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Emily Wymer, Sinéad Dwyer
July 13, 2022
The COVID-19 crisis revealed serious gaps in health system structures, particularly in disease surveillance capacity and financing worldwide. Momentum for disease surveillance scale-up has increased in the wake of the COVID-19 pandemic and advocates should capitalize on intensified support to encourage donors to fill the gaps.
SEEK Development, with support from the Bill and Melinda Gates Foundation, set out to address the gap in disease surveillance financing knowledge by estimating a baseline level of funding that is currently directed toward disease surveillance systems worldwide. The resulting report presents our best estimate of existing international and domestic funding for disease surveillance.
Our frontline defense - strong surveillance systems that can rapidly detect emerging infectious diseases and respond to them - was exposed by the COVID-19 pandemic and had serious shortcomings. Lack of diagnostic capacity, limited contact tracing, and fragmented and incomplete data systems prevented rapid identification and containment of SARS-CoV-2. Collected information on the virus was not shared quickly or consistently enough at both the domestic and international levels, limiting individual, government, and multilateral capacity to make well-informed public health decisions.
In addition to pandemic threat response, disease surveillance systems are fundamental to effective national and global health systems. Information collected from disease surveillance systems enables policymakers to allocate scarce resources based on population needs and health burdens, monitor the effectiveness of public health interventions, and identify high-risk population groups or risk factors for disease causation. Policymakers need real-time accurate intelligence to make evidence-based public health decisions to inform disease prevention and control efforts.
Stronger surveillance systems are needed if we are to better respond to the next pandemic threat, tackle emerging global health threats, such as anti-microbial resistance (AMR), and endemic diseases, such as tuberculosis (TB). There has been no transparency on how much money is actually being spent by whom to support disease surveillance in low-resource settings. This report seeks to provide transparency and inform decisions on how funding for disease surveillance can be scaled up and made more efficient.
In 2021, the G20 High Level Independent Panel (HLIP) estimated that an additional US$74 billion in public investment for robust surveillance and detection is needed over the next 5 years to prevent and detect emerging infectious diseases.The panel recommended that US$48 billion (or 66%) of this should come from national budgets, while the remaining US$26 billion should come from international financing.
These estimates provide direction for the global community to improve disease surveillance capacity with a focus on pandemic preparedness, but they do not provide an insight into the current funding situation. Without clarity on current funding trends, it is challenging to translate high-level financing estimates into concrete strategies on how to best mobilize and allocate financing. An enhanced understanding of existing flows is also essential for advocates to champion increased funding for disease surveillance targeted toward areas with the greatest impact.
Currently, international and domestic funders alike do not have a shared definition of funding for disease surveillance. Their different motivations for investing in disease surveillance result in different perspectives on what constitutes disease surveillance, for example, on whether the cost of diagnostics should or should not be included. In addition, the importance of wider health systems in enabling disease surveillance systems makes it hard to disentangle investments in disease surveillance systems from broader investments in health system strengthening. For example, community health workers (CHW) play an important role in detecting and reporting on health events but disease surveillance is only a small part of their role.
As defined by International Health Regulations (IHR), disease surveillance is, “the systematic ongoing collection, collation and analysis of data for public health purposes and the timely dissemination to those who need to know for public health action”. Within this study, we also incorporated components of the disease surveillance system proposed by the “Not the last pandemic” costing exercise. For the purposes of tracking funding, we grouped the components of a disease surveillance system into the following four functions:
Given there is no common definition of disease surveillance, there is also no systematic tracking of activities or funding that support disease surveillance. Our analysis focused on identifying funding flows from three key categories of international funders - donor governments, multilateral organizations, and philanthropic foundations - for 2019 and 2020 (the first year of the COVID-19 crisis). Given the lack of a comprehensive data source, the analysis made use of a mixed-methods estimation approach, drawing on keyword analysis of OECD CRS datasets on ODA flows, as well as desk research and interviews. Informed by this quantitative and qualitative assessment of the baseline, we then developed recommendations on how financing for disease surveillance can be scaled up and made more efficient.
US$2.3 billion in international funding in 2019 was related to disease surveillance, reflecting its enabling function, even before the COVID-19 crisis’ impact on funding priorities.
More than half (63%) of identified international funding was channeled through the multilateral system, including as earmarked funding to specific programs and funds managed by multilateral organizations. All the major multilateral organizations in global health (The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), World Health Organization (WHO), United Nations Children's Fund (UNICEF), World Bank and Gavi, the Vaccine Alliance (Gavi)) funded disease surveillance activities in 2019, reflecting both the complexity and cross-cutting nature of international funding for disease surveillance. The Global Fund, WHO, and World Bank provided more than 80% of total multilateral funding, equivalent to more than half of all international funding.
15% of identified international funding for disease surveillance flowed as bilateral ODA from a small number of donors, notably the US and UK. We sought to determine whether the largest government donors were also using non-development budgets to finance bilateral disease surveillance initiatives. With the notable exception of the US, which has invested internationally using ODA and non-ODA sources since the 1990s to reduce the threat of emerging infectious diseases, we did not identify significant flows that were not already included in bilateral or multilateral ODA estimates.
13% of funding was provided through philanthropic donors in 2019, with the largest contributors being the Bill & Melinda Gates Foundation, Bloomberg Philanthropies, and The Wellcome Trust. The philanthropic funding estimate is conservative, as some philanthropic organizations’ contributions were not quantifiable.
Funding increased by 64% in 2020 to US$3.8 billion. At least US$1 billion (68%) of the US$1.5 billion increase was directly related to COVID-19 activities. Total ODA only increased by 3.5% in 2020, implying that most of the increased funding for disease surveillance was reallocated from other priorities. Significant amounts of COVID-19-related surge funding came from emergency budgets and went to short-term spending needs; much of this funding is unlikely to contribute to long-term improvements in disease surveillance capacity.
Multilateral funders significantly scaled up funding for disease surveillance in 2020 in response to the COVID-19 crisis. The World Bank increased funding by 169% as a result of significant new programming to support countries to prevent, detect and respond to COVID-19. The Global Fund increased its funding for disease surveillance by 66% in its role as co-convenor of the Access to COVID-19 Accelerator (ACT-A) Diagnostics Pillar, providing additional funding for COVID-19 diagnostic procurement and reinforcing national COVID-19 responses, including case detection, lab capacity, and data collection and analysis; additional resources came from the Global Fund COVID-19 Response Mechanism. WHO increased funding for disease surveillance by 34%, enabling it to provide emergency support for global, regional, and country-level surveillance of COVID-19. WHO’s COVID-19 resources came from the WHO Emergencies Fund, which increased by 141% between 2019 and 2020. Gavi carried out some COVID-19-related disease surveillance in early 2020 before deciding to focus its COVID-19 response exclusively on vaccine equity.
International funding for disease surveillance is overwhelmingly disease-specific, evidenced by international funders’ rapid scale-up for COVID-19 support in 2020. Significantly less international funding is available for integrated disease surveillance systems or surveillance of often neglected diseases. This trend creates a focus on disease-specific outcomes rather than strengthening integrated disease surveillance systems.
Multilateral funding for disease surveillance is particularly disease-specific. The Global Fund, as the largest funder in 2019, mostly provided disease surveillance funding for its focus diseases, HIV, TB, and malaria. WHO, the second-largest funder in 2019, played a coordinating role, but its funding was still largely disease-specific and responsive. More than one-third (37%) of its estimated funding for disease surveillance comes from the Global Polio Eradication Initiative (GPEI). This funding could contribute to broad disease surveillance systems strengthening but demonstrates that funding allocation is weighted toward polio-related needs.
Given the multilaterals’ focus on disease-specific surveillance, it is unsurprising that the largest share of disease surveillance funding in 2019 and 2020 went to programmatic surveillance. In 2020, the volume and share of funding for programmatic surveillance increased as a result of additional COVID-19-related funding. The second-largest share of funding went to laboratory capacity, including from the Global Fund, WHO, and World Bank. Governance, analysis, and decision-making were the third-largest category and came predominantly from WHO and bilateral donors. 11% of disease surveillance funding went to foundational components of disease surveillance in 2019 and came predominantly from the Global Financing Facility (GFF) at The World Bank, UNICEF, and bilateral donors. 13% of funding in 2019 supported ‘surveillance general’, which is indicated for cross-functional projects and non-disease-specific functions; this funding came largely from the World Bank and bilateral donors.
The G20 HLIP called for additional disease surveillance funding - an additional US$5.2 billion per year over five years above 2019 and 2020 estimates. To meet the additional need identified by the G20, international funding for disease surveillance would need to increase more than threefold from a 2019 baseline. Even the significantly increased 2020 funding levels for disease surveillance are far below what is needed to adequately prevent and detect emerging infectious diseases. The emergency nature of these uses and sources of funding during 2020 suggests that there is a significant risk that funding may revert to the baseline level once the COVID-19 crisis is considered ‘over’.
Information on domestic level funding for disease surveillance is scarce and inconsistent. Despite limited data, we know that funding at the domestic level for disease surveillance is extremely low, especially in low-income countries (LICs) and lower-middle-income countries (LMICs). Tracking this funding is difficult because country-level reporting is irregular, and the data are not granular enough to specifically measure disease surveillance funding.
The National Health Accounts (NHA) data provides the best estimates available for country-level spending. Examining subfunction HC6.5, Epidemiological Surveillance and Risk and Disease Control Programmes (subfunction HC.6.5), while including far more than just disease surveillance spending, gives us a range within which we can estimate domestic level spending on disease surveillance. The data demonstrates significant underspending in LICs and LMICs compared to both high-income countries (HICs) and the G20 HLIP target.
International funders and HICs should ramp up funding for LICs and LMICs for domestic disease surveillance capacities. While more international funding is necessary on the domestic level for LICs and LMICs, in-country capacity for disease surveillance would need to be scaled up in tandem to increase individual countries’ ability to absorb international funding.
While the COVID-19 pandemic exposed challenges in disease surveillance, it also intensified efforts to fill the gaps, leading to new investments at the national and global levels. Momentum in the wake of COVID-19 should be maintained to ensure that shortcomings are addressed appropriately, and additional funding is mobilized. To improve disease surveillance systems, advocates, governments, and multilaterals need to ‘scale, integrate, and track’.
By scaling up, integrating, and tracking disease surveillance funding, advocates, public and private financiers, and governments will be better prepared to respond to the next pandemic and support more robust health systems overall.
The OECD’s dataset on Official Development Assistance (ODA) is not set up to track cross-cutting flows to topics such as disease surveillance. Many of the multilateral and philanthropic organizations we interviewed had no centralized overview of their disease surveillance activities or funding. At a domestic level, there is no comparable national tracking of funding for disease surveillance systems.
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