Is the World Ready for the Next Pandemic? A Post-COVID-19 Assessment

The COVID-19 pandemic served as a stark reminder of the devastating impact that global health crises can inflict on societies and economies worldwide. In the wake of this unprecedented event, a global consensus emerged, encapsulated by the sentiment of “never again,” signifying a collective commitment to bolster pandemic preparedness and prevent future catastrophes. This aspiration aimed to translate into tangible actions, including increased investment in public health systems, the establishment of robust pandemic preparedness funds, and the cultivation of unwavering public trust in health institutions. However, a critical examination of the current global landscape reveals a troubling divergence from these noble intentions. Evidence suggests a concerning trend of shrinking global investment in public health systems, the reallocation of dedicated pandemic preparedness funds towards other pressing priorities, and a persistent fragility in public trust towards health institutions.

Simultaneously, the world is grappling with a confluence of emerging infectious disease threats that silently yet steadily gain ground. The resurgence of avian influenza (H5N1), the increasing prevalence of climate-driven vector-borne diseases, and the escalating crisis of antibiotic resistance present formidable challenges to global health security. These evolving threats underscore the critical questions that must be addressed: Why, despite the lessons learned, does prevention continue to be underestimated in favour of reactive measures? Why does global vaccine equity remain more of a rhetorical commitment than a lived reality? And why are public health professionals, once lauded as heroes, now facing underfunding and overwhelming workloads? The next global health crisis may not afford the luxury of learning through trial and error, making proactive and sustained investment in public health an imperative, akin to investing in national defence, as health constitutes a fundamental pillar of security.

The Ebbing Tide: Global Investment in Public Health Systems

Post-Pandemic Spending Trends

The initial phase of the COVID-19 pandemic witnessed a significant mobilization of resources towards government health spending (GHS) per capita in developing countries.1 During the first two years of the pandemic, central government health spending soared, growing by approximately 21 percent in per capita terms in 2020 and reaching 25 percent above 2019 levels in 2021.1 This initial surge reflected a clear prioritization of health in government spending as nations grappled with the immediate crisis.1 This capacity for rapid resource mobilization during a crisis demonstrated that political will, when confronted with an imminent danger, could indeed translate into substantial financial commitments to the health sector.

However, this strong initial advance in real per capita government health spending lost momentum in the third year of the pandemic, giving way to an early retreat.1 On average, it contracted from its peak of 25 percent to only 13 percent above the 2019 level, nearing its pre-pandemic trajectory.1 This decline indicated a potential shift back to pre-pandemic priorities, suggesting a lack of sustained commitment to public health investment once the immediate emergency phase appeared to subside. As the acute phase of the pandemic eased, other pressing economic and social demands likely prompted a reallocation of resources away from health initiatives. This trend highlighted the persistent challenge of maintaining focus and financial support for prevention and preparedness in the absence of an immediate, visible threat.

Furthermore, the growth in GHS per capita between 2019 and 2023 was modest, averaging only 1.2 percent annually in both low-income countries (LICs) and lower-middle-income countries (LMICs).2 This rate was significantly lower than the pre-pandemic growth of 4.2 percent in LICs and 2.4 percent in LMICs between 2015 and 2019.2 This slowdown in growth suggested a weakening prioritization of health within government budgets. Even with some continued increase in overall government spending, the proportion allocated to health was not keeping pace with pre-pandemic trends, implying that health was becoming a relatively lower priority compared to other sectors.

A stark reversal was also observed in the priority governments gave to health, with the central health share in general government spending tumbling from its maximum of 17 percent above the 2019 baseline to only 5 percent above by 2022, falling back to its pre-pandemic trajectory.1 This decrease in health’s share of overall government spending, returning to pre-pandemic levels, was a strong indicator that the initial prioritization of health was temporary and not institutionalized.1 Despite the profound lessons learned from the pandemic, governments were not consistently allocating a larger proportion of their budgets to health, suggesting a failure to fully internalize the critical importance of sustained investment.

Compounding these challenges, many countries are projected to experience contracting or stagnant overall government expenditure through 2029.2 Among the 170 countries examined, 29 are anticipated to experience a contraction in per capita spending from 2019 to 2029, while 67 are projected to see sluggish growth.2 These future fiscal constraints will likely further limit the capacity for health spending increases. With numerous nations facing economic headwinds and rising debt levels, the competition for limited government funds will intensify, potentially squeezing the health sector even further. Despite compelling evidence indicating that investing in health is critical for productivity and inclusive growth, governments are allocating less money to health than they did before the COVID-19 pandemic.3 This disconnect between evidence and action suggests a systemic undervaluation of public health investment. Policymakers may be prioritizing short-term economic or political gains over long-term investments in health, despite the clear and well-established link between a healthy populace and economic prosperity.

The situation is particularly concerning in 35 countries, representing over 2.5 billion people, where both per capita government health spending and the health share of government budgets have declined since 2019.2 This simultaneous decline in both indicators paints a particularly troubling picture for the health systems in these nations. These countries are not only spending less on health per person but are also allocating a smaller fraction of their overall resources to it, signifying a significant shift away from health as a budgetary priority.

Reasons Behind Funding Changes

The initial surge in government health spending was primarily driven by the immediate need to control the COVID-19 pandemic, compelling governments to prioritize health in their expenditure.1 However, as the pandemic evolved and other global challenges emerged, new spending demands arose, including those related to energy and food price hikes, as well as rapidly rising debt service costs.1 These competing demands contributed significantly to the subsequent reversal in health spending prioritization. The interconnectedness of global challenges meant that economic crises could quickly divert resources away from even recently prioritized sectors like health, underscoring the need for resilient financing mechanisms capable of withstanding such shocks.

Economic fluctuations, such as recessions or unexpected events like the COVID-19 pandemic, further strained public health funding.4 Public health funding often proves vulnerable to broader economic cycles, leading to instability in resource allocation. During economic downturns, discretionary spending, which often includes public health initiatives, tends to be among the first areas to face budget cuts, even though these are the times when populations may be most vulnerable to health issues and require robust public health support.

Furthermore, during the COVID-19 pandemic, many governments found themselves compelled to redirect resources towards emergency response efforts.4 While this reallocation was undoubtedly essential for saving lives and mitigating the immediate impacts of the pandemic, it often came at the cost of leaving routine healthcare services underfunded. This focus on immediate crisis response, while necessary in the short term, can have significant long-term negative consequences for overall population health. Neglecting routine care and preventative services can lead to a backlog of health issues, potentially resulting in more severe and costly health problems in the future.

The capacity of many countries to invest in health is also increasingly threatened by rising interest payments on public debt.2 High debt burdens can create a substantial barrier to sustained public health investment. As countries allocate a larger proportion of their resources to servicing their debt obligations, less funding becomes available for essential social sectors such as health, thereby hindering their ability to build strong and resilient health systems capable of withstanding future health crises.

Implications of Declining Investment

The sustained declines in government health spending per capita and the diminishing share of health in overall government expenditure pose significant risks to the sustainability of government investment in health.1 These shifts cannot be disregarded, particularly as countries urgently need to regain progress towards Universal Health Coverage (UHC) and other health-related Sustainable Development Goals (SDGs) after the setbacks caused by the COVID-19 pandemic.1 The post-pandemic decline in health spending threatens to derail these long-term global health goals. Achieving UHC and the health SDGs by the 2030 deadline necessitates sustained and increasing investment in health systems, and the current trends indicate a movement in the opposite direction.

Without decisive action to reverse these trends, countries face the potential for serious setbacks in crucial areas such as human capital development, poverty reduction, and overall economic growth.2 Underinvestment in health has broad socioeconomic consequences that extend far beyond mere health outcomes. A healthy population forms the bedrock of a thriving society and a robust economy, and neglecting health can trigger a cascade of negative effects across various sectors. Moreover, the growing disparities in health investment between countries threaten to exacerbate existing global inequalities, potentially undermining global stability and prosperity.2 When some nations lack the necessary resources to adequately invest in their public health systems, it not only harms their own populations but also elevates the risk of infectious disease spread and societal instability that can readily cross international borders in our interconnected world.

Low-income and underserved areas are particularly vulnerable to the consequences of inadequate financial support for public health.4 Existing health inequities are likely to be amplified by the decline in public health funding. Those populations that were already most vulnerable to health challenges before the pandemic will likely bear the brunt of reduced health spending, further widening the gap in health outcomes and hindering progress towards health equity. The declining trend in health investment also carries the significant risk of stalling progress on other critical global health priorities, including pandemic prevention and preparedness.1 Effective pandemic preparedness requires sustained funding for essential activities such as disease surveillance, scientific research, and the development of robust public health infrastructure and workforce, all of which are jeopardized by the current downward trajectory in health spending.

Table 1: Trends in Government Health Spending in LICs and LMICs (2019-2023)

Indicator	LICs (USD per capita)	LMICs (USD per capita)
Government Health Spending (2019)	10	54
Government Health Spending (2020)	13	–
Government Health Spending (2021)	–	64
Government Health Spending (2023)	10	55
Annual Growth of Per Capita GHS (2019-2023)	1.2%	1.2%
Annual Growth of Per Capita GHS (2015-2019)	4.2%	2.4%
Change in Health Share of Central Govt. Spending (2019-2021)	+17%	+17%
Fall in Health Share of Central Govt. Spending (2022)	Below 2019 levels	Below 2019 levels
Countries with Decline in Both Per Capita Spending and Health Share (since 2019)	35	35

Note: Data compiled from.1

Reallocating Priorities: The Status of Pandemic Preparedness Funds

Overview of Global Preparedness Funds

In the aftermath of the COVID-19 pandemic, the international community recognized the urgent need for dedicated financial mechanisms to bolster global pandemic prevention, preparedness, and response (PPR) capacities, particularly in low- and middle-income countries. This recognition led to the establishment of the Pandemic Fund, launched in November 2022 under the auspices of the World Bank.6 The Pandemic Fund aims to finance critical investments to strengthen these capacities at national, regional, and global levels.7 To date, it has committed a total of US$885 million in grant financing across two funding rounds, mobilizing an additional US$6 billion in resources for PPR investments in 75 countries spanning six geographical regions.7 Furthermore, in December 2024, the Pandemic Fund announced a third round of funding, with a grant envelope of $500 million, inviting new proposals to further scale up efforts in disease surveillance, diagnostics and laboratory systems, and health workforce strengthening.6 The creation of the Pandemic Fund signifies a crucial step towards acknowledging and addressing the persistent gaps in pandemic financing that were so starkly exposed by the COVID-19 crisis.

Complementing the Pandemic Fund, the Resilience and Sustainability Facility (RSF) was established at the International Monetary Fund (IMF) in October 2022.6 The RSF’s mandate encompasses a dual focus: supporting climate transition and enhancing pandemic preparedness in eligible countries, which include all low-income countries, developing and vulnerable small states, and lower-middle-income countries, totalling 143 nations.6 Since its inception, the RSF has committed over $11 billion in financing to 22 countries through long-term concessional loans.6 The RSF’s substantial financial capacity suggests a potentially significant role in bolstering global health security alongside its climate-related objectives. The dual mandate underscores the growing recognition of the intricate links between environmental changes and the emergence and spread of infectious diseases.

Maintenance, Reallocation, and Implications

Despite the establishment of these dedicated funds, significant challenges persist in ensuring their effective utilization and preventing the reallocation of resources away from pandemic preparedness. The demand for financing from the Pandemic Fund has consistently and substantially exceeded the available supply.6 During its first call for proposals in March 2023, the demand for funding outstripped the supply by an astonishing factor of 24.6 This overwhelming oversubscription underscores the profound and widespread unmet need for pandemic preparedness funding, particularly in developing countries striving to strengthen their defences against future health threats.

A concerning observation is that, despite its explicit mandate to support pandemic preparedness, the RSF has not yet included pandemic preparedness as a condition in any of its approved programs to date.6 This underutilization of the RSF for a key aspect of its intended purpose represents a significant missed opportunity in the global effort to enhance pandemic readiness. Several potential reasons may account for this gap. One possibility is a lack of in-depth health policy expertise among the IMF staff, which might hinder their capacity to effectively integrate pandemic preparedness measures into the design and conditionality of RSF programs.6 Insufficient collaboration between the IMF and institutions possessing specialized health policy expertise, such as the World Health Organization (WHO) or the World Bank, could also contribute to this underutilization.6 Furthermore, ministries of finance, which typically lead negotiations for IMF programs, may prioritize macroeconomic stability and climate-related concerns over public health matters like pandemic preparedness.6 Countries themselves might also prioritize climate finance when accessing the RSF, especially after the substantial health expenditures incurred during the COVID-19 pandemic, leading them to focus their requests on climate-related vulnerabilities.6 The IMF has also reportedly acknowledged its own lack of specific expertise in the area of pandemic preparedness, potentially leading to an institutional preference for focusing on climate-related funding where its expertise is more established.6

The reallocation of existing pandemic preparedness funds to other priorities carries significant implications. While expenditure reallocation can be a necessary part of a government’s disaster response financing, especially for cash-strapped nations, it often necessitates cutting other important areas of public expenditure.9 This presents an opportunity cost in terms of foregone or delayed returns on investments in sectors like education, infrastructure, or social welfare, potentially undermining hard-won development gains.9 Such impacts are particularly pronounced in countries with limited fiscal space or those lacking pre-arranged disaster risk financing instruments.9 There is also a concern that the shift in funding towards immediate COVID-19 response and broader PPR activities might be inadvertently exacerbating existing health vulnerabilities and weakening overall global health systems by diverting resources from essential programs addressing other health challenges.10 This highlights the delicate balance required to address immediate health crises without compromising long-term investments in overall health system resilience.

Alignment and Future Directions

Recognizing the need for greater synergy and alignment between the available financing mechanisms, a cooperation framework has been established between the Pandemic Fund, the IMF, and the WHO.6 This framework aims to better integrate pandemic risks into economic policy considerations, leverage the WHO’s technical expertise in health matters, and align the financing strategies of the different institutions to achieve more effective outcomes in pandemic preparedness.6 However, despite this collaborative framework, recent RSF arrangements approved since its establishment have continued to focus almost exclusively on climate resilience, with no specific provisions for pandemic preparedness included in their programs.6 This suggests that further efforts are needed to translate the principles of the cooperation framework into concrete actions and ensure that pandemic preparedness receives due consideration within RSF financing.

Looking ahead, it is vital to strategically focus the resources of both the RSF and the Pandemic Fund on countries identified as high-risk hotspots for infectious disease outbreaks.6 Nations like the Democratic Republic of the Congo, which frequently battle Ebola outbreaks and serve as an epicenter for mpox, require targeted and sustained pandemic preparedness efforts.6 Prioritizing these high-risk countries aligns with the Pandemic Fund’s Results Framework, which emphasizes high-impact investments, while the RSF, with its larger financial scale, is uniquely positioned to amplify these efforts if pandemic preparedness is effectively integrated into its programs.6

The scheduled comprehensive review of the RSF in 2026 presents a crucial opportunity to clarify the facility’s role in global health financing and to potentially enhance collaboration with the World Bank and WHO in the area of pandemic preparedness.6 If the RSF continues to exclude pandemic preparedness as a condition in its financing, the review should seriously consider removing this mandate to avoid ambiguity and ensure that resources are channelled effectively through more appropriate mechanisms like the Pandemic Fund. Enhanced collaboration, alongside potential technical adjustments to the RSF’s operational guidance, such as removing the requirement for a concurrent upper credit tranche (UCT) program for repeat borrowers or raising access limits for countries seeking financing for pandemic preparedness, could enable the RSF to play a more significant and impactful role in strengthening countries’ health systems and bolstering global health security.6 By aligning the mandates, expertise, and financing capacities of the Pandemic Fund and the RSF, the global community can be better equipped to prepare for future pandemics and reduce vulnerability to emerging infectious diseases.

Table 2: Comparison of Global Pandemic Preparedness Funds (2024-2025)

Feature	Pandemic Fund	Resilience and Sustainability Facility (RSF)
Hosting Institution	World Bank	IMF
Total Committed Funding (Early 2025)	US$885 million	Over US$11 billion
Additional Funding Opportunities	US$500 million (Phase 3)	–
Focus/Mandate	Pandemic prevention, preparedness, and response	Climate transition and pandemic preparedness
Grant vs. Loan	Grant	Loan (concessional terms)
Commitments per Capita	US$0.39 – US$4.25	US$17.45
Number of Recipient Countries	75	22
Utilization for PPR	Primary focus	Limited/None
Key Challenges	High demand, limited funding	Underutilization for PPR, UCT requirement

Note: Data compiled from.6

A Crisis of Confidence: Public Trust in Health Institutions

Global Trends in Public Trust

The COVID-19 pandemic, despite its role in underscoring the critical importance of robust public health systems, paradoxically led to a significant decline in public trust in health institutions globally.11 This erosion of trust occurred within a broader societal context marked by a decades-long decline in public confidence across various institutions, suggesting that the pandemic exacerbated pre-existing trends rather than initiating them in isolation.11 In the United States, a survey study revealed a substantial decrease in trust in physicians and hospitals over the course of the pandemic, falling from 71.5% in April 2020 to a concerning 40.1% by January 2024.13 This decline in trust even extended to traditionally well-regarded professions within the healthcare sector.

Interestingly, this trend was not universally observed. A large study conducted in China found that trust in physicians actually increased markedly over the course of their COVID-19 response. This divergence highlights that the impact of the pandemic on public trust in health institutions varied significantly across different countries and contexts. Factors such as the specific strategies employed by governments in their pandemic response, prevailing cultural norms regarding authority and healthcare, and the level of transparency and consistency in public health communication likely played a crucial role in shaping these differing trajectories of public trust.

Factors Influencing Public Trust

Public trust in health institutions is a multifaceted phenomenon influenced by a complex interplay of individual and external factors.14 Individual factors, such as personal beliefs, values, and prior experiences with the healthcare system, can significantly shape an individual’s level of trust. Simultaneously, external factors, including political beliefs, the perceived trustworthiness of the institution delivering health information, and the platforms used to disseminate that information (such as traditional media and social media), also exert a powerful influence.14 Notably, political ideology has emerged as a significant determinant of institutional trust, with increasing political polarization often correlating with divergent levels of trust in health authorities and public health recommendations.14

The proliferation of misinformation and disinformation during the pandemic played a particularly damaging role in fostering distrust towards scientific evidence, medical expertise, and governmental bodies.14 The rapid and widespread dissemination of inaccurate or misleading information through various online platforms created an “infodemic” that sowed confusion, amplified doubts, and made it exceedingly difficult for the public to distinguish between credible and unreliable sources of information. This infodemic directly contributed to a decline in public confidence in the very institutions safeguarding public health. Research indicated that lower levels of public trust were often linked to perceptions that health recommendations were being driven by political considerations rather than solely by scientific evidence, and also by inconsistencies in the guidance provided by health authorities over time.18

Conversely, the provision of clear, consistent, and demonstrably science-based recommendations, coupled with the effective availability of protective resources such as testing and vaccines, were identified as crucial factors in building and maintaining public trust during a health crisis.18 Transparency regarding the scientific basis of policy decisions and the consistent delivery of essential resources fostered a sense of reliability and competence, which are fundamental to public confidence. Furthermore, levels of trust varied across different tiers of public health agencies. Trust in federal agencies was often more closely associated with beliefs in their scientific expertise, whereas trust in state and local public health agencies tended to be more strongly linked to perceptions of their provision of direct, compassionate care.18 This suggests that communication strategies aimed at building trust may need to be tailored to the specific roles and perceived strengths of different levels of health institutions.

Strategies for Rebuilding Trust

Given the significant erosion of public trust in health institutions, concerted efforts are essential to rebuild this crucial foundation for effective public health action. Strategies for restoring confidence need to focus on three key areas: engaging with communities, enhancing communication, and demonstrating competence.11 A useful framework for this endeavour is provided by the “four factors of trust”: humanity, transparency, reliability, and capability.19 Demonstrating genuine care and empathy for the well-being of the communities they serve (“humanity”), openly sharing information and acknowledging mistakes (“transparency”), consistently acting in a dependable and trustworthy manner (“reliability”), and showcasing the necessary skills and expertise to effectively address health challenges (“capability”) are all vital for regaining public confidence.

Actively engaging with communities, fostering genuine partnerships, and involving trusted local figures and organizations are critical for rebuilding trust at the grassroots level.17 Trust is often built through direct interaction and collaboration within local contexts. Empowering community leaders, working closely with community-based organizations, and ensuring that public health efforts are culturally relevant and responsive to local needs can significantly enhance trust and the effectiveness of interventions. Effective communication is paramount, requiring public health leaders to convey information clearly, consistently, and with empathy.18 Acknowledging public concerns, explaining the scientific basis for recommendations in an accessible manner, and demonstrating empathy for the challenges faced by individuals and communities can foster greater understanding and trust.

Transparency is another cornerstone of trust-building, necessitating that health institutions operate with openness, readily share information, and are willing to admit when errors occur.19 Being accessible to the public and engaging in open dialogue can further enhance trust. Moreover, demonstrating reliability and capability requires investing in modernizing data systems, ensuring the public health workforce is highly skilled and adequately resourced, and consistently delivering effective public health services.19 Finally, health organizations must actively listen to the concerns and perspectives of the communities they serve and incorporate patient voices in the planning and delivery of health programs.21 This two-way communication and responsiveness are essential for building lasting trust and ensuring that public health efforts are truly aligned with community needs and values.

The Gathering Storm: Emerging Infectious Disease Threats

Avian Flu (H5N1): Current Situation and Potential Risks

The H5N1 avian influenza virus continues to pose a significant threat to global health security. Currently, the virus is widespread in wild bird populations across the globe and has caused notable outbreaks in poultry and, more recently, in dairy cows within the United States.12 This widespread prevalence in animal populations underscores the persistent potential for the virus to cross the species barrier and infect humans. Indeed, recent human cases of H5 bird flu have been reported in the U.S., primarily among workers in the dairy and poultry industries who have had close contact with infected animals.12 While these cases highlight the risk of zoonotic transmission, the Centres for Disease Control and Prevention (CDC) currently assesses the overall public health risk to be low.12 However, the CDC is actively monitoring the situation, working closely with state health authorities to track individuals with animal exposures and utilizing its influenza surveillance systems to detect any signs of H5 bird flu activity in the human population.12

A key factor in the current low-risk assessment is the fact that person-to-person spread of the H5N1 virus has not been identified in the United States to date.12 This lack of sustained human-to-human transmission is reassuring but does not negate the potential for the virus to evolve. Historically, avian influenza A(H5N1) infections in humans have been associated with a high mortality rate globally.24 However, the recent human infections in the U.S. have generally resulted in milder illness, with only one reported death among the 70 cases identified since April 2024.24 This lower severity in recent cases might be attributable to various factors, including potential pre-existing immunity from seasonal influenza viruses.24 Nevertheless, the evolutionary potential of influenza viruses remains a significant concern. Experts emphasize that if the H5N1 virus were to mutate in a way that allows it to spread easily and sustainably between humans, it could trigger a severe global pandemic.27 The ongoing circulation of the virus in animal populations increases the opportunities for such mutations to occur, underscoring the critical need for continued surveillance, robust biosecurity measures in animal agriculture, and proactive preparedness planning for the possibility of increased human transmissibility.

Climate-Driven Vector-Borne Diseases: Trends and Projections

Climate change is increasingly recognized as a significant driver in the emergence and spread of vector-borne diseases (VBDs). Rising global average temperatures and altered precipitation patterns are creating more favorable conditions for disease-spreading insect vectors, such as mosquitoes and ticks, to expand their geographic ranges, lengthen their transmission seasons, and increase their overall populations.29 For instance, warmer temperatures can accelerate the development of pathogens within vectors and increase vector activity, leading to more opportunities for disease transmission.29 The projected increases in global average temperatures, estimated to rise by 1.5 °C above preindustrial levels by 2040 and potentially by 2.1 °C to 4.6 °C by the end of the century, are expected to manifest locally as changes in precipitation, humidity, temperature ranges, and an increased frequency of extreme weather events like floods and tropical cyclones.30 These environmental shifts will have far-reaching effects on human health, particularly by facilitating the spread of infectious diseases transmitted by insect vectors.

Already, we are witnessing the emergence of novel VBDs and the expansion of the geographic range of known VBDs, such as Oropouche virus and malaria.30 Outbreaks of diseases like eastern equine encephalitis and West Nile virus have also been linked to changing climatic conditions.30 Projections indicate a concerning trend of increasing prevalence and geographic spread of VBDs in the coming decades. A study projecting trends until 2050, under a medium climate change scenario, anticipates a 9.6% mean increase in the endemic area size for zoonotic and vector-borne diseases globally.32 This expansion is expected across continents and priority pathogen groups, with range shifts of host and vector animal species potentially driving higher disease risk in areas near the poles by 2050 and beyond.32 The WHO estimates that between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year from malnutrition, malaria, diarrhoea, and heat stress alone.33 This stark projection underscores the profound impact that climate change will have on global health, including a significant increase in the burden of vector-borne illnesses, necessitating urgent action to mitigate climate change and strengthen public health systems to adapt to these evolving threats.

Antibiotic Resistance: Global Situation and Risks

Antimicrobial resistance (AR) stands as an urgent and escalating global public health threat, responsible for millions of deaths worldwide each year.35 This phenomenon occurs when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them, making infections increasingly difficult, and sometimes impossible, to treat. The emergence and spread of new forms of antibiotic resistance, along with a rise in resistant infections occurring in community settings (outside of hospitals), are particularly concerning trends.35 These community-acquired resistant infections can put a larger segment of the population at risk, make their spread more challenging to identify and contain, and threaten the progress made in protecting patients within healthcare facilities.

The United States experienced a setback in its efforts to combat antibiotic resistance in 2020, largely attributed to the effects of the COVID-19 pandemic.35 The pandemic led to increased antibiotic use, potentially due to secondary bacterial infections and prophylactic use, coupled with disruptions in data collection and prevention activities, thereby accelerating the development and spread of resistance. Recognizing the gravity of this global challenge, the World Health Organization (WHO) has developed a Global Action Plan on Antimicrobial Resistance.37 The overarching goal of this plan is to ensure the continued success of treating and preventing infectious diseases with effective and safe medicines that are of assured quality, used responsibly, and accessible to all who need them. The plan outlines five strategic objectives: to improve awareness and understanding of AMR, to strengthen the knowledge and evidence base through surveillance and research, to reduce the incidence of infection, to optimize the use of antimicrobial agents, and to ensure sustainable investment in countering AMR.

In a significant step towards addressing this crisis at the highest political level, global leaders at the 79th United Nations General Assembly in September 2024 approved a political declaration on Antimicrobial Resistance.41 This declaration commits nations to a clear set of targets and actions aimed at reducing the estimated 4.95 million human deaths associated with AMR. It emphasizes the need for a One Health approach, acknowledging the interconnectedness of human, animal, plant, and environmental health in the development and spread of antibiotic resistance.41 The declaration sets ambitious targets, including ensuring that at least 70% of antibiotics used for human health globally should belong to the WHO Access group by 2030, and achieving significant reductions in the quantity of antimicrobials used in agri-food systems through measures to prevent and control infections and promote prudent use.41 These global action plans and high-level political commitments underscore the urgent need for coordinated, multi-sectoral efforts to combat the growing threat of antibiotic resistance and safeguard the future of modern medicine.

The Prevention-Reaction Divide: Political, Social, and Ethical Dimensions

Political Factors Underestimating Prevention

A significant political barrier to prioritizing pandemic prevention lies in the often short-term focus of policymakers, who are frequently driven by the electoral cycle and may find it challenging to invest substantial time, resources, and political capital in addressing the abstract possibility of a future crisis that may not materialize during their term.42 The benefits of pandemic prevention are often diffuse and not immediately visible, making such investments less politically appealing compared to addressing more immediate and salient issues that resonate with the electorate. Moreover, political dynamics played a crucial role in shaping health outcomes during the COVID-19 crisis, with geopolitical tensions and domestic political divisions frequently hindering effective and coordinated responses at global, national, and local levels.15 The pre-eminence of domestic political interests over the imperative for global cooperation in pandemic preparedness and response also emerged as a significant barrier.46 During the COVID-19 pandemic, many states prioritized national interests, such as in vaccine procurement processes, sometimes at the expense of broader global efforts like the COVAX program.

The increasing difficulty in achieving consensus and common agreements on global health issues due to multilateral gridlock presents another formidable political challenge.46 Long-term structural trends in global politics, including multipolarity, institutional inertia within international organizations, and increasing fragmentation, contribute to this difficulty in forging effective international cooperation on health security. Furthermore, the current international regime for pandemic preparedness suffers from a lack of robust political commitment and limited enforcement mechanisms.47 The absence of strong, legally binding international agreements with clear incentives and disincentives for compliance weakens the overall global preparedness framework. Divisive political leadership within nations can also significantly undermine social unity and the willingness of populations to accept necessary public health measures, including those aimed at prevention.15 Leaders who downplay the severity of health threats or politicize public health guidance can erode public trust and hinder the implementation of effective preventative strategies. Finally, the inherent tension between the principle of national sovereignty and the imperative for international cooperation in pandemic response poses a fundamental political challenge.45 Effective pandemic prevention and response often require states to cede some degree of autonomy in areas such as early information sharing about emerging pathogens and the regulation of international travel, which can be politically sensitive and face resistance from nationalist perspectives.

Social Factors Contributing to Underestimation

Societal polarization represents a significant social factor contributing to the underestimation of pandemic prevention efforts.15 In highly polarized societies, public health issues, including pandemic prevention, can become deeply intertwined with political and social identities. This can lead to the rejection of well-intentioned, safety-focused information and recommendations simply because they are perceived as aligning with a particular political or social group. The rapid and widespread dissemination of misinformation and disinformation through social media and other online platforms during health crises also plays a critical role in creating confusion, undermining trust in established health authorities, and fostering scepticism towards preventative measures like vaccination.14 This “infodemic” can significantly hinder the public’s willingness to adopt behaviours that are crucial for pandemic prevention. Over time, pandemic fatigue can also set in, leading to a decline in public perception regarding the importance of adhering to public health guidelines.14 As the immediate threat of a pandemic recedes from public consciousness, complacency can grow, resulting in a reduced willingness to support or comply with preventative measures that may seem inconvenient or intrusive in the absence of an active crisis.

Ethical Factors Contributing to Underestimation

Ethical considerations also play a role in the potential underestimation of pandemic prevention compared to reaction. During an active pandemic, the ethical dilemmas surrounding the allocation of scarce life-saving resources, such as ventilators, ICU beds, and vaccines, often take centre stage, potentially overshadowing the long-term importance of investing in prevention to avoid such crises in the first place.48 The immediate and pressing ethical challenges of responding to a pandemic can divert attention, resources, and political will away from the often less visible and more abstract benefits of proactive prevention efforts. Furthermore, public health interventions aimed at pandemic prevention, such as mandatory vaccination policies or quarantine measures, can raise complex ethical questions related to the balance between individual rights and the collective public good.48 Navigating these ethical tensions and achieving a societal consensus on the appropriate balance can be challenging and may sometimes lead to a reluctance to fully embrace potentially effective but ethically sensitive preventative measures. Conversely, the ethical principles of community engagement, empowerment through education, and ensuring inclusivity are crucial for enhancing the quality and effectiveness of public health communication and pandemic prevention efforts.17 Prevention strategies that are developed and implemented in an ethical manner, respecting individual autonomy, promoting equity, and actively involving communities in the decision-making process, are more likely to build public trust and achieve greater success in the long run.

More Talk Than Action? Global Vaccine Equity Post-COVID-19

Progress Made in Global Vaccine Equity

Since the onset of the COVID-19 pandemic, significant strides have been made in the rapid development and subsequent distribution of vaccines on a global scale. International collaborations and initiatives, such as the COVID-19 Vaccines Global Access (COVAX) facility, played a crucial role in accelerating the availability of vaccines, particularly for low- and middle-income countries.49 COVAX aimed to ensure equitable access to vaccines by pooling resources from wealthier nations to procure and distribute doses to countries that might otherwise struggle to afford them. As a result of these efforts, vaccination rates have indeed increased in low-income countries since the initial stages of the vaccine rollout.52 This expansion of vaccine coverage beyond high-income nations represents a notable achievement in global health.

Remaining Challenges and Obstacles

Despite the progress made, significant inequities in vaccine access persist between high-income and low-income countries.51 As of November 29, 2023, while 79.86% of people living in high-income countries had been vaccinated with at least one dose, the corresponding figure for low-income countries was a starkly contrasting 32.82%.52 This substantial disparity underscores the fact that global vaccine equity remains a significant challenge. Several factors have undermined the goal of equitable vaccine distribution. “Vaccine nationalism,” wherein wealthy nations prioritized their own populations through bilateral deals with manufacturers, resulted in limited supply for LMICs, particularly in the early phases of the pandemic.49 Issues such as vaccine hoarding by some countries, export bans on vaccine components, and the refusal of some manufacturers to share vaccine know-how further exacerbated these inequities.49

Low-income countries also face considerable financial challenges in both affording the vaccines and covering the costs associated with their delivery.52 The average cost per COVID-19 vaccine dose ranged from US$ 2 to $ 40, with an additional estimated delivery cost of US$ 3.70 per person for a two-dose regimen.52 For low-income countries, where the average annual per capita health expenditure is already severely limited, these costs represent a staggering financial burden, requiring an average increase in healthcare spending of 30-60 percent to vaccinate 70% of their population within a year.52 Logistical and health system challenges in LMICs also pose significant obstacles to achieving vaccine equity. These include inadequate healthcare infrastructure, unreliable vaccine supply chains, and a shortage of trained healthcare personnel needed for vaccine administration.53 Even when vaccine doses are available, many countries lack the necessary capacity to distribute and administer them effectively, particularly in remote or underserved areas. Furthermore, vaccine hesitancy and waning demand in some regions have also hindered efforts to achieve high vaccination coverage rates.53 Misinformation, cultural beliefs, and a perceived decrease in the risk of COVID-19 have contributed to lower vaccine uptake in certain populations. Finally, while vaccine donations from wealthier nations have been welcomed, they have sometimes presented challenges due to short shelf lives and the limited capacity of recipient countries to absorb and administer them before expiration.53

Ongoing Initiatives and Solutions

Despite these persistent challenges, various ongoing initiatives and proposed solutions aim to address the issue of global vaccine equity. The Global Vaccination Initiative, along with projects like DRIVE Demand, the Mercury Project, and the Vaccination Action Network (VAN), are working to boost vaccination rates and improve equity through community engagement, leveraging digital tools, and understanding behavioural drivers of vaccine uptake.55 The COVID-19 Vaccine Delivery Partnership (CoVDP), a collaboration between WHO, UNICEF, Gavi, and other partners, provides targeted operational support to countries with the lowest vaccination coverage to accelerate their rollout efforts.51 Efforts are also underway to establish regional vaccine technology transfer and manufacturing hubs in LMICs to enhance local production capacity and reduce reliance on external suppliers, which is seen as crucial for long-term vaccine equity and pandemic preparedness.49 Moreover, there is a growing recognition of the need to strengthen both global and local governance mechanisms to ensure greater accountability for achieving equitable vaccine access and administration at national and subnational levels.49 Addressing demand-side factors, strengthening health systems, and actively engaging communities in vaccination campaigns are also considered essential for making meaningful progress towards global vaccine equity.

Table 3: COVID-19 Vaccination Coverage: High-Income vs. Low-Income Countries (as of November 2023)

Metric	High-Income Countries	Low-Income Countries
Population Vaccinated with at Least One Dose	79.86%	32.82%
Average Healthcare Spending Increase Needed to Vaccinate 70% of Population	0.8%	56.6%

Note: Data compiled from.52

Underfunded and Overstretched: The State of Public Health Professionals

Global Challenges in Funding and Resources

Health workforces around the world are facing persistent and significant challenges, including chronic understaffing, inadequate funding, and a pervasive sense of underappreciation, issues that affect a wide range of roles within both public health and healthcare delivery systems.58 These systemic problems, which predate the COVID-19 pandemic, have been considerably exacerbated by the unrelenting nature and global scale of the crisis. In the decade leading up to the pandemic, the United States, for example, witnessed workforce reductions of nearly 10% in state health agencies and approximately 16% in local health departments.59 The immense pressures and demands placed on public health professionals during the pandemic have taken a heavy toll, with surveys indicating that around 44% of public health workers considered leaving their jobs due to high levels of burnout and stress.58 This potential exodus of experienced professionals poses a significant threat to the future capacity of public health systems to respond effectively to ongoing and emerging health challenges.

A fundamental challenge lies in the persistent issue of insufficient and unstable funding for public health agencies globally.4 This chronic underfunding often results in understaffed departments with limited resources, hindering their ability to effectively deliver essential public health services to communities. While the COVID-19 pandemic led to a temporary infusion of public health funding in some regions, this support has often proven to be unsustainable. For instance, in the United States, a substantial amount of federal COVID-19 funding was rescinded in FY24, meaning these funds are no longer available to pass through to state and local health departments.59 This instability in funding makes it exceedingly difficult for public health agencies to engage in long-term planning, recruit and retain qualified staff, and implement crucial preventative programs. Furthermore, there are notable skillset gaps within the public health workforce. The field requires professionals with specialized training in areas such as epidemiology, data analysis, biostatistics, health informatics, executive leadership, and policy development to effectively address the increasingly complex and evolving public health landscape.59 Finally, issues of diversity and equity within the public health workforce remain a significant concern, with public health workers of colour often being underrepresented and underpaid.59 This lack of diversity can hinder the delivery of culturally competent care and undermine efforts to address health disparities within communities.

Initiatives and Solutions to Address Challenges

Recognizing the critical need to strengthen the public health workforce, several initiatives and solutions have been implemented or proposed to address the challenges of funding and resources. In the United States, the CDC Public Health Infrastructure Grants provide direct funding to state, local, and territorial health departments over five years to support the recruitment, retention, training, and overall support of the public health workforce.59 These grants aim to build capacity and ensure a more robust and sustainable workforce for the future. The Public Health Workforce Loan Repayment Program is another key initiative designed to make public health careers more accessible by offering financial assistance to those who commit to working in underserved areas.59 At the state level, initiatives like Health First Indiana are providing increased resources to local health departments, offering flexibility to address specific community needs, particularly in rural areas.59 Academic institutions, such as those belonging to the Association of Schools and Programs of Public Health, play a vital role in educating and training the next generation of public health professionals to tackle emerging challenges and advance health equity.59

Beyond direct funding and workforce development programs, strategies to maximize the impact of existing resources are also crucial. Prioritizing investment in primary health care, embracing technological advancements to improve efficiency, fostering partnerships with other healthcare providers and community organizations, and focusing on data-driven decision-making are all approaches that can help public health agencies make the most of limited funding.4 Additionally, advocating for policies that support the well-being of the public health workforce, such as ensuring access to paid sick leave, including mental health days, and championing peer support programs, is essential for improving retention and reducing burnout.59 Ultimately, a multi-faceted approach involving increased and sustained funding, strategic resource allocation, workforce development initiatives, and supportive policies is necessary to ensure that public health professionals are adequately supported and empowered to protect and improve the health of communities globally.

Health is Security: Investing in Prevention as a Strategic Imperative

Arguments for Investing in Public Health as Security

The COVID-19 pandemic has unequivocally demonstrated that infectious diseases pose a significant threat not only to public health but also to national and global security.61 Disease outbreaks can endanger citizens both at home and abroad, threaten military readiness and deployed forces, and exacerbate social and political instability in key countries and regions. In this context, investing in public health should be viewed as a fundamental aspect of national and global security, akin to investments in traditional defense.61 Preventing health crises before they escalate is a far more cost-effective approach than dealing with the immense human and economic consequences of a full-blown pandemic.66 The trillions of dollars spent globally on responding to the COVID-19 pandemic dwarf the relatively modest investments required for effective pandemic preparedness.

Investing in global health security helps to contain disease outbreaks at their source, preventing them from crossing borders and threatening domestic populations.62 In an increasingly interconnected world characterized by rapid travel and trade, a disease threat anywhere can quickly become a threat everywhere. U.S. leadership in global health security efforts, including the detection and containment of outbreaks, not only makes the nation safer but also strengthens its credibility, bolsters strategic alliances, and enhances its influence in international negotiations.63 Furthermore, supporting the strengthening of outbreak monitoring and rapid response mechanisms in other countries helps to avoid deep economic losses and disruptions to global supply chains that can result from large-scale pandemics.63 Investing in the overall development of countries through health partnerships can also foster more stable economies and reduce the likelihood of humanitarian crises and mass migrations, which can have significant security implications.62

Evidence and Examples

The economic toll of health emergencies is staggering. Research estimates that global losses from pandemics could average around $700 billion each year going forward.63 This immense economic burden underscores the compelling financial case for investing proactively in health security and pandemic preparedness. Historically, the United States has made significant investments in global health initiatives that have successfully contained infectious disease threats before they reached U.S. soil, demonstrating the tangible security benefits of such investments.62 Recent outbreaks of diseases like Ebola, avian flu, mpox, and Marburg serve as stark reminders of the ongoing and evolving threats to global health security and the continuous need for sustained investment in preparedness and response capacities.6 The impact of avian flu outbreaks on food prices and supply chains provides a clear example of how health threats can have far-reaching consequences for broader economic security.63 An OECD report recently highlighted the significant funding gaps that persist in global health security, particularly in low- and middle-income countries, despite post-COVID commitments, further emphasizing the urgent need for increased and smarter investments in this critical area.36

Conclusion: A Call to Action for a Pandemic-Ready World

The global response to the COVID-19 pandemic revealed both the remarkable capacity for rapid action during a crisis and the significant vulnerabilities that persist in our collective preparedness for future health threats. While the world initially promised “never again,” the current trends of declining investment in public health systems, the underutilization of pandemic preparedness funds, the fractured public trust in health institutions, and the growing menace of emerging infectious diseases paint a concerning picture. The persistent underestimation of prevention in favour of reaction, the slow progress towards achieving global vaccine equity, and the chronic underfunding and overstretching of public health professionals all contribute to a state of precarious readiness.

The evidence overwhelmingly supports the argument that investing in public health is not merely a matter of healthcare policy but a fundamental imperative for national and global security. The economic, social, and human costs of failing to adequately prepare for pandemics far outweigh the investments needed for robust prevention and preparedness measures. Addressing the identified gaps requires a concerted and sustained effort from policymakers, international organizations, civil society, and the public. It is time to move beyond rhetoric and translate the lessons learned from COVID-19 into concrete actions that prioritize public health as a strategic investment in a secure and prosperous future for all.

Recommendations

(To be developed based on the analysis in the main body, providing specific, actionable, and multi-layered recommendations for policymakers, international organizations, and other stakeholders.)

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