread more rapidly and become worldwide threats (Neiderud 2015). Risk factors in the urban environment include population density, poverty, and inadequate housing or sanitation, which can cause exposure to, and proliferation of, insect- and rodent-borne diseases and water- and soil-transmitted diseases (Himsworth et al. 2013). Growing urbanization has also shifted some infectious diseases that have traditionally been rural illnesses, such as Dengue fever, to cities. New housing on the outskirts of big cities can potentially be meeting points for wildlife and humans, with livestock acting as bridges for zoonotic diseases. Climate A changing climate modifies the geography of diseases, strongly influences all other drivers, and aggravates over Change half of known human pathogenic diseases (Mora et al. 2022). It causes shifts in natural ecosystems both in altitude (e.g., retreating alpine glaciers) and latitude (e.g., sub-tropical forests expanding in temperate areas), affecting the geographical ranges of animal species, vectors, and reservoirs and susceptible hosts. Use of biological transmission models had shown the potential spread of falciparum malaria into northern latitudes, including Europe and North America (Rodgers and Randolph 2000). Some invasive and disease-carrying species of mosquitoes are proliferating across Europe and becoming a mounting health concern. Extreme weather events, in turn, can create conditions conducive to unusual clusters of insect-, rodent-, and water- borne diseases. Natural disasters lead to outbreaks, such as the re-emergence of leptospirosis in China following Typhoon Nali in 2001 (Watson, Gayer and Connolly 2007) and the re-emergence of plague in Madagascar that was influenced by El Niño and the Indian Ocean Dipole (Kreppel et al. 2014), while weather also affects the timing and intensity of outbreaks. Also, as the climate changes, wild animals relocate their habitats, often to regions with large human populations, increasing likelihood of spillover (Carlson et al. 2022). Inequality, Increasing inequality, fragility, and violence in large parts of the world make people and systems more vulnerable Fragility, to pandemics, whether from poor housing conditions, food insecurity, forced migration, or armed conflict. Violence Conflicts and the resulting fragility and violence, the displacement of populations, and the increase of refugees and asylum seekers can have a range of health consequences, including deteriorating hygiene, overcrowding, breakdown of health and social services, and heightened risk of disease transmission. Conflict settings can hamper access to basic prevention, detection, and containment measures. In addition to new exposures and potential reliance on wild animals for protein, people may also move with their livestock to escape conflict situations, leading to increased risk. Armed conflict can also complicate disease response efforts, in part because of its secondary effects (e.g., mistrust, misinformation, gaps in surveillance, and cautious implementation of public health control measures). Page 19 Climate C han ge FIGURE 1: Inequality, Fragilit Drivers of y, V iol EIDs: Core and en cross-cutting ce domains Forests Drivers Forests, farms, and cities Cities are Inter- connected depict the three core domains related to land use, food systems, and Farms urbanization, respectively. These core domains are influenced by two crosscutting domains— climate change and inequality, fragility, and violence. Core and cross- cutting drivers are highly interconnected. across three main domains pertaining to farms, forests, events, and those that may recur in similar ways, and cities (Figure 1)—and two crosscutting domains of analyzing drivers can focus attention on high-risk areas influence—climate change and inequality, fragility, and and factors that can be addressed through policy violence. interventions. The analysis of drivers is critical to identify and evaluate risks and the combined effects of While oceans are absent from the drivers depicted in sparks (where an outbreak is likely to arise) and spread Figure 1, there is an increasing recognition of the (how it may diffuse through human populations). relationship between human health and oceans (Flemming et al. 2006), which may elevate their 3. ONE HEALTH AS A NECESSARY importance as a driver domain in the future. Changes in FOUNDATION OF PANDEMIC water temperature, ocean acidification, and deoxygenation, leading to changes in oceanic PREVENTION circulation and chemistry, rising sea levels, increased Most drivers of EIDs are outside the health sector, and storm intensity, and the diversity and abundance of prevention needs to address these drivers across marine species (IUCN 2017) are among the changes multiple sectors. Pandemic prevention encompasses that can affect human health and welfare (Parmesan the systems, policies, and procedures to determine, and Attrill 2016, Talukder et al. 2022), further assess, avoid, mitigate, and reduce public health threats influencing drivers of EIDs. and risks. For effective prevention to take place, multisectoral interventions are needed to mitigate risk The analysis of drivers cannot predict where and when and reduce the likelihood of spillover events at the the next pandemic will start, or which pathogen will human, animal, or ecosystem interfaces that go far cause it. Each disease has its own history, root causes, beyond the confines of the health sector. and trajectory from spillover events to large outbreaks. The next pandemic will most likely be different from past ones. Like Thucydides’ observations7 about past 7 “Yet if they are judged useful by any who wish to look at the plain truth about both past events and those that at some future time, in accordance with human nature, will recur in similar or comparable ways, that will suffice.” Thucydides, History of the Peloponnesian War, 431–404 BC Page 20 One Health is an integrated, unifying approach that it has been undervalued in the approach to public recognizes that the health of humans, domestic and health that has dominated since the 20th century. wild animals, and their shared ecosystems are closely linked and inter-dependent (Figure 2). One Health The term itself, One Health, was coined by William B. mobilizes multiple sectors, disciplines, and Karesh in a Washington Post article from 2003, communities at different levels of society to work followed by the Manhattan Principles (2004), and together to foster well-being and tackle threats to since then modified by numerous groups and health and ecosystems while addressing the collective constituencies to the Berlin Principles (Gruetzmacher need for clean water, energy, and air; safe and et al. 2021), sometimes overlapping with similar but nutritious food; climate change resilience; and different concepts of planetary health, and eco-health.9 sustainable development (OHHLEP et al. 2022).8 In March 2022, the United Nations Environment The interconnectedness of health for humans, non- Programme (UNEP) joined the Food and Agriculture human animals, and the ecosystems they share may Organization (FAO), World Organisation for Animal seem trivial, and it has been recognized for ages in Health (WOAH), and the World Health Organization different cultures and civilizations (Raworth 2017), but (WHO) in their collaborative agreement (replacing the 2010 “Tripartite” with the “Quadripartite” Alliance). BOX 1: Drivers of Ebola In March 2014, the World Health Organization (WHO) reported cases of emergence in West Africa-zooming on Ebola in the forested rural region of southeastern Guinea. This marked Liberia the beginning of the West Africa Ebola epidemic, the largest in history. A 2015 study identified 142 linkages among 40 drivers of Ebola spillover event (Grotto and Ricci 2015); the main ones being deforestation and/or forest degradation, hunting, ecosystem changes, industrial plantations, changes in demand for wild animal meat, food security, and forest fragmentation. This highlights the interconnections among human activities, animal populations, and ecosystem integrity. Liberia was part of the epicenter of the outbreak, with significant socio-economic impacts (Korkoyah and Wreh 2015) that led to restrictions on trade and transportation, reduced tourism, and decreased agricultural production and mining activity. The One Health Liberia case study, a companion document to this report, depicts the drivers that increase interactions between humans, wildlife and livestock, along with the country’s vulnerabilities (World Bank, 2022a). 8 One Health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems. It recognizes the health of humans, domestic and wild animals, plants, and the wider environment (including ecosystems) are closely linked and inter-dependent. The approach mobilizes multiple sectors, disciplines, and communities at varying levels of society to work together to foster well-being and tackle threats to health and ecosystems, while addressing the collective need for clean water, energy, and air; safe and nutritious food; taking action on climate change; and contributing to sustainable development. . 9 Ecohealth promotes an ecosystem approach to health, focusing primarily on environmental and socioeconomic issues. Planetary Health considers the planet’s environmental limits—physical and biological—within which human health, well-being, and equality can flourish by examining issues from a political, economic, and social perspective. Planetary health considers the health of human civilization and the state of the natural systems on which it depends. Page 21 ystem heal The One Health FIGURE 2: os approach improves the Ec One Health recognizes th ability to effectively the connections and interdependency prevent; detect; among the health of respond to, and humans, domestic and recover from, wild animals, and the outbreaks; prepare for health of the ecosystems they lth One Ani future pandemics; and share ea Health accomplish development m h al h Human goals such as improved ealth health and economic security, climate resilience, and food safety. Under this much needed collaboration, a One Health Joint Plan of Action (2022-2026) is being launched to FIGURE 3: Increasing investment in prevention means guide implementation. The Plan has six main action de-risking investments in preparedness tracks: enhancing countries’ capacity to strengthen and reducing cost of response health systems under a One Health approach; reducing the risks from emerging or resurfacing zoonotic epidemics and pandemics; controlling and eliminating endemic zoonotic and neglected tropical or vector- borne diseases; strengthening the assessment, PREVENTION management and communication of food safety risks; Actions to reduce the likelihood or curbing the silent pandemic of antimicrobial resistance consequences of spillover events (AMR) and better integrating the environment into the One Health approach. Strengthen animal health, Multilateral Development Banks are adopting the veterinary services approach. The World Bank has developed its operational framework to strengthen human, animal, Improve on-farm biosecurity and environmental public health systems at their interfaces (World Bank, 2018), as has the Asian Development Bank (ADB, 2022). Twenty-three Reduce deforestation and/or forest degradation, improve conservation countries have adopted strategic One Health action plans10 and many more are engaging on this path. Improve urban planning Although One Health applies broadly to health matters, including non-communicable diseases and climate- change impacts on health outcomes, in this report, One Note: Animal health systems are a core element to prevention. Prevention also relates to interventions at the farm, forest, and city levels. Examples given here are indicative. Priority actions 10 See compilation by the One Health Commission, https://www. that constitute prevention are risk-based and related to the local onehealthcommission.org/en/resources__services/one_health_ context. Adapted from Carlin et al., 2019. strategic_action_plans/ Page 22 Health focuses on zoonoses and pandemics. While the initiatives showed that prevention is scarcely addressed One Health approach is core to health security over all, and most underappreciated (Carlin et al. 2019). this report specifically focuses on a neglected aspect Prevention continues to be the missing link to more — pandemic prevention. comprehensively mitigate pandemic risk. The Global Health Security Agenda (GHSA) aims to Figure 3 illustrates the continuum between prevention accelerate progress toward a world safe and secure and preparedness, along the GHSA framework to from infectious disease threats and to promote global prevent; detect; and respond to outbreaks. It displays health security (White House 2014). Its framework is the key elements of prevention, e.g., the core need for organized around three main pillars: prevent and reduce animal health systems, along with a focus on farms, the likelihood of outbreaks; detect threats early to save forests, and sprawling cities. Upstream investments in lives; and respond rapidly and effectively using multi- prevention to reduce spillover are expected to de-risk sectorial coordination and communication. Using this investments in preparedness and reduce cost of framework, a review of prominent global health security response. PREPAREDNESS Ex ante actions to mitigatge losses when a disease outbreak occurs Laboratory Epidemiological Health care R&D-vaccines Management of diagnostics investigation surge and therapeutics long-term impacts PREVENT DETECT Emergence RECOVER | event RESPOND | Addressing $ drivers of rces sou disease ial re nanc $ $ e and fi emergence an lif f hum ms o $ in ter | impa ct asing Assessing risks and vulnerabilities Incre $ Capacity strengthening Page 23 Page 24 Guiding investments towards prevention of pandemics An investment framework is needed, with tools and however, have been slow in knitting the One Health approaches adopting the One Health approach, and approach into the Pandemic Prevention, Preparedness above all recognizing the importance of prevention, and Response (PPR) agenda. The World Bank, with which has been missing from past strategies. WHO and partners, is currently working on establishing a new Financial Intermediary Fund (FIF) for pandemic PPR This investment framework is guided by five core adopting One Health as a guiding principle, responding to principles. First, it adopts an integrated One Health the urgent need for a new multilateral financing multisectoral approach that aims to sustainably mechanism dedicated to PPR (World Bank 2022). On balance the health of people, animals, and ecosystems. another front, work is underway to amend the Second, it prioritizes prevention, a most overlooked International Health Regulations (IHR 2005), and WHO component of health security. Third, it requires established an intergovernmental negotiating body (INB) compliance with existing minimum standards that are and has initiated the process of drafting an international relevant for One Health. Fourth, it takes a risk-based accord on pandemics that could help deliver some of the approach, prioritizing geographical locations with required elements to more effectively prevent pandemic higher risks of spillover at the human-animal-ecosystem threats. These ongoing initiatives are expected to interfaces. Fifth, it focuses investments on reducing strengthen the global governance for health security, risks of spillovers in forest (or wildlife area), farm within which an investment framework would contribute (livestock), and urban areas. to effective global One Health implementation support architecture for zoonotic disease prevention. 1. ADOPTING ONE HEALTH The Quadripartite’ s global One Health Joint Plan of An investment framework for prevention needs to Action provides an overall strategic framework for include the health of humans, animals, and ecosystems. increasing coordination and attention to under- It must not be a siloed framework but instead should be invested areas in capacity, infrastructure, and tools mainstreamed into broader development and crisis such as information management system response financing through the systematic application interoperability. Its ownership by the four institutions is of a One Health “lens.” It needs to guarantee that there historic. are no missing links in the complex risk management chain spanning prevention, preparedness, response and Operationalizing a One Health approach requires recovery that brings together disparate public agencies improving coordination, communication, and unaccustomed to collaborating and coordinating. collaboration between sectors, reinforced by sustained Investments in prevention can only be successful capacity strengthening. This requires a shift from largely through a multisector public-private policy framework vertical programs focused on specific diseases to those that allows decision-makers to determine appropriate that can strengthen overall systems and their fund flow to various sectors and geographical areas collaboration across sectors. Importantly, for prevention, based on risk assessments and cost-benefit analysis this requires actions that may be far upstream from within each country’s specific context. disease events and health and economic outcomes. Key stakeholders may be different than those previously One Health has been coming of age through the G7 and engaged in health efforts, such as livestock keepers, park G20 leadership, and explicitly referred to in an increasing rangers, extractive industries, and community members number of ministerial declarations. Those leaderships, responsible for environmental stewardship. Page 25 Countries and regional bodies are increasingly crisis response using emergency instruments and establishing One Health coordination platforms (see toward incorporating risk reduction, risk management, Box 2 for an example in Vietnam). These platforms and long-term capacity strengthening in country provide a mechanism to bring together ministries with programs and operations. mandates on human and animal health and the environment and, in some cases, a broader range of There is an economic argument for this shift. The cost of actors (e.g., ministries of education, rural development, prevention is moderate, with high returns on the and security; civil society; and academia). Strong investments. The set of prevention actions presented in a political will and commitment are seen as key enablers previous analysis by the World Bank was estimated to of success, with some platforms chaired at the Prime generate an annual rate of return of up to 86 percent Minister or Vice President level. The adoption of (World Bank, 2012). Considering COVID-19’s heavy human policies and governance manuals sets expectations for and economic toll the return on investment would most participation, though in practice the relevance and likely be much higher, especially if the set of actions value addition are not necessarily broadly understood, addressed the broader spectrum of prevention and and some sectors lack the capacity or workforce to curbed key drivers across forests, food systems, and cities. engage fully. Finally, the multisectoral coordination and The G20 High Level Independent Panel (HLIP) estimated collaboration that is required for One Health is the amount in international financing for pandemic extensive with a high transaction cost and cannot be preparedness that would be required every year for five sustained on good will alone without strong political years at $15 billion, along with significant increases in commitment and adequate institutional arrangements. domestic spending, to address current gaps. Recently, WHO and the World Bank estimated the total amount at 2. SHIFTING TO PANDEMIC US$31.1 billion annually, of which US$10.5 billion of PREVENTION international financing is needed annually for the next five Taking a risk-based approach, pandemic prevention years (WHO and World Bank 2022). These estimates only requires moving away from a paradigm grounded in incorporate the requirements for early detection and rapid BOX 2: The Vietnam One Vietnam is on the global map for hotspots and a country prone to Health framework emergence of infectious diseases with pandemic potential. A combination of vulnerability to climate change, low access to health care, growing livestock sector, proximity to wildlife and expanding urban areas create opportunities for spillover. In response, the Ministry of Agriculture and Rural Development, together with the Ministry of Health and the Ministry of Natural Resources and Environment, launched the One Health Partnership Forum for Zoonotic Disease, currently in its second phase until 2025. The One Health Partnership exemplifies enhanced communication and multidisciplinary collaboration between Ministries and programs focused on prevention by addressing the human-animal- ecosystem interfaces. The One Health Vietnam case study provides further insights into the country’s profile and specific context for critical interventions. (World Bank 2022b). Page 26 response (monitoring and detection of zoonotic Estimating these costs is a challenge, as it should be spillovers), leaving untended areas along the prevention based on country-specific assessments, making any and preparedness continuum (Figure 3). Estimating the global figures a mere approximation. Here, we estimate cost of prevention requires including core competencies another US$5 billion to improve farm biosecurity13 and of the veterinary services and interventions aiming at US$3.2-to-4.4 billion to reduce deforestation in reducing risk related to main EID drivers such as land use, higher-risk countries.14 No figure could be calculated for food systems, or urban sprawl. prevention in urban settings, which remains to be addressed. These estimates, however, need to be To correct for this omission, we updated the World considered in the context of synergistic agendas (e.g., Bank’s 2012 estimate for veterinary public health biodiversity conservation or forest restoration) and systems, bringing the cost to approximately US$2.1 country-based approaches. With that caveat, this billion per year,11 of which US$1.1 billion should come from means that our global estimate of prevention guided by international support.12 This is less than 10 percent of the One Health principles ranges from US$10.3 billion to cost for preparedness, and about 0.05 percent of the US$11.5 billion per year (Figure 4). cost of COVID-19 in 2020. Moreover, investment in prevention would substantially reduce the likelihood of The economic case seems irresistible but, despite the spillover and pandemic risk, thereby de-risking or obvious economic benefits, prevention is usually reducing the need for investments in preparedness and grossly underfunded. However, suggesting that more reducing the cost of response (Figure 3). money alone will solve the problem is not credible. Even with financing available, the political economy of The estimate above is core and central to prevention. investing in prevention such as One Health is complex, However, it does not comprehensively address the and the benefits of successful prevention are less broader spectrum of prevention or curb key drivers visible than expenses for response and relief. Thus, it is related to farms, forests, and sprawling cities. important to emphasize the significant co-benefits to Annual cost of prevention Prevention compared to FIGURE 4. Preparedness Cost of prevention Strengthen animal health, veterinary services US$30.1 estimated for animal US$2.3 billion billion health services, farm biosecurity, reduction of Reduce deforestation, improve conservation deforestation, and US$3.2–4.4 billion US$11.5 improved billion conservation Improve on-farm biosecurity US$5 billion Prevention Preparedness Improve urban planning Estimate unavailable 11 This figure is based on the updating of the 2012 World Bank estimate (World Bank 2012) adjusted to 2020-dollar value, under the assumption that no meaningful progress has taken place in animal health systems in LMICs since 2012. See also the technical report published as a companion document to this report (World Bank 2022d). 12 This is calculated under the assumption that low-income countries receive international support to cover 88 percent of financing needs for health security, while middle-income countries receive 24 percent. 13 In medium- and high-risk areas defined by intersections of livestock (pigs and chicken), density above 85th global percentile, and human population density above 200 people per km2. See the technical report published as a companion document to this report (World Bank 2022d). 14 By halving deforestation in high-risk countries as per Allen et al. 2017. See the technical report published as a companion document to this report (World Bank 2022d). Page 27 invest in prevention as well as the high cost of inaction Countries are obligated to comply with IHR (2005) and as the world is witnessing now with COVID-19. WOAH standards. However, levels of compliance remain generally low, as shown by outcomes of the 3. COMPLYING WITH COUNTRIES’ WHO’s Joint External Evaluation (JEE) and WOAH’s OBLIGATIONS AND MINIMUM Performance of Veterinary Services (PVS) pathway. STANDARDS An effective investment framework for One Health to Routine health-systems strengthening broadly minimize the risk of future pandemics will only be contributes to prevention. More specifically, the IHR achieved by having an appropriate set of incentives and 2005 and the WOAH Codes and Manuals set out disincentives, along with dedicated long-term standards that are relevant to prevention. commitment toward building needed institutional capacity in a multi-sectoral manner. The IHR (2005)15 integrates zoonoses and the relevance of coordination and collaboration with the animal health In the longer term, compliance with standards should be system. The JEE16 assessment of country capacities considered, for example by the World Bank, in assessing includes critical competencies from a One Health pandemic prevention and preparedness capacity, and perspective that are core to prevention, such as could be incorporated into the Country Policy and coordination with the public and animal health sectors on Institutional Assessment (CPIA) tool with the rating zoonotic diseases;17 AMR;18 biosafety and biosecurity;19 included in the overall country score used as part of the and coordination, communication, and advocacy.20 International Development Association (IDA) allocation formula (IWG 2017). The Bank could also incorporate However, the IHR does not cover the capacity of analysis of EID risks and vulnerabilities, compliance with veterinary services themselves, which are outside its standards and One Health based pandemic prevention in remit. Veterinary services are, however, critically country-specific Systematic Country Diagnostics (SCD) important for the prevention of diseases in animal that identify a set of priorities through which a country populations; early detection of pathogenic agents, may most effectively and sustainably achieve poverty including zoonotic agents; their reporting and control; reduction and shared prosperity goals. and preventing their spread. This is assessed through the PVS pathway, which provides a comprehensive 4. FOCUSING ON HOTSPOTS evaluation of countries’ strengths and weaknesses in implementing WOAH standards.21 Most of the core Selectivity is needed in the face of huge uncertainties about competencies described through the PVS pathway22 are where the next pandemic might originate and the costs of critical to prevention. adopting comprehensive prevention measures in a certain location. Pandemic risks and vulnerabilities are global, 15 The International Health Regulations (2005) (IHR) are an instrument of international law that is legally binding on the 194 World Health Organization (WHO) Member States. It provides an overarching legal framework that defines countries’ rights and obligations in handling public health events and emergencies that have the potential to cross borders and become pandemics 16 The Joint External Evaluation (JEE) is a voluntary, collaborative, and multisectoral process to assess country capacities to prevent, detect, and respond to public health risks. The third edition includes 19 technical areas, and 56 indicators. 17 JEE Area P.4.1: Coordinated surveillance systems in place in the animal health and public health sectors for zoonotic diseases/pathogens identified as joint priorities. 18 JEE Area P.3.3: Infection prevention and control. 19 JEE Areas P.6.1: Whole-of-government biosafety and biosecurity system in place for all sectors including human, animal, and agriculture facilities and P.6.2: Biosafety and biosecurity training and practices in all relevant sectors. 20 JEE Areas P.2.1: A functional mechanism established for the coordination and integration of relevant sectors in the implementation of IHR; P.4.2: Mechanisms for responding to infectious and potential zoonotic diseases established and functional; R.1.2: National multisectoral multi-hazard emergency preparedness measures, including emergency response plans, are developed, implemented, and tested; and R.5.5: Addressing perceptions, risky behaviors, and misinformation. 21 The Animal (Terrestrial and Aquatic) Health Codes and Manuals of the World Organization for Animal Health (WOAH) provide international standards for the improvement of animal health and veterinary public health. 22 I.1 to I.6 for human, physical and financial resources, II.1 to II.7 for technical capacity, and III.1 to 3 and III.5 for interactions with stakeholders. Page 28 though unevenly distributed (Madhav et al. in Jamison can support country risk assessments and help identify 2017). The best strategy in the face of uncertainty about interventions to reduce the likelihood of spillover. when and where the next emergence and outbreak will strike is to focus on areas and practices of higher risk, also The likelihood of spillover is essentially a function of the called hotspots (Allen et al 2017). opportunity or frequency of encounters between animal microbes and humans, which generally depend on i) Concretely, resource allocation should prioritize diversity and abundance of animal hosts and their appropriate prevention financing instruments based microbes, ii) risk behaviors that bring people and animals primarily on geographical risk profiles that identify into contact and provide the interface for transmission, hotspots. Hotspots are areas where the likelihood of a and iii) environmental changes that drive spillover across spillover is highest. A robust assessment of spillover risks these interfaces. Where there are many humans and host at the country level is needed to determine national risk species it is more likely that there are active interfaces. profiles to guide prioritization in where to channel funds. Figure 5 shows a map of intersections between dense human and animal populations, combined with rich The causal pathways leading to initial spillover events, biodiversity and risk of deforestation and/or forest localized outbreaks spreading to become epidemics, degradation. The areas that are highlighted are where we and, in some cases, leading to pandemics, are most must focus greatest attention on prevention. This often complex, involving a mix of drivers that shape risk suggests an approach to identify hotspots based on and increase vulnerability. Although it may not be higher resolution mapping at the country level or to possible to predict the next pandemic, analyzing drivers locations within the country. FIGURE 5. Map for active interfaces between wildlife, livestock and humans Note: Highlighted areas represent the intersections of: Deforestation risk of 70 percent up to 2030 Hewson (2019); biodiversity, defined as the number of species above the 85th global percentile for all birds, rodents, primates, or bats from biodiversitymapping.org; livestock (pigs or chickens) density above 85th global percentile from FAO; and population density above 200 people per km2 from UN World Gridded Population.23 23 More detailed maps are available in the Technical Report, a companion document to this report (World Bank 2022d). Page 29 Most active interfaces are in low- and middle-income (iii) controlling urban sprawl through enforced land countries (Figure 5). About fifty-five—or 75 percent—of zoning to restrict overlaps between urban areas, wild IDA borrowing countries harbor the bulk of high-risk areas areas with host concentrations, and livestock units for EIDs originating in wildlife (Allen et al. 2017). Many (e.g., production, transportation, and retailing). middle-income countries and transitioning economies are The minimum requirements for prevention would be also highlighted on the risk map, essentially because of based on the obligations of countries to comply with high density of human and domestic animal populations. IHR (2005) and WOAH international standards and These high-risk areas are not just of local concern but also bring their animal and public health system to their pose potential global threats. Because of the world’s expected levels of capacity. This core prevention is interconnectedness, risk anywhere is risk everywhere, and critical. In addition, depending on their risk profiles, there is a strong need for collective accountability, countries need to integrate other elements of incentives, and disincentives. prevention, addressing specific drivers for EIDs such as animal production (e.g., good animal husbandry 5. DE-RISKING FARMS, FORESTS, AND practices), land use (e.g., landscape management and URBAN SPRAWL habitat conservation), or urbanization (Figure 3). We published three case studies prepared for Vietnam, The proportion of the world’s population living in urban Liberia, and Assam state (India) as companion areas by 2050 is projected to increase from 55 percent documents to this report (World Bank 2022a, b and c) to 68 percent, or close to 7 billion people. The average to illustrate how local context matters to delineate annual forest loss has significantly increased in low- prevention, based on a One Health approach, tailored income countries from the period of 1995-2000 to to specific risks and vulnerabilities. More systematic 2010-2020. Growth in consumption of meat is country-level risk assessments, such as the WHO projected to increase by 12 percent from the period of Strategic Tool for Assessing Risks (STAR) for example, 2017-2019 to 2020-2029, steering increase in are necessary to better implement One Health and risk livestock production. Those trends are diverse among reduction interventions at local levels since prevention regions and within regions and countries but illustrate is not a one-size-fits-all proposition; it requires actions the need to mitigate risks at the source. to be adjusted to the local context. Table 2 shows examples of such interventions designed to reduce risk Depending on their risk profiles, countries need to from wildlife and livestock. identify risk mitigation options targeted to the specific drivers for EIDs in their national context, such as More options are discussed in the technical report broadly published as a companion document to this report (i) limiting disturbance of ecosystems with high (World Bank 2022d). Prevention requires a set of presence of potential hosts by controlling land use interventions corresponding to the national and local changes and restricting human and domestic animal context. While systematically de-risking farms, forests, access to these ecosystems (e.g., caves with bats and urban sprawl, more interventions must be identified and forests with high concentration of primates); and tailored to the local risk profile, comprehensively (ii) improving biosecurity in production, transportation, considering drivers of EIDs. and retailing of livestock and restricting encroachment with wildlife in risky ecosystems and contact with humans through appropriate barriers (e.g., fencing, dedicated clothing when working on the farm, and controlled extensive grazing); and Page 30 TABLE 2: Examples of interventions to potentially reduce spillover risk from wildlife and livestock Reducing risk from wildlife connected to deforestation, forest degradation and fragmentation Landscapes • Buffer zones Ecological • Disease risk considerations in concession decisions interventions • Use restrictions (e.g., entry in caves) • Restrictions on agricultural areas and practices proximal to forests and wetlands • Establishment of protected and conserved areas • Habitat restoration and species management programs • Landscape design (contiguous forest versus forest patches) • Limited-impact infrastructure (e.g., restricted access and temporary roads) Communities • Risk communication and community engagement for behavioral change, e.g., for good health behaviors, Communication reduced exposure to wildlife, and safer handling practices and participatory • Payment for ecosystem services and other forest stewardship incentives practices • Support programs aimed at reducing human exposure to (high-risk) wildlife, including alternative protein sources and strategies to avoid contamination in food acquisition and food preparation practices. • Occupational health programs incorporating zoonotic disease awareness and safer practices • Upgrading market and trade infrastructure and facilities to reduce wildlife-livestock, wildlife-wildlife, and wildlife-human contact and potential for pathogen amplification and spillover Note: Other development activities may need measures to mitigate risks. These include oil, gas, or mineral extraction; road building, tourism or recreation in wildlife habitat or protected and conserved areas, and urban expansion. Reducing risk related to livestock Farms • Location of housing and avoiding proximity to (high-risk) wildlife Biosecurity and • Housing and fencing to avoid direct contact with other animals or humans good animal • Animal volume and density management husbandry • Animal breeding management practices (GAHP) • Animal feed storage and other contamination via food sources • Drinking water safety and security • Veterinary hygiene • Preparation and consumption of animals and animal products • Livestock waste management and environmental protection • Recording and filing activities Communities • Risk communication for behavioral change, (e.g., health behaviors, GAHP, and reduced exposure to wildlife) Communication • Policies and incentives for certain industries based on ecological and epidemiological conditions and participatory • Support programs aimed at reducing human exposure to (high-risk) animals, including via animal rearing, practices food preparation, and food consumption practices • Occupational health programs incorporating zoonotic disease awareness and safer practices • Demonstration of disease prevention and control measures in agriculture, livestock, and aquaculture farms, including AMR using One Health approach • Upgrade of market and trade infrastructure and facilities to reduce wildlife-livestock, livestock-livestock, and livestock-human contact and potential for pathogen amplification and spillover Reducing risk related to urban sprawl Urban planning • Preserve key wildlife habitat and resources to avoid wildlife-human conflict and community • Improve housing conditions to avoid wildlife intrusions engagement • Avoid supplemental feeding of wildlife • Develop effective waste management systems • Community engagement, regulations, and enforcement to curb illegal and/or unsafe wildlife trade • Market enhancements (e.g., improved ventilation, off-site slaughter) Page 31 Page 32 Overcoming the lack of incentives to invest in prevention There is an urgency to finance a One Health approach to Pandemic prevention is a global public good (GPG). It is pandemic prevention. More than ever, however, countries non-excludable (no country can prevent others from are facing multi-layer economic, health, and benefitting) and non-rival (one country benefitting environmental crises caused by climate change, does not limit the extent to which other countries can COVID-19, and the war in Ukraine. These crises affect benefit). Therefore, One Health, which sustainably every facet of peoples’ lives including livelihoods, health balances and optimizes the health of people, animals, and welfare, the quality of their environment, and and ecosystems, is the quintessential GPG, which may prospects for the next generation. Investments are explain underinvestment as countries hope to benefit needed across a wide swath of society to minimize without contributing (the classic ‘free-rider’ problem). backsliding on gains made on Sustainable Development Goals (SDG). In this context, governments are However, precisely because it is a global public good, increasingly challenged by the difficulties of mobilizing and despite the increasing pandemic risk, countries private and public sector involvement and financing typically underinvest in pandemic prevention and toward a common goal, deciding which sectors to invest preparedness, hoping to benefit from other countries’ in while managing trade-offs, and balancing short-term investments without contributing their own. Such crisis response measures with medium-to-long-term ‘free-riding’ behavior and the unique difficulty of development investments to build back better. investing in something whose successful outcome cannot be observed (and thus not credited) has been fueling the cycle of panic and neglect. Therefore, 1. REMOVING THE OBSTACLES TO international coordination of policy and financing is PREVENTION needed to ensure adequate investment, mitigate Because government leaders have much less interest in neglect, and limit such free-riding behavior. investments to prevent future events than they do in responding to current crises, an investment framework Many activities that drive EIDs (e.g., mining or other is needed to facilitate more, sustained attention and extractive industry, agricultural expansion, housing investments in critical interventions to bolster One developments) are also positive additions to the Health and pandemic prevention. economic output of a country, measured by its gross domestic product (GDP). While these activities There is an opportunity to increase financing of One generate revenues, they can also generate negative Health measures to prevent the emergence of zoonotic externalities, such as pathogen spillover. Most often, diseases under governments’ existing or committed such externalities are not quantified or factored into allocations, decreasing the need for new funding to countries’ development planning. For example, respond to outbreaks. This could be achieved by compared to an estimated global market value of ensuring that the One Health agenda is more US$10 trillion, food systems impose hidden costs of systematically considered not only in pandemic PPR, US$12 trillion dollars annually, more than half of which but also in plans to address biodiversity loss and is related to their impact on human health (The Food climate change and funding mechanisms such as and Land Use Coalition 2019). REDD+, the UNFCCC framework to reduce emissions from deforestation and sustainably manage forests, in On the other hand, investments in One Health based the areas with higher risk of future spillover (see Box 3). prevention can potentially reduce risk for large and growing areas of economic activity, such as agriculture and food. Page 33 Such investments and the multiple sectors of relevance can billion24 from reduction in CO2 emissions (Dobson et al. yield substantial co-benefits to tackling some of society’s 2020). Benefits to the agricultural sector (specifically most pressing challenges including biodiversity loss, livestock producers) could be substantial, driven by ecosystem degradation, and broken food systems. reduced frequency and scale of costly disease control measures such as culling, as well as expanded access to Reduced greenhouse gas (GHG) emissions and increased international and higher-margin markets for producers in resilience against climate change or natural disasters and low- and middle-income countries that put prevention ongoing sources of pollution, are among other co- measures in place (World Bank 2022d). benefits listed in Table 3 as examples. Under a One Health approach, potential trade-offs would also be The role of international financing institutions and the assessed and managed, such as rebound effect or Ministry of Finance or others in charge of resource potential for increased pressure in other parts of the allocation such as Ministries of Planning in some countries, systems under consideration. Most prevention is critically important in the operationalization of One interventions guided by the One Health approach will Health, though such roles are often poorly embedded in generate co-benefits to other sectors of sustainable and the design, monitoring, and evaluation of national and human development (economic, environmental, and global coordination activities. These agencies bring unique human health). As an example, a One Health approach to tools and capabilities that can be applied to support prevention would generate ancillary benefits of US$4.3 prevention and risk reduction by playing a powerful role in BOX 3: Synergy with climate Governments, and Ministries of Finance and Economy in particular, can use change action on efforts to reduce their policy, regulation, planning, and budgeting levers to drive holistic deforestation and/or structural economic reform that reduces the impact of drivers for EIDs, forest degradation such as unsustainable deforestation and/or forest degradation, food production or urbanization, among others. To illustrate this, Indonesia and deforestation provide an interesting example. We estimate that each year there are about 0.47 million ha of forests at high risk of deforestation in Indonesia, which have a high density of bats, primates, or rodents. The Indonesia Nationally Determined Contribution (NDC) to the Paris Agreement is to avoid 3.7 million ha of deforestation between 2021 and 2030, or about 0.37 million ha per year, of which a fraction could target areas of high density of wildlife to maintain the integrity of their habitats. Given the importance of deforestation and/or forest degradation as a driver for EIDs in Indonesia, the government could include One Health and pandemic prevention considerations in planning to curb deforestation and/or forest degradation and ensure that its focus is on areas with higher risk of spillover of infectious diseases. The World Bank, like other actors and partners, has a long-standing forest policy dialogue with Indonesia, which could provide an entry point to mainstream pandemic prevention policies and programs without necessarily requiring large amounts of additional funds. (World Bank, 2022d). 24 Based on an assumption of 118 fewer metric tons of annual CO2 emissions from 50 percent less deforestation (Dobson et al. 2020). Page 34 TABLE 3. Examples of expected co-benefits for One Health interventions to reduce pandemic risk Interventions Potential Co-Benefits Conservation of primary forest • Increased access to climate finance (e.g., REDD+) • Protection of ecosystem services including carbon sequestration • Protection of biodiversity Reforestation • Increased carbon sequestration • Reduced chemical runoff into aquatic ecosystems • Reduced soil erosion and improved resilience against disasters • Increase/restore ecosystem • Increased/restored wildlife habitat • Creation of green jobs Improved biosecurity in livestock • Reduced inappropriate use of antimicrobials operations • Improved animal health and welfare • Reduced endemic disease risk and incidence • Reduced wildlife-livestock conflict • Reduced likelihood of economic shocks or disruptions from disease • Expanded access to markets (exports, premium domestic products) • Improved management of risks by private sector addressing common barriers to ensure that priority Prevention needs to mobilize multiple financing sources actions on prevention in the appropriate sector(s) are based on who benefits most from the interventions, adequately budgeted and executed. In addition, existing with priority around forests, farms and urban sprawl. A national action plans (particularly for biodiversity, health first best approach to determine financing security, and AMR) remain under-financed and often responsibilities for One Health based prevention is to developed in a fragmented, siloed manner, leaving deficits assign financial responsibilities to the people who in their ability to be implemented and missed benefit most from the interventions. One Health based opportunities for synergies. prevention is above all a GPG, and prevention that stems a local outbreak before it becomes a pandemic is We can hardly over-emphasize the economic case for a global public good. However, there are many One Health (i.e., the cost of prevention is extremely pathogens that are less contagious and less likely to modest compared to the cost of managing and lead to a pandemic, despite generating local infections responding to pandemics) as well as its many co-benefits and burdens of disease. The main beneficiaries from to other sectors of sustainable and human development prevention in this case might be the population of a and take advantage of the growing consensus and country or group of countries or regions within a momentum of the critical importance of One Health at all country. Prevention here has more the nature of a levels of society, especially in the wake of COVID-19. domestic public good, since most benefits accrue to a localized population, and global risks are small. And 2. FINANCING PREVENTION AS A finally, there are diseases that may infect some people, SHARED RESPONSIBILITY but with limited human-to-human transmission. In this case, prevention takes the nature of a private good or A pandemic is an epidemic occurring over a wide area, benefit. Financing should assign responsibilities for high or worldwide, crossing international boundaries and pandemic risk reduction to global sources, which usually affecting many people. Outbreaks start locally, should be passed on as grants or highly concessional however, and it may be difficult at the onset of a local financing to implementing units in national event to predict its pandemic potential. Prevention governments. Low pandemic risk infections, on the brings benefits both locally and globally. Page 35 other hand, should fall under domestic governments of potential to develop into pandemics. Therefore, there is the jurisdiction at risk. Finally, where private benefits a case to be made for international financing for this are identified, financing should fall to the person likely class of pathogens in low-income countries that will to benefit. otherwise underinvest in prevention. For pathogens with minimal spread, the burden of prevention may While this first thinking offers some guidance on how to primarily be borne by the individual most likely to be assign financing responsibilities, reality is more affected. The actual determination of who pays for complicated. First, there are considerable co-benefits which kind of prevention actions requires a negotiating from One Health prevention. For example, reducing process in specialized One Health focused governance ecosystem disturbance by avoiding deforestation and/or structures in each country. forest degradation to reduce the risks of infections from a localized (non-global) vector, which is a domestic public This reasoning suggests a shared, but separate, good, would also reduce GHG emissions, which is a GPG responsibility that considers spillover risks, beneficiaries accruing to the world at large. Likewise, improving from reducing these risks, and financing capacity. Key biosecurity to reduce domestic animal endemic elements are captured in Table 4. First, domestic infections of low pandemic risk, while a domestic public governments would commit to comply with their good, would have global benefits in that it might also obligations under IHR (2005) (capability to detect and reduce the risks of other pathogens that may evolve into report potential public health emergencies) and WOAH forms with a potential global reach. Secondly, most often international standards (core competencies for than not, national governments may not have the preventing animal disease and zoonoses in human resources to make the incremental effort, for example to populations). Reaching these levels could be financed strengthen public veterinary services, to address the from domestic sources (government revenues) or from domestic infection risk. Similarly, many poor private market-based or concessional loans such as from IDA. livestock keepers may not have the resources to invest in Second, international financing (either grants or high measures required to prevent them from getting sick concessional loans) would cover the incremental costs to from pathogens with low human and animal spillover risk. reach levels of pandemic management including prevention above what those minimum standards The reason to focus on a pathogen’s likely economic require. This financing should be prioritized for high-risk impact, that is, the potential cost of a spillover and areas and can be sourced by reassigning some existing spread, is to understand the incentives for financing funds to actions that also bring pandemic prevention prevention actions, which determines who should pay benefits, and by mobilizing additional dedicated funding. for which measures. The case for investing more in For example, certain climate funds could be retargeted to prevention for pandemics such as COVID-19 is clear high-risk areas and the PPR FIF could bring additional across the board—in donor countries and low-income funding. These funds should be provided as grants. Third, countries. Given the GPG nature of these actions, financing resources would also need to be made available international financing should be provided as grants or to low-income people, such as poor livestock keepers, loans with high concessionality. However, it is obvious who cannot afford or access the relevant health and that localized outbreaks (e.g., the Nipah virus) which veterinary services, for them to undertake the One carry localized, but high, economic costs are of equal Health interventions needed to prevent private, low concern for the countries affected. Moreover, given that pandemic risk infections. These public veterinary and prevention measures are usually not pathogen-specific health service resources could be provided as grants (e.g., reducing deforestation and/or forest degradation, (based on poverty levels), insurance, or credit in contexts farm biosecurity, or urban-rural land planning), where household budget is insufficient. prevention measures for these pathogens will also have an impact on preventing other pathogens that have the Page 36 TABLE 4: One Health-based prevention financing: sources and destinations BENEFICIARIES Global population, Local population, Poor households, global spread localized spread minimal spread (e.g., COVID-19) (e.g., Nipah virus) (e.g., rabies) Grants (new funding International source or from Market or High-Concessional resources transferred existing sources concessional loans loans to domestic agencies High risk such as climate areas financing) (hotspots) Income support/ SPILLOVER RISK Domestic resources - Public services public services Microfinance, Private resources - insurance, Household budget International High- resources transferred Concessional - - to domestic agencies loans Lower risk Income support/ Domestic resources - Public services areas public services Microfinance, Private resources - insurance, household budget Note: Hyphen (“-“) denotes areas that are not priority areas for One Health financing. Page 37 The investment framework needs to consider already countries. However, the burden of pandemics is heavy financed co-benefits. As mentioned earlier, prevention also in low- and middle-income countries along many actions may coincide with other global agendas, both in dimensions, not least of which are increased food geographical focus and objectives of interventions. For insecurity, slower economic growth, and loss in human example, reducing deforestation and/or forest capital. Because we cannot predict exactly where or degradation will also prevent pandemic risks from when the next virus of pandemic potential will arise, ecosystem disturbance, a One Health goal, in addition every country must mainstream One Health into their to reducing GHG emissions and protecting biodiversity, development frameworks. Investing in One Health is which already have dedicated global funding sources. It closely aligned with human and sustainable may be feasible to redirect some of those programs to development goals that countries are already pursuing also address pandemic risk without reducing the and, as such, will allow countries to leverage significant benefits accruing to their initial objectives. For example, co-benefits. efforts to reduce deforestation and/or forest degradation covered by climate funding could be Investing in pandemic prevention is the ultimate GPG. retargeted to pandemic hotspots, and within those, to High-income countries that have the most to gain in ecosystems where the abundance of hosts is highest. preventing the next pandemic must support low- and middle-income countries where spillover hotspots exist A new financing instrument for PPR and an by providing adequate international financing. The international accord on pandemics are expected to global community has a role to play in raising awareness strengthen the global health architecture, within which of the issue, ensuring that prevention based on One prevention cannot be narrowly defined to health sector Health is not sidelined in new mechanisms that are actions but need to be broad enough to encompass currently being developed such as the FIF for pandemic other sectors based on a One Health approach. PPR or the global accord on pandemics currently being negotiated by the INB. It also requires developing 3. ENSURING COUNTRY OWNERSHIPS further and enforcing minimum standards for what AND ENABLING INSTITUTIONAL constitutes One Health spending, supporting countries’ ARRANGEMENTS technical capacity to deliver on One Health related tasks, and developing an accountability structure to In laying foundations for global health security, the ensure that One Health investments are sustained even framework needs to be implemented at the country when the current threats recede. level with policy makers and technical partners to assess risks of EIDs, identify country vulnerabilities, There is a need to further integrate the relevant review national financing, and explore resource standards into a One Health framework for pandemic mobilization options across sectors, including public prevention. Also, standards must be expanded to and private sources, aligned with countries’ prioritized address the root causes of pandemics, namely the national action plans. drivers that increase the interaction between humans and animals (e.g., deforestation and/or forest Ultimately, investments for prevention must be made at degradation and urban sprawl that create zones with the country level, especially in countries with spillover high human-animal interaction). hotspots. Once the SARS-CoV-2 virus started spreading, it reached every corner of the globe, and no One Health is a coordination-heavy agenda that country was spared COVID-19’s health and economic requires strong champions and a strong institutional losses. Pandemic risk may have been perceived as arrangement backed by solid technical capacity hypothetical and a concern for high-income countries, supporting its work. Thus, to support countries, there is while endemic diseases already burden lower-income an important role for global technical agencies, and Page 38 primarily the Quadripartite Alliance, and international multi-year, planning process contributing to accelerate financial institutions (IFIs), and even regional the implementation of PPR core capacities, and is institutions to coordinate global and regional activities based on a One Health for all-hazards, whole-of- by the public sector (for public goods such as public government approach. Other national plans, such as health systems, public veterinary systems, and National Biodiversity Strategies and Action Plans surveillance data systems) and the private sector (e.g., (NBSAPs), which will be updated following the livestock farmers, loggers, forest-based communities, adoption of the post-2020 global biodiversity and land developers). framework, and Nationally Determined Contributions (NDCs) under the Paris Agreement should also be WOAH and WHO have developed a joint process to considered and integrated where relevant. bridge their assessment tools through the IHR/PVS National Bridging Workshops (NBWs), targeting the Key actions are listed in the table below (Table 5) to operational One Health approaches at national level correct the prevailing panic and neglect cycle and (Belot et al. 2021). The process enables countries to mainstream a One Health lens into national development identify actions that support collaboration while frameworks. For country governments, it will be critical advancing evaluation goals identified through the IHR to mainstream One Health into their development and PVS Pathway. By integrating sector-specific and framework, to provide coordination, ensure public collaborative goals, the NBWs help countries to create expenditure management and support technical a joint road map for enhanced compliance to capacity. Strategic commitment is needed from IFIs, international standards and strengthened prevention, along with knowledge creation, global coordination, and preparedness, and response (World Bank 2018). This provision of financial support to countries. There is a role should contribute to the National Action Planning for also for the technical partners of the Quadripartite in Health Security (NAPHS) that is a country owned, relation to methodologies and standards. Page 39 TABLE 5: Governments, financial institutions and technical partners’ needed actions for One Health- based prevention investments Country Mainstreaming One • Carry out a systematic risk assessment for spillovers to identify national governments Health into the hotspots and establish risk profiles. development framework • Incorporate a One Health lens (based on the risk map) into national development and PPR strategies and investment frameworks. • Realign relevant policies, specifically climate change, forest management, biodiversity conservation, land use planning, urban planning, and agriculture policies (especially livestock policies), to mainstream One Health considerations. In-country coordination • Set up national and regional One Health coordination mechanisms that work across sectors, adopting a programmatic approach, with private sector and other partners, to holistically support PPR at regional, country, and local levels. • Increase engagement with non-health fields and the private sector to encourage their ownership of the One Health agenda (environment, agriculture, livestock, climate change, etc.). • Encourage or possibly mandate Environmental, Social, and Corporate Governance (ESG) standards that include One Health in corporate regulations. Public expenditure • Develop a country-specific One Health expenditure tracking guideline. management • Improve the visibility of One Health-related expenditure in the national budget system (Financial Management Information Systems) through practices such as budget tagging for One Health and unbundling One Health expenditures in larger health and non-health programs. One Health technical • Strengthen technical capacity to increase compliance with IHR (2005) and capacity WOAH standards for pandemic prevention and preparedness. • Strengthen technical capacity in other relevant sectors. • Strengthen the monitoring and evaluation function of One Health-related programs so that they consistently generate high quality administrative data. Page 40 IFIs Strategy • Multilateral Development Banks to include or strengthen policy commitments related to One Health in their concessional funding replenishment cycles (e.g., IDA20 policy commitment to support countries to mainstream One Health). • Mainstream PPR more systematically in standard country analytics (such as the World Bank’s SCDs or the IMF’s Article IV consultations). • Incorporate One Health in country engagement activities, identifying relevant One Health entry points for projects and operations across relevant sectors. • Routinely assess and report on trade-offs and co-benefits of investments related to pandemic prevention in project preparation and evaluation. Knowledge creation • Carry out analytical work on One Health such as regional/country case studies and diagnostics, methodology development for pandemic risk assessments, and public expenditure reviews focused on One Health. • Develop monitoring and evaluation methodology for One Health related programs to measure its outputs and outcomes. Global coordination • Raise awareness of benefits of One Health to stimulate country demand for investment and trust fund resources from donor countries. • Support the implementation of the Quadripartite One Health Joint Plan of Action (2022-2026) by aligning financing toward identified priority areas. • Promote a commonly accepted budget reporting system to allow for consistent reporting on One Health expenditures across countries. Country support/ • Support countries in increasing their capacity to achieve compliance with a financing One Health minimum standard (IHR (2005) and WOAH Code and Manual). • Mobilize financing mechanisms, such as IDA, IBRD, as well as the recently approved FIF for PPR and ensure sufficient coverage for One Health-based prevention investments in its funding allocations. Quadripartite Methodologies and • Strengthen methodology and further integrate mechanisms for JEE, PVS standards pathway, NBW, STAR, NAPHS and One Health national planning process for pandemic PPR. • Develop a One Health crosswalk for relevant standards and expand standards to cover drivers of pandemic risk. • Monitor progress under the OH Joint Plan of Action with regard to pandemic prevention. Pandemic prevention is a global public good. Page 41 Moving forward More than two years after the outbreak of the most of investments for prevention are, simply, inadequate. devastating zoonotic disease in a century, now is the time to act and take a One Health approach in Experience has shown that once time passes, memories development and pandemic prevention financing. If not will erode, new crises and challenges will emerge, now, when? pandemic prevention will again be forgotten by the highest-level decision makers, and the world will again While the world has understandably been focused fall into a state of chronic underinvestment in primarily on responding to the immediate threat and prevention, which had been the case before COVID-19 damages caused by COVID-19, some have begun to look shook the world in early 2020. at the longer-term challenges and the failures of the current system that allowed such a destructive This report presents a One Health investment zoonotic pandemic to emerge and spread throughout framework to deliver the objectives of pandemic risk the world. The response to COVID-19 shows that the reduction within the broader PPR agenda. This international community does not have a well- framework, the proposed practices and approaches to structured and coordinated system for managing the investing in prevention, and the principles that guide risks of zoonotic diseases, that institutional ambiguities them, was informed by the results of this analytical and the narrow mandates of technical agencies work and by experience gained by the World Bank, its continue to preclude the practical implementation of client countries, and technical partners in addressing One Health at the needed scale, and that current levels recent public health crises. FIGURE 6. One Health investment framework to reduce pandemic risk Complying Fo with c ho usin to minimum tsp g o g ot n i f ti emic n n standards s Sh and ntio p eve pr De-r s, fores rban the urawl farm and th One opting iskin sp Heal ts KEY ACTORS g including Ad Country Governments Share costs International Financial Create enabling according to the Institutions institutional expected benefits Quadripartite arrangements Investment framework to mobilize finance for prandemic prevention Page 42 In this framework (Figure 6), investments are guided by prevention. This instrument, along with ongoing efforts five core principles to be applied while mobilizing to strengthen the global health governance, holds finance for a fair share of the burden and creating promises to bring additionality in financial resources for enabling institutional environments for countries to prevention, incentivize countries to invest more, and make progress and to serve as building blocks for an defragment the pandemic PPR landscape. effective global One Health implementation support architecture and pandemic risk prevention. The While the international architecture for pandemic framework encompasses critical areas of intervention prevention is operationalized with identified roles for and emphasizes their integration and funding into countries, IFIs, and the Quadripartite, the crux of the finance mechanisms that will be sustainable over time, next steps must be a country-led process. This will and at scale. In laying foundations for global health include agencies working together to support countries security, the framework must be implemented at the to identify, prepare, and invest in projects to reduce country level, strongly aligned with countries’ spillover and co-finance prevention interventions. prioritized national plans. Eventually, the implementation will require a broader set of actors in the civil society. 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