LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA © 2019 The World Bank/Vincent Tremeau Cover photo: Vincent Tremeau/World Bank Abstract: This World Bank Group qualitative study examines whether lessons learned during the financing of the West Africa Ebola crisis of 2014–2015 have resulted in more effective and efficient financing responses from the international development community during more recent disease outbreaks, including in Nigeria (Lassa Fever, 2018) and the 9th outbreak of Ebola in the Democratic Republic of the Congo. The study reflects on positive changes in the affected countries, identifies remaining persistent challenges, and offers recommendations on the way ahead for the consideration of the international development community. FINAL REPORT LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA May 2019 CONTENTS ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Report Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Analysis: Four Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 3. THE EPIDEMICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 West Africa Ebola Virus Disease (Ebola) in Guinea, Liberia, Sierra Leone, 2014–2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 General Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Key Study Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Lassa Fever Epidemic, Nigeria, 2018 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Financing the Outbreak Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Study Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Ebola, Outbreaks #9 and #10, Democratic Republic of Congo (DRC), 2018–19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Financing the Outbreak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Study Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 4. WHAT HAS CHANGED IN THE EPIDEMICS OF 2018? CONTINUING CHALLENGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Efficiency of Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Effective Use of Financial Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Financing Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Limitations of Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 5. CONCLUSION AND RECOMMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 APPENDIX. LIST OF ORGANIZATIONS INTERVIEWED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39   iii LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA Boxes Box 1 Avian Influenza: Missed Opportunity for Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Box 2 World Bank Ebola Recovery and Reconstruction Trust Fund (ERRTF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Box 3 Regional Disease Surveillance Systems Enhancement (REDISSE) Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Box 4 Impact of Insecurity on Outbreak Detection, Response, and Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Box 5 Financial Ownership of Preparedness and Response Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Figures Figure 1 West Africa Ebola Outbreaks, 2014–2015: Epidemiological Curve, Key Events, and Funding Commitments (US$) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Figure 2 Amount of WA 2014–15 Ebola Financing Disbursed by Donor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Figure 3 Nigeria Lassa Outbreak, 2018: Epidemiological Curve, Key Events, and Funding Commitments . . . . . . . . . . . 18 Figure 4 DRC 9th Ebola Outbreak: Epidemiological Curve, Key Events, and Funding Commitments, 2018 . . . . . . . . . . 19 Figure 5 DRC 10th Ebola Outbreak: Epidemiological Curve, Key Events, and Funding Commitments. . . . . . . . . . . . . . . 20 Figure 6 Insecurity and Weak Community Engagement Hindered Ebola 10 Response Efforts, DRC . . . . . . . . . . . . . . . . 24 Figure 7 Selected Funding Sources during Stages of an Outbreak and Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Figure 8 “Readiness” Score Based on Joint External Evaluations in Sub-Saharan Africa, 2019 . . . . . . . . . . . . . . . . . . . . 29 Tables Table 1 ERRTF Contributing Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Table 2 Selected World Bank and Other Development Public Health Emergency Financing Tools and Contingency Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Table A1 List of Organizations Interviewed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 iv  ACKNOWLEDGMENTS We would like to extend our appreciation to all the individuals, report contributes to an essential body of work that strength- organizations, and institutions who provided their knowledge ens our global and local ability to prepare for and manage and expertise to the development of this report. In particular, epidemics. we would like to thank the governments of the Democratic This report was prepared by Sulzhan Bali, Andre Carletto, Republic of Congo, Guinea, Liberia, Nigeria, and Sierra Leone John Paul Clark, Sara Hersey, Alicia Hetzner, Hadia Samaha, for graciously giving their valuable time and insights. We Nicholas Studzinski, and Mazvita Zanamwe. Olusoji Adeyi, would also like to acknowledge the numerous development Ivar Cederholm, and Trina Haque provided strategic guidance agencies, international organizations, and nongovernmental throughout this project. Fieldwork oversight was provided by organizations who contributed to this work. We are grateful Noel Chisaka, Preeti Kudesia, Ibrahim Magazi, Munirat Ogun- to the World Bank staff in headquarters and country offices layi, Michael Olugbile, and Shiyong Wang. Norosoa Andriana- who shared their insights and inputs with the team. ivo, Karine Noelle Mouketo-Mikolo, and Amba Denise Sangara Finally, we would like to thank the World Bank Ebola provided the team with crucial operational and administrative Recovery and Reconstruction Trust Fund for their generous support. The team also benefitted immensely from the peer funding which enabled us to document the lessons learned in review provided by Uma Mathur, Adrienne McManus, David financing responses to disease outbreaks. We hope that this Oliveira De Souza, and Netsanet Walelign Workie. THIS STUDY IS FUNDED BY THE EBOLA RECOVERY AND RECONSTRUCTION TRUST FUND (ERRTF) Countries contributing to the ERRTF include:  Russia–Ministry of Finance of the Russian Federation  United Kingdom–Department for International Development (DFID)  Norway–Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation  Netherlands–Ministry of Foreign Affairs  Denmark–Danish Ministry of Foreign Affairs  Japan–Ministry of Foreign Affairs   v ABBREVIATIONS AAR After Action Review JICA Japanese International Cooperation Agency Africa CDC Africa Centres for Disease Control and LHSSP Liberia Health Systems Strengthening Project Prevention LMIC  Lower- and Middle-Income Countries ALIMA Alliance for International Medical Action M&E Monitoring and Evaluation APL Adaptable Program Lending MIGA Multilateral Investment Guarantee Agency ARC Africa Risk Capacity MDTF Multi-Donor Trust Fund AU African Union MERS  Middle East Respiratory Syndrome-Related CAT DDO IBRD Catastrophe Deferred Drawdown Option Coronavirus CEPI  Coalition for Epidemic Preparedness MOF Ministry of Finance Innovations MOH Ministry of Health CERF Central Emergency Response Fund MSF Médecins Sans Frontières CERC Contingent Emergency Response Component MOU Memorandum of Understanding CFE WHO Contingency Fund for Emergencies NAPHS National Action Plans for Health Security CHAI Clinton Health Access Initiative NCDC Nigeria Centre for Disease Control CRW World Bank IDA Crisis Response Window OIE World Animal Health Organization DFID  United Kingdom—Department for PEF Pandemic Emergency Financing Facility International Development PDSS  DRC Health System Strengthening for Better DRC Democratic Republic of Congo Maternal and Child Health Results Project DRM Disaster Risk Management RCC Regional Coordinating Center ECHO  European Commission’s Humanitarian Aid REDISSE Regional Disease Surveillance Systems and Civil Protection department Enhancement EERP Ebola Emergency Response Project RVF Rift Valley Fever ERRTF  Ebola Recovery and Reconstruction Trust SARS Sever Acute Respiratory Syndrome Fund SLRCHP  Sierra Leone Reproductive and Child Health EOC Emergency Operations Center Project Ebola Ebola Virus Disease SRP Strategic Response Plan FCAS Fragile and Conflict-Affected Situations UN United Nations FGON Federal Government of Nigeria UNFPA United Nations Population Fund GCRP Global Crisis Risk Platform UNICEF United Nations Children’s Fund GDP Gross Domestic Product UNMEER  United Nations Mission for Ebola Emergency GIZ  Deutsche Gesellschaft für Internationale Response Zusammenarbeit UN MPTF United Nations Multi-Partner Trust Fund GPMB Global Preparedness Monitoring Board UNOCHA  United Nations Office for the Coordination of IDA  International Development Association Humanitarian Affairs IFC International Finance Corporation UNOPS United Nations Office for Project Services GPAI Global Pandemic and Avian Influenza USA Unites States of America HCW Health care workers WAHO West African Health Organization HIP Humanitarian Implementation Plan WBG World Bank Group IHR International Health Regulations WHA World Health Assembly IMF International Monetary Fund WHE  World Health Organization Health IPC Infection Prevention and Control Emergencies Program JEE Joint External Evaluations WHO World Health Organization vi  EXECUTIVE SUMMARY When the Ebola Virus Disease (Ebola) struck Guinea, Libe- • In response to comprehensive recommendations from ria, and Sierra Leone in 2014, the affected countries and the multiple assessments, the international development international community were poorly equipped to provide a community has taken several institutional and oper- timely financial and technical response to contain the regional ational steps to improve the efficiency and effective- epidemic. Lack of adequate disease surveillance and response ness of financing public health emergencies. These systems hampered detection of the Ebola outbreak in all three include the adaptation of policies and procedures countries. As a result over 11,000 persons died and although that increase the agility of financing while decreasing the populations of the three most affected countries suffered the processing time, as well as developing new plan- the bulk of the direct and indirect costs of the epidemic, there ning tools and financing mechanisms. Some examples were significant health, social, and economic consequences include incorporating instruments that permit rapid across the subregion. The economic and social costs of the access to funds into World Bank–financed projects West Africa Ebola crisis were recently estimated at US$53 bil- and establishing new financing mechanisms such as lion (Huber, Finelli, and Stevens 2018). the World Bank Group (WBG)’s Pandemic Emergency Although delayed by several months from the onset of Financing Facility (PEF), World Health Organization cases, the global response eventually was effective in stop- (WHO)’s Contingency Fund for Emergencies (CFE), and ping the outbreak. The response ultimately mobilized over the African Union (AU)’s Africa Risk Capacity (ARC) for US$5.91 billion by February 2015 and started a chain of orga- Outbreaks. There have also been efforts to establish nizational, strategic, and financial reforms that continue. and strengthen institutions with global, regional, and While there is a significant body of work examining les- national mandates for preparedness and response, sons from the 2014–15 Ebola outbreak in West Africa (2014– such as the WHO Health Emergencies Program (WHE), 15 WA Ebola), there is limited literature on how those lessons Africa Centres for Disease Control and Prevention have been applied to successive epidemics in the subregion, (Africa CDC), and National Public Health Institutes particularly on the financing of outbreak response. This report (NPHIs). examines the extent to which these lessons have changed • Although financing routine systems to prevent and institutional behavior and contributed to improved domestic detect health threats has lagged behind initiatives to and international coordination of subsequent disease out- respond to emergencies, new disease surveillance and breaks in the region. Specifically, it highlights how these les- response programs have been introduced in the African sons have been applied to the 2018 Lassa Fever outbreak in subregion. One such example is the WBG’s Regional Nigeria, the 9th Ebola outbreak in the Democratic Republic Disease Surveillance Systems Enhancement (REDISSE) of Congo (DRC), and the ongoing 10th Ebola outbreak in DRC. Program, which leverages efficiency gains of scale by The report illustrates the unique challenges posed in financ- strengthening disease surveillance, detection, and ing each outbreak, identifies best practices that have been response systems across 11 countries in West Africa. established, and underscores the obstacles and challenges that • In addition to delayed disease detection and resource remain. The findings will guide policy decisions and help inform mobilization, the 2014–15 WA Ebola outbreak was hin- domestic and international institutions on the challenges that dered by weak coordination and accountability includ- remain in financing emergency response to epidemics. ing lack of systems to accurately track funding, which Lessons learned from the West Africa Ebola outbreak have further delayed disbursements. It took approximately benefitted subsequent outbreaks, including the 2018 Lassa Fever two months before funds were available for WHO due epidemic in Nigeria and the 2018 and 2019 Ebola outbreaks in to complex financial controls. WBG pledged funds DRC. The study found strong consensus among informants that within five days of the first emergency declaration in the financial response to these outbreaks is markedly improved Sierra Leone on July 31, 2014. However, it took WBG compared to that of the 2014–15 Ebola outbreak in West Africa.   1 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA nearly two months1 to secure and disburse the funds. 10th Ebola outbreak in DRC was the second largest Ebola The regional outbreak lasted over one and a half years outbreak to date. With a protracted response, donor and the response ultimately cost US$6 billion. Early fatigue remains a risk that could also hamper financing of access to flexible funds, even in small amounts, would the epidemic response going forward. have mitigated many of the adverse health conse- quences of the outbreak. (WHO, 2015a). This report confirms improvements in the timeliness • In contrast to the 2014–15 Ebola outbreak, the and efficiency of financing to contain outbreaks of infectious response to the 2018 Lassa Fever outbreak exhibited disease at all levels––country, regional, and global. Today, more efficient coordination and improved timeliness in Guinea, Liberia, Sierra Leone, Nigeria (Lassa Fever outbreak, resource mobilization. Leadership capacity of the Nige- 2018), and the Democratic Republic of Congo (DRC) (9th and ria Center for Disease Control (NCDC), establishing the 10th outbreaks of Ebola) have demonstrated improved capac- Lassa Fever Technical Working Group (TWG), and the ity for governance and operational response to outbreaks. use of CFE and Contingent Emergency Response Com- This capacity growth, in turn, has contributed to the more ponent (CERC) mechanisms facilitated these improve- efficient use of domestic and external financing. ments. However, CERC activation was set back by more However, many challenges remain. The capacity of high- than two weeks due to complex interministerial pro- risk countries to address public health emergencies will be dif- cesses and lack of prepositioned response tools. Con- ficult to sustain without a shared, continued commitment of tracts and disbursements were also delayed while staff both domestic and external financing. International develop- were familiarized with the new funding mechanism. ment and public health agencies such as the World Bank and • The 9th Ebola outbreak in DRC benefitted from the WHO have also demonstrated significantly greater agility in presence of an existing World Bank disease surveillance their institutional responses due, in part, to the development project that enabled immediate procurement using pre- of a number of new and improved funding instruments and viously allocated funds. Funding for the response was planning tools that enable more timely and flexible financing mobilized in less than one week through a number of of outbreaks. Other national and regional entities including modalities including the PEF cash window, CERC, and CFE. NPHIs and the Africa CDC are also poised to provide increased The Strategic Response Plan (SRP) also greatly improved indigenous support as their institutions mature. government and development partner coordination. Adequate domestic investment in outbreak prevention and Funds that were not used to respond to this outbreak preparedness remains a critical challenge. The barriers to such were applied to the 10th Ebola outbreak in DRC, which investment stem from a combination of scarce resources and was declared shortly after the end of the 9th outbreak. competition across sectors in prioritizing the resources avail- • In contrast to the 9th Ebola outbreak in DRC, the 10th out- able. Following the West Africa Ebola outbreak, although inter- break occurred in an area of ongoing insecurity. The out- national investments have proved adequate to address acute break was confirmed nearly three months after the first outbreak needs, funding for preparedness has severely waned. community deaths due to frequent health worker strikes Given its financing mandate, convening authority, and and lack of health facility access. Despite rapid initial access to economic/financial policy decision makers, the resource mobilization and extensive national and inter- World Bank is well positioned to lead a scaled-up, multi- national efforts to interrupt disease transmission, many stakeholder initiative on innovative financing to strengthen challenges impede resolving the outbreak. These include country-owned and country-led capacity for preparedness. In community mistrust, an increasingly insecure environ- the context of the demonstrated importance of global health ment for response workers, and difficulty in coordinating security, the time is also opportune for international devel- multiple response actors. At the time of this report, the opment partners to systematically examine their overall strat- egies. These strategies encompass the flexibility, agility, and 1 In Sierra Leone, the emergency was declared on July 31, 2014. The World efficiency of existing financing tools for emergency response Bank Ebola Emergency Response Project (EERP) was declared effective on Sep- and building country-owned capacity for financing prepared- tember 19, 2014, and it became effective in Sierra Leone on September 24, 2014. ness and emergency response. 2  INTRODUCTION 1 © 2019 The World Bank/Vincent Tremeau LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA In the wake of the 2014 Ebola Virus Disease (Ebola) crisis, This report assesses if and how these new instruments, the international development community, including the investments, and changes in institutional behavior are improv- World Bank Group (WBG), have taken various institutional ing the timeliness, sufficiency, and effectiveness of financing and operational steps to improve the advice, investments, for recent and ongoing epidemics in the Africa region, spe- and financing instruments to support both the efficiency and cifically the 2018 Lassa Fever outbreak in Nigeria and the effectiveness of emergency responses to infectious disease 9th and 10th Ebola outbreaks in the Democratic Republic of outbreaks. Several World Bank instruments have been devel- Congo (DRC). The study illustrates how each new outbreak oped or adapted to more promptly deliver financial resources. poses unique challenges, while underscoring the persistence These instruments include a Contingent Emergency Response of common obstacles and weaknesses. It will identify good Component (CERC) which permits rapid access to funds in and best practices that have been adopted based on recent existing bank-financed projects; the Catastrophe Deferred experience and examine the unresolved gaps and weaknesses Drawdown Option (Cat DDO) which is newly available to the in systems capacity and resilience to epidemic outbreaks at International Development Association (IDA) eligible coun- country and local levels in the Africa Region (AFR) as well as in tries and functions as a contingency fund; and the Pandemic the regional and global contexts. Three years after the end of Emergency Financing Facility (PEF), with its parametric insur- the West African Ebola epidemic, this study will explore: ance and cash windows. Other international stakeholders and How well have the lessons from the West Africa Ebola crisis donors, including the World Health Organization (WHO), Afri- of 2014–15 on the financing of epidemic response been docu- can Union (AU), and United Nations Office for the Coordina- mented and applied to subsequent outbreaks? What additional tion of Humanitarian Affairs (UNOCHA), have developed new lessons have we learned from these more recent outbreaks in or improved rapid response instruments. These include WHO Nigeria and DRC? and What have we still to learn? Contingency Fund for Emergencies (CFE); Africa Risk Capacity (ARC), an insurance-based financing scheme; and a modified OBJECTIVE Central Emergency Response Fund (CERF) for health emergen- cies for the respective organizations. The objective of the study is to inform the design and imple- Additionally, multiple institutions have moved to mentation of financing for rapid response to outbreaks strengthen regional and international capacity to respond to through an analysis of lessons learned from recent outbreaks disease outbreaks. Two examples are the establishment of the in West and Central Africa. The study aimed to: (1) Health Emergencies Program (WHE) by WHO and (2) Africa Centres for Disease Control and Prevention (Africa CDC) by 1. Document the institutional steps and progress made the African Union. The adoption of the Global Health Security by development partners, including the WBG, to Agenda (GHSA) by over 50 countries and the implementation adapt, develop, and implement financing tools to of Joint External Evaluations (JEEs) in more than 85 countries respond to disease outbreaks and other public health have resulted in higher quality and more transparent imple- emergencies. mentation and monitoring of country progress toward WHO 2. Identify the lessons learned from financing the imme- International Health Regulations (IHR-2005). WHO, the World diate response to recent outbreaks in West and Cen- Bank, and other stakeholders recently established the Global tral Africa, specifically, the 2014–15 Ebola outbreak in Preparedness Monitoring Board (GPMB) to provide oversight West Africa, the 2018 Lassa Fever outbreak in Nigeria, of international health security efforts. Although financing for and 9th and 10th Ebola outbreaks in the DRC in 2018. the strengthening of routine systems to prevent and detect 3. Document the principal barriers and enablers to health threats has lagged behind initiatives to respond to external and domestic financing for rapid response emergencies, new regional disease surveillance and response to epidemics. Documentation focuses on efficiency programs have been introduced in Africa such as the World (including timeliness and flexibility), sufficiency Bank Regional Disease Surveillance Systems Enhancement (resource mobilization and disbursement), and effec- (REDISSE) Program. tiveness of coordination and use of funds. 4  Introduction  4. Provide key recommendations on how to accelerate REPORT STRUCTURE external and domestic financing and operationaliza- This report will explain the methodology used to collect and tion of response to future disease outbreaks. analyze study data. It will then review the background, find- ings, and observations on mobilizing domestic and external OUTCOMES funds for response in light of the evolution of epidemics in West Africa (Ebola, 2014–15), Nigeria (Lassa Fever, 2018), and The primary outcomes of this study are to (1) inform stake- DRC (Ebola, 2018–2019). The following section will summarize holders, including development partners and countries, of the recent changes and key remaining challenges globally and lessons learned in financing responses to recent epidemics in select countries summarized by the four selected themes in the West and Central Africa regions; and (2) increase the (Governance, Effective Financing, Efficient Use of Resources, knowledge resources at the country, regional, and global lev- and Preparedness). The report then will offer conclusions and els on expeditious financing of responses to infectious disease recommendations from this qualitative study. outbreaks.   5 METHODOLOGY 2 © 2019 The World Bank/Vincent Tremeau METHODOLOGY  This study was designed as a cross-sectional qualitative Leader; Field Project Manager); country government officials; study. To capture the lessons learned from financing rapid and international development partners including financing, response to recent outbreaks in West and Central Africa, the technical, and implementing organizations (multilateral, bilat- study employed semi structured, in-depth interviews comple- eral, or NGO). The question categories included the process mented by an exhaustive review of the published literature of resource mobilization; the timeliness, flexibility and suffi- and unpublished documentation. The data were collected ciency of financial resources; and the effectiveness of coordi- in Conakry, Guinea; Monrovia, Liberia; Abuja, Nigeria; Free- nation and use of funds. town, Sierra Leone; Geneva, Switzerland; London, UK; and Document and interview-derived data were analyzed, and Washington, DC, USA. Purposive sampling was used to cre- codes were collated into four high-level themes. Findings on ate the researcher’s guide to key stakeholder organizations lessons learned were categorized according to these themes. and names. The list was cross-checked with key informants, Although some findings were cross-cutting and spanned mul- and 138 persons2 were interviewed during both phases. The tiple categories,3 they were placed where they were most rel- in-depth interviews were conducted in English or French and evant to the context. The themes are described below: lasted ~45–75 minutes each. The interviews were conducted primarily face to face; a small number were conducted by 1. Governance—Management of the response including video or audio conference. coordination, planning, leadership, and decision mak- Coding was used to analyze the data, and the data were ing; collaboration and information sharing between interpreted continuously throughout the coding process to stakeholders. identify key themes and subthemes. Audio recordings of the 2. Efficiency of financing for outbreak response— interviews were transcribed, and the text was analyzed using Resource mobilization and transfer of authorized a two-step approach. Primary coding was performed using funding to the recipient (government or implement- Microsoft Word. Analytic memos were written to summarize ing organization) using streamlined procedures; time- and organize the data into major themes by combining the liness, agility, and sufficiency of financing based gaps initial coding insights for each outbreak. Key themes emerged identified in strategic plans. from the data and, where appropriate, were supplemented 3. Effective use of financial resources in outbreak with the literature review. response—Financial commitments met their prede- The preliminary report was shared with select key infor- termined objectives and were not misused or wasted; mants and stakeholders in November and December 2018 to absorptive capacity, accountability, monitoring and validate observations and identify priority issues for further evaluation of emergency financing, procedures for investigation. A second round of interviews and data collec- reporting, and allocative efficiency.4 tion were conducted in the first quarter of 2019. 4. Financing for preparedness—Prevention and early detection of disease outbreaks. ANALYSIS: FOUR THEMES Three questionnaire instruments were developed. Each instrument contained questions tailored to a specific category of informant: World Bank staff (Senior, HQ level; Task Team 2 Key informants from WBG (18), government (52), international 3 For example, fiduciary procedures were relevant to both efficiency of organizations (31), bilateral donors (14), and nongovernmental organizations financing and effective use of financing. (NGOs) (23) participated in the in-depth interviews and focus group 4 Qualitative assessment of whether financing met prioritized local needs, discussions. improved local ownership, and was cost effective.   7 THE EPIDEMICS 3 © 2019 The World Bank/Vincent Tremeau The Epidemics  West Africa Ebola Virus Disease (Ebola) in 2015). Due to (1) the reduction of both demand for and avail- Guinea, Liberia, Sierra Leone, 2014–2015 ability of general health services resulting from fear of con- tracting Ebola; (2) lack of access to health care during the crisis; “The money came out plenty, but late.” and (3) the absence of staff and supplies, as many as 10,600 Delayed resource mobilization, insufficient immediate excess deaths were attributed to untreated HIV, tuberculosis response, inefficient coordination, delayed disbursement (TB), and malaria (Parpia and others 2016). Diverted resources, closed health facilities, and fear of Ebola transmission in health facilities further broke down trust in the health systems in the BACKGROUND Ebola-affected countries (Elston and others 2017). The West African (WA) Ebola epidemic began in Guinea in early In the three countries combined, an estimated 17,300 chil- 2014 and was remarkable for its unprecedented spread, which dren were orphaned; students lost 33–39 weeks of schooling; exceeded all other recorded outbreaks of Ebola. The disease was and child vaccinations decreased by 30 percent (CDC 2016). The transmitted intensively throughout the West African countries combined economic costs in Guinea, Liberia, and Sierra Leone of Guinea, Liberia, and Sierra Leone, and eventually included are estimated at US$53 billion, including the social costs of a minimal and more rapidly controlled spread to seven other deaths and morbidity from Ebola and other diseases during the countries in West Africa, Europe, and the United States. There epidemic (Huber and others 2018). A World Bank study found have been multiple studies in peer reviewed and gray literature that Ebola in West Africa resulted in a US$2.2 billion loss in Gross documenting the impact and lessons learned from the outbreak. Domestic Product (GDP) for the three Ebola-affected countries, For this study, an extensive literature review was conducted, and and that the medium-term impact may have caused economic key themes and findings identified were documented. losses of up to US$25 billion for West Africa (World Bank 2015b). Effects/Impact of the 2014–15 WA Ebola outbreak. The Outbreak timeline and response. Deaths from Ebola may direct human and indirect socioeconomic impacts among have occurred as early as December 23, 2013. However, Ebola the countries most affected by the epidemic were severe. was not confirmed until March 27, March 30, and May 24, The outbreak infected over 28,000 people, and the combined 2014 in Guinea, Liberia, and Sierra Leone, respectively (Fig- deaths included over 11,000 persons (WHO 2016). Economic ure  1) (Global Ebola Response 2019; CDC 2015). A state of losses included investments, agricultural production, and food emergency due to the outbreak was first declared in Guinea security, and the diminished growth of the private sector.5 The on August 6, 2014, 131 days after confirmation of the first human and socioeconomic impacts of the epidemic were large case; in Liberia on August 13, 136 days after confirmation; and severe in all three of the countries most affected. Eco- and in Sierra Leone on July 31, 67 days after the first case was nomic losses also included deferred investments, diminished confirmed. WHO declared an Ebola public health emergency agricultural production and food security, and the diminished of international concern on August 8. The United Nations (UN) growth of the private sector. outbreak coordinating body, UN Mission for Ebola Emergency There were additional pronounced direct and indirect Response (UNMEER), was constituted on September  19. impacts on the health care, education, and social protection Declarations of the end of the country-specific outbreaks system of the affected countries. These impacts included the were announced 14–18 months later: May 9, 2015 in Liberia, complete disruption in the delivery of health, education, and November 7 in Sierra Leone, and December 29 in Guinea. social services. These disruptions caused disastrous effects on Late detection of Ebola coupled with delayed outbreak vulnerable populations, particularly children and the elderly. declarations hampered the international response efforts to In Liberia, 8 percent of health care professionals died; Sierra trigger emergency financing mechanisms (DuBois and others Leone lost 7 percent, and Guinea 1 percent (Evans and others 2015; Lupel and Snyder 2017; Moon and others 2015; Spen- gler and others 2016; WHO 2015a; WHO 2015b). The delayed 5 detection and declaration resulted in a lag of approximately Losses were US$600 million for Guinea, US$300 million for Liberia, and US$1.9 billion for Sierra Leone.   9 10  FIGURE 1  West Africa Ebola Outbreaks, 2014–2015: Epidemiological Curve, Key Events, and Funding Commitments (US$) UN MPTF (Total US$166 million) first disbursements WB pledges US$200 million August 4, 2014 to WFP for US$8 million by October 30, 2014 WHO declares PHEIC on August 8, 2014 World Bank reallocates US$6 million in Liberia and Sierra Leone (each) EVD confirmed in EERP effective September 19, 2014 Guinea March 22, 2014 UN MEER created September 19, 2014 Liberia Emergency US$114.4 million of US$117 million (EERP, reallocations) disbursed September 26, 2014 2,000 declared, UN MPTF launched EVD case August 6, 2014 1,800 confirmed EERP AF US$285 million approved November 18, 2014 Sierra Leone Guinea 1,600 May 24, 2014 Emergency 1,400 declared, US$5.4 billion allocated by USG, US$3.7 billion for international efforts on August 13, 2014 December 16, 2014 (US$2.25 billion rescinded from total) 1,200 Ebola outbreak ends in Sierra Sierra Leone 1,000 Emergency US$118 million of UN MPTF Leone November 7, 2015 Liberia confirms EVD declared, disbursed by February 6, 2015 800 Ebola outbreak ends March 30, 2014 July 31, 2014 Ebola outbreak ends in Liberia Number of cases 600 in Guinea May 9, 2015 December 29, 2015 400 200 0 2015 W1 2015 W5 2015 W9 2016 W1 2016 W5 2014 W13 2014 W17 2014 W22 2014 W26 2014 W30 2014 W34 2014 W38 2014 W42 2014 W47 2014 W51 2015 W13 2015 W17 2015 W21 2015 W25 2015 W29 2015 W33 2015 W37 2015 W41 2015 W45 2015 W49 2016 W12 2016 W15 WHO Ebola Road map estimates cost of Delayed early financing US$490 million on August 28, 2014 Guinea Liberia Sierra Leone The Epidemics  five months6 for the international community to declare an Delays in disbursement of funds and effective use of emergency and to develop a coordinated and funded contain- financing were exacerbated by bureaucracy, earmarked and ment response appropriate to the severity of the outbreak. inflexible funds, and poor transparency and information Because several generations of transmission had occurred sharing. These delays in funding led to a realization that flex- prior to detection, it was difficult to quantify the magnitude ible (un-earmarked), rapidly disbursable funds are critical to of the outbreak with any accuracy or the funding required to respond to the changing needs of a public health emergency contain it. One study highlights how the funding estimates (DuBois and others 2015). Lack of strong governance and for the outbreak response changed from US$4.8  million in accountability as well as systems to track funds also hindered April 2014 to US$71 million in August of the same year, then the international response to the Ebola outbreak. Low insti- to US$490 million just a few weeks later. In September 2014, tutional capacity to manage data collection, keep records, WHO estimated that the cost of the response had spiraled ensure proper procurement, and enforce financial manage- up US$1 billion (Flessa and Marx 2016; Grépin 2015; Harman ment meant there were instances of corruption, which fur- 2014). By December 2014, the official WHO request for fund- ther reduced trust in government (Coltart and others 2017; ing to respond to the 2014–15 WA Ebola outbreak had risen to Elmahdawy and others 2017). For example, there were US$1.5 billion (Global Ebola Response 2014). reports of officers being bribed at the West Point area of Libe- Even as the estimated cost surged nearly 10-fold, ria to break quarantine (Pring 2015); and cases of ghost work- resource mobilization took off slowly (Lupel and Snyder 2017). ers being paid in Sierra Leone, which delayed salaries for front As a result, there were significant funding gaps in the imme- line responders and led to strikes and interruption of activities diate response (Elmahdawy and others 2017). As of Novem- (Audit Services 2015a, 2015b). ber 2014, eight months after the declaration of the outbreak, The outbreak underscored the importance of investing in a financing gap of 39 percent, or US$988 million, remained preparedness and disease detection, the importance of com- (Office of the UN Special Envoy on Ebola 2014). The Ebola munity engagement, and the necessity for financing mecha- response was characterized by inadequate coordination of nisms that are quick and easy to activate and flexible enough national and international partners, which impacted the time- to address changing needs in an unpredictable, dynamic liness and efficiency of the resource mobilization and inter- outbreak (World Bank 2017a; Govindaraj, Herbst, and Clark ventions (Coltart and others 2017; Cangul and others 2017; 2017; Oleribe and others 2015). Major global missions that Ross and others 2017; Fielding and others 2016; Gostin and reviewed the West Africa Ebola response outlined several les- Friedman 2015; Moon and others 2017). In contrast, when sons and recommendations for WHO, UN, World Bank, and Ebola was detected in Nigeria, caused by an imported case other development partners. These included to (1) strengthen linked to the West Africa outbreak, the disease was controlled IHR core capacities, (2) improve community engagement, swiftly due to effective, government-led coordination as well (3)  institute system-wide accountability in response oper- as to multisectoral engagement. (Bali and others 2016; Cangul ations, (4)  improve donor coordination, and (5) establish and others 2017). contingency financing for emergency response (Gostin, The creation of UNMEER helped to galvanize political sup- Mundaca-Shah, and Kelley 2016; Gostin and others 2016; Kik- port for the response. However, UNMEER’s lack of proximity to wete and others 2016; Moon and others 2015; WHO 2015a). the crisis7 made field coordination challenging (Lupel and Sny- der 2017; USAID, OFDA 2018). The lack of coordination contrib- Financing the WA 2014–15 Ebola response. The final report, uted to delayed response efforts and duplication of activities “Resources for Results,” revealed that, as of October 31, 2015, and funding in some areas (Elmahdawy and others 2017). a total of US$5.9 billion had been disbursed to respond to the 2014–15 Ebola outbreak (Office of the UN Special Envoy on Ebola 2016). Of the US$5.04 billion pledged for immedi- 6 The delay from outbreak occurrence to confirmation in Guinea was ate response, US$4.67 billion had been disbursed by Octo- approximately four months. The delay between the first confirmed case and ber 31, 2015 (Office of the UN Special Envoy on Ebola 2016). the declaration of emergency in Guinea was nearly five months. 7 UNMEER headquarters was in Ghana, a nonaffected country. Bilateral donors collectively disbursed over US$3.9 billion in   11 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA FIGURE 2  Amount of WA 2014–15 Ebola Financing Disbursed by Donor WHERE DID THE MONEY COME FROM? Amount disbursed by donor category Largest bilateral donors: (contribution > $20 million) 145.7 Private foundations • US 721.3 Regional organizations • UK • Japan • Germany 1,088.8 International financing institutions • China • France 3,960.0 Governments • Canada • Netherlands 0 1,000 2,000 3,000 4,000 5,000 • Denmark • Belgium USD million • Ireland • Norway • Switzerland • Australia • Russia financing (Figure 2). Financing disbursed to the affected coun- In parallel, World Bank staff prepared to activate the tries (including debt relief and financial assistance from the IDA Crisis Response Window (CRW) by modifying it to enable WBG and the International Monetary Fund (IMF) amounted funding for public health emergencies (Box 1), and activated to US$1.352 billion, while United Nation entities received for US$420 million (World Bank 2015a). US$1.157 billion (Office of the UN Special Envoy on Ebola Strong support from World Bank senior managers and 2016). That only 22.9 percent of the financing was disbursed the ability of task teams to coordinate various moving parts directly to countries reflects the top-down nature of emer- enabled the World Bank to utilize the IDA funds from CRW to gency aid and the challenges pertaining to country ownership launch the Ebola Emergency Response Project (EERP), and dis- of the response (DuBois and others 2015). burse US$105 million in financing within 47 days (World Bank 2014a; Frost 2015).9 Later, financing of US$285 million was World Bank response. A number of reports highlight World added to bolster support to the EERP response efforts (World Bank as one of the first institutions that provided much Bank 2014b). needed financing to the affected countries (Gostin and others Of the US$1.62 billion financing attributed to the World 2016; Frost 2015). The World Bank pledged US$200 million Bank Group for the outbreak, US$518 million was provided in financing by August 4, 2014. However, by April 2015, total for immediate response. This amount included US$390 mil- World Bank and IMF funding for the outbreak and recovery lion financing via EERP and additional financing, US$18 million efforts, including debt relief, exceeded US$1.6 billion (Office in reallocated funds, and US$110 million in budget support. of the UN Special Envoy on Ebola 2016). Beginning in August Post-Ebola recovery efforts were supported by US$650 million 2014, the World Bank restructured three existing projects. Two in IDA grants and loan contributions and US$450 million in of these projects8 totaling US$6 million were restructured by International Finance Corporation (IFC) investments in com- August 8, 2014, and an additional US$6 million was advanced mercial financing (Reynolds 2015).10 to Guinea through reallocation of a social protection project. 9 Time from WBG pledge on August 4, 2014, to EERP effectiveness. EERP was approved by the board on September 16, 2014, and became effective on 8 Sierra Leone Reproductive and Child Health Project (SLRCHP) and Liberia September 19, 2014. Health Systems Strengthening Project (LHSSP). 10Including lines of credit to enable trade and employment. 12  The Epidemics  BOX 1  Avian Influenza: Missed Opportunity for Preparedness Between 2005–10, the global community committed US$3.9 The World Bank endorsed the declaration and three pri- billion to Avian and Pandemic Influenza preparedness and ority program areas:13 response. Of this amount, US$2.7 billion was disbursed (WBG 2010). Avian Influenza was recognized as one of the primary 1. Continue collaboration among governments, indus- zoonotic threats to global health security, and a number of try, and communities to pursue prevention, pre- global initiatives to prepare for outbreaks were supported, paredness, and response systems in animal, human, including the World Bank Pandemics Global Program and and environmental health disciplines Partnership (PGPP), which spanned 2006 to 2020. PGPP was 2. Move from limited emergency measures, to long-term coordinated with key human and animal health organizations investments in animal and human health to sustained including WHO, FAO, OIE, and UNSIC; and focused on advo- disease prevention and development of capacities to cacy, coordination, strengthening health systems, and com- respond and eradicate disease at their sources and plying with IHR. Several initiatives were included in the PGPP before cross-border regional and global spread including the Global Pandemic and Avian Influenza (GPAI) 3. Emphasize strengthening country/local animal and initiative11 (over US$1 billion), and the Avian and Human Influ- human systems including emergency response and enza (AHI) Facility trust fund (US$127 million) for GPAI proj- contingency planning reflecting global IHR and OIE ects.12 The World Bank also managed a multi-donor reporting veterinary standards. system between 2005–10, involving financing US$4  billion from 35 donors to over 100 lower- and middle-income coun- Despite these commitments, in the wake of the 2008 tries (LMIC). financial crisis, funding for disease preparedness lagged, “The Fifth Global Progress Report on Avian and Pan- and program priorities shifted. Prior to the West Africa Ebola demic Influenza: A Framework for Sustaining Momentum” outbreak in 2014, little progress had been made in adapting was endorsed at the April 2010 International Ministerial financial tools to respond to emerging disease threats. An Conference on Avian and Pandemic Influenza (IMCAPI) in example was the absence of infectious disease outbreaks Hanoi (WBG 2010). Three streams of work were agreed: from funding eligibility under the Crisis Response Window. (i)  prevention and control of the highly pathogenic Avian In the 2013 Independent Evaluation Group (IEG) report on Influenza, (ii)  adoption of the animal-­ human-environmental the GPAI, evaluators noted that the report’s “. . . most impor- “One Health” approach, and (iii) readiness for response to tant finding was that after 2010, the World Bank has not sus- influenza pandemics. The consensus reached through the tained the zoonotic disease risk management and pandemic “Hanoi Declaration” stated that international policies and preparedness agendas and failed to mainstream them into financial support need to transition from emergency projects Bank strategy and operations.”(IEG 2013). As detailed in this and special initiatives to build long-term system capacity for report, momentum has been re-established to support pre- multisectoral preparedness and response to pandemics to paredness for outbreaks. However, Avian Influenza should avert potential pandemics of animal origin, and mainstream be held up as an example of how not to allow priorities to investments and capacity in country health systems (Jeggo be diverted from financing longer term preparedness efforts. and Mackenzie 2014; WBG 2010). Otherwise, the global community may find itself once again unable to respond to a global pandemic. Concurrently, World Bank also launched a US$53 mil- Netherlands, Norway, Russia, and the United Kingdom. The lion Ebola Recovery and Reconstruction Trust Fund (EERTF) pooled MDTF mechanism enabled resources to become (Box  2). This effort was a Multi-Donor Trust Fund (MDTF), quickly available and expedited the implementation of 19 which received contributions from Denmark, Japan, the Ebola recovery projects (Rey 2018; World Bank 2018). 11 Approved in January 2006, GPAI provided for an “adaptable program lending” (APL) approach that financed 72 projects in 60 countries; with US$1.3 billion in financing for country-based programs from IBRD/IDA/TFs. GPAI projects ending in FY 2015. 13 Animal and Pandemic Influenza: A Framework for Sustaining Momentum.  12 The AHI facility closed in 2014. Fifth Global Progress Report.   13 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA BOX 2  World Bank Ebola Recovery and Reconstruction Trust Fund (ERRTF) The World Bank Ebola Recovery and Reconstruction Trust The fund contributed US$51 million to economic, social, Fund (ERRTF) was launched in September 2014 to support the and health systems recovery, including supporting critical post-Ebola economic, health, and social recovery of Guinea, activities around infrastructure, supplies and equipment, Liberia, and Sierra Leone. These funds provided support to medicines, capacity building, education, and livelihoods recovery and reconstruction efforts and to bridge financing (Table 1). The remaining US$1.55 million is supporting the gaps between emergency response and long-term develop- ongoing 10th Ebola outbreak in DRC. ment investments such as the REDISSE program. TABLE 1  ERRTF Contributing Partners AMOUNT CONTRIBUTED PARTNERS (US$ MILLION) Norway Ministry of Foreign Affairs 10.2 Danish Ministry of Foreign Affairs  4.9 Japan Ministry of Foreign Affairs 20.0 Russian Federation Ministry of Finance  3.0 United Kingdom (DFID)  4.5 Norwegian Agency for Development Cooperation (NORAD)  4.9 Netherlands Ministry of Foreign Affairs  5.4 Other international financing. Bilateral donors were by the major lessons documented from the World Bank MDTF far the biggest contributors to the 2014–15 Ebola response and the UNMPTF is that pooled funds can fill critical gaps in (Figure 2). By December 2014, the U.S. government had financing during a health emergency through rapid injection allocated US$2.4 billion for international efforts (USAID of non-earmarked funds (Lupel and Snyder 2017). 2016). Financing support came from multiple African insti- tutions. The African Development Bank (AfDB) contributed GENERAL LESSONS LEARNED US$525 million in grants and loans. The African Union made direct contributions of US$1 million from the AU Special Multiple studies have looked at the overarching lessons from Emergency Assistance Fund for Drought and Famines, with the 2014–15 West Africa Ebola epidemic (Coltart and others another US$1 million contributed from Special Fund Con- 2017; Commons 2016; Gostin and Friedman 2015; Heymann tributions for IDPs and Refugees (Loewenson, Papamichail, and others 2015; Moon and others 2017; Moon and others and Ayagah 2015). African resources in total contributed 2015; Ravi, Snyder, and Rivers 2019; UNMPTF 2017; USAID, US$600 million to the outbreak (Loewenson, Papamichail, OFDA 2018; WHO 2015a; Yamey and others 2017). The follow- and Ayagah 2015). ing major themes stand out: The United Nations leveraged pooled funding from 43 UN Member States in the form of the Ebola Response 1. As the first line of defense, it is important to strengthen Multi-­Partner Trust Fund (MPTF), which provided a flexible public health capacity and preparedness in the region, funding pool for UNMEER and other UN partners to respond including human and animal disease surveillance. to the epidemic. The Ebola MPTF leveraged US$157 million Swift detection enables swift response and more lead to finance over 70 different projects (UNMPTF 2017). One of time to mobilize resources. 14  The Epidemics  2. Timely and agile financing for rapid response is crit- transmission was widespread, and much of the damage ical, but sustainable financing for routine prepared- already had been done. More modest and flexible funding, if ness and response systems in the region is equally made available earlier, may have more effectively contained important. The outbreak underscored the importance the epidemic, limiting human and economic losses, and obvi- of investing in disease detection, the importance of ated the need for the unprecedented amount of resources community engagement, and the need for financing required to end the outbreak. mechanisms that are quick and easy to activate and flexible enough to adapt to rapidly shifting needs in an Effective use of resources. Weak and often opaque country unpredictable, dynamic outbreak. financial management systems as well as outdated informa- 3. Effective preparedness and response depend on tion systems made financial accountability a persistent prob- having in place an adequately financed and country- lem. Lack of financial accountability had implications for the owned public health system. efficient use of resources and wasteful spending. Inefficient administration of health worker hazard incentives was a crit- ical problem and severely impeded the response workforce. KEY STUDY FINDINGS Lack of in-country capacity to manage local procurement also Governance. Weaknesses in country ownership, leadership, contributed to excessive response costs and often resulted in operational management, and the capacity to coordinate mul- the payment of high overhead costs to external implementing tiple implementing partners were evident from the outset. agencies. Additional related problems arose from the lack of transpar- ent decision making, competing lines of action, duplication of Preparedness. The weaknesses in the countries’ outbreak efforts, and lack of community trust. readiness were starkly revealed during this epidemic. Disease surveillance, particularly at the human/animal/environmental Efficient financing. The mobilization of domestic and exter- interface, was sorely lacking in all three countries. Also lack- nal financial resources initially was delayed primarily due ing were laboratory diagnostic capacity, human resources to the late detection, confirmation, and declaration of the with skills in applied epidemiology, community intervention, emergency. Once the funds were committed, cumbersome and emergency management. The epidemic underscored the country and external donor procedures and time-intensive urgency of investing to strengthen health systems and human procurement systems further delayed effective containment resource development for outbreak prevention, detection, operations. and response. Another gap to be filled is the development The World Bank’s grant-funding mechanisms were inade- of a multisectoral One Health Approach to public health risk quate and overly complex for use in a public health emergency. management that coordinates across the human, animal, and Immediate steps had to be taken to modify instruments, such environmental sectors. as the World Bank’s Crisis Response Window, to make them responsive to health emergencies. Given the instruments available, the accelerated WBG effort successfully overcame Lassa Fever Epidemic, Nigeria, 2018 many constraints in team organization, coordination among Efficient coordination improved timeliness of resource multiple partners, and expedited project approval and dis- mobilization, but delays in financial request and bursement. Nevertheless, the Bank’s efforts also underlined centralized procedures delayed disbursements the necessity to develop and adapt financing mechanisms for public health emergencies. The international response eventually gained momen- BACKGROUND tum through contributions of the WBG, United States, United Lassa Fever is endemic to Nigeria. Typically, over 100 infec- Kingdom, United Nations, and many other donors. Never- tions occur every year, usually in specific geographic areas of theless, by the time funding became available, geographic the country. The illness is a viral hemorrhagic and zoonotic   15 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA disease, transmitted to humans on food or household goods bureaucratic procedures and lack of legal autonomy delayed contaminated with rat urine or feces. Nigeria’s request for external assistance.16 2018 outbreak timeline. A cluster of four cases of Lassa Fever FINANCING THE OUTBREAK RESPONSE among health care workers in Ebonyi State were reported to the Nigeria Centre for Disease Control (NCDC) in January 2018. Prior to 2018, Nigeria had no contingency preparedness plan The government immediately deployed an outbreak investiga- in place for a Lassa Fever outbreak. On March 2, 2018, 24 days tion team (NCDC 2018c). These cases, which involved health after the initial emergency had been declared,17 a SRP was for- care workers, were the harbinger of what was to become, at mulated with WHO’s assistance. The SRP estimated a funding that time, the largest Lassa Fever outbreak in the country’s gap of US$4.85 million. WHO promptly released US$950,000 history. In January 2018 alone, there were 203 suspected from its CFE to cover needs for the initial three months (WHO cases––more in one month than the 143 confirmed cases in all 2018a).18 of 2017, or the 109 cases in all of 2016 (Beaubien 2018). WHO graded the outbreak as Level 2 on February 6, 2018 (WHO World Bank activates CERC. Of the estimated US$4.85 mil- AFRO 2018). The outbreak was upgraded by the government lion required to implement the SRP for Lassa Fever, the Gov- to a Level 3 on February 28, 2018. The outbreak was declared ernment of Nigeria identified a US$2.5 million funding gap over on May 10, 2018, by which time it had lasted 4.5 months (World Bank communications). On March 12, 2018, NCDC and resulted in 1,706 suspected cases, 423 confirmed cases, requested the Ministry of Health (MOH) and the Ministry of and 106 confirmed deaths (NCDC 2018a). Finance (MOF) to seek financing from the World Bank REDISSE Program under its CERC. The request was made on March 29, Response. Since Lassa Fever is endemic in Nigeria and the 2018––within weeks of the declaration of effectiveness for country faces yearly outbreaks, the initial cases were not the REDISSE 2 Project in Nigeria.19 The Bank activated the interpreted as indicating an unusual or severe event. How- CERC within nine days, on April 6, 2018. The Government of ever, the cluster of cases among health care workers in Janu- Nigeria directed that the funding be provided to WHO and the ary 2018 and the rapid increase in case reporting that month United Nations Children’s Fund (UNICEF) to complement the indicated that the outbreak had deviated from patterns of ongoing response in the country. The Bank disbursed a total previous outbreaks. Transmission took place in a densely pop- of US$2.5 million as follows: US$565,000 to UNICEF on April 2 ulated area in which surveillance was compromised by lim- and USS$1,935,00 to WHO on June 27, 2018. This was the first ited health care worker presence. The challenge of response time that the World Bank had activated a CERC mechanism to was compounded by a labor union strike,14 hostile community address a public health emergency in Africa. reactions in some regions, and lack of preparedness at state Use of CFE and CERC mechanisms for financing, and the and local levels. The endemic nature of Lassa Fever resulted in establishment of the Lassa Fever Technical Working Group complacency and delayed comprehension of the magnitude (TWG) by NCDC were some of the game changers that facilitated of the outbreak. The severity of the outbreak quickly out- stripped resources, making for cumbersome, inefficient oper- 16 Review of documents and findings from this study reveal that the time ational coordination, particularly at the state and local levels. between NCDC’s request to MOH and MOF for WBG financing and the Although NCDC was instrumental in the response efforts,15 receipt of Nigeria’s CERC activation request by the World Bank was 18 days. 17 Nigeria declared Lassa Fever as a Level 2 emergency on January 22, 2018 and a Level 3 emergency on February 28, 2018. 18 CFE disbursements are aligned with WHO’s Emergency Response Framework (ERF): “The Emergency Framework, which provides all hazards of emergency assistance, is being piloted according to a country model based 14 Focus group with state epidemiologists and Emergency Operations Center on a defined, graded level of emergency. Level 1 is expected to be managed (EOC) leads highlighted that health care worker (HCW) strikes interrupted at the country level; Level 2 requires regional support; and Level 3 depends service delivery for Lassa Fever due to the high risk of Lassa Fever for HCWs, on global WHO headquarters engagement for up to US$1 million in eligible and issues of delayed/low hazard allowances. assistance.” 15 NCDC started to respond from January 2018 and played a key role in 19 REDISSE had been declared effective in Nigeria one month earlier on coordinating and implementing Nigeria’s national response to Lassa Fever. February 13, 2018. 16  The Epidemics  responses to the Lassa Fever outbreak. Lack of familiarity perceived need for adjustments in the use of CERC resources21 with the CERC financing instrument (“learning by doing”); and required additional documentation. Delays in contract signing delayed contract signing (among Nigeria, WHO, and UNICEF) made it difficult for agencies to utilize resources most effi- due to centralized and bureaucratic procedures were some of ciently to meet the outbreak at its peak. The CERC should be the challenges reported during the interviews. The contract sufficiently flexible and nimble to respond efficiently to the between the Government of Nigeria and UNICEF was signed on changing dynamics of epidemiologic emergencies as they April 18, 2018. The contract between the Government of Nige- run their course. After Action Review (AAR) of CERC after 12 ria and WHO was signed on June 11––well after the outbreak months to identify bottlenecks, and workshops to familiarize had been declared ended on May 10, 2018 (NCDC 2018b, NCDC country managers, and countries with CERC and other such 2018d). The findings are elaborated in the next section. financing mechanisms/tools would improve efficiency of financing. STUDY FINDINGS Effective use of resources. National governments and inter- Governance. In the last two years, NCDC has strengthened national partners’ lack of familiarity with in-process amend- its leadership capacity, activated five emergency operations ments under the new World Bank financing procedures (including for meningitis, cholera, and monkey pox), and delayed the use of funds. FGON’s centralized procurement deployed 32 outbreak investigation teams. However, during policies and procedures and the lack of prepositioned agree- the 2018 Lassa Fever outbreak, the legal status of NCDC was ments delayed procurement contracting. Although resources still under discussion and the organization was dependent on at the national level were sufficient, state and local levels the mediating authority of the MOH to request the MOF for experienced a significant lack of funding. All external financ- funding, contributing to the delayed response. The Nigeria ing was required to be deposited in a single Treasury account, Health Act provides for an earmarked contingency fund for making the approval processing cumbersome. Engagement health emergencies, although it is limited. The Nigerian Par- with the private sector would maximize resources for out- liament is supportive of health security and a stronger NCDC. break response and could be leveraged to reduce misuse of As of November 11, 2018, the Centre has had full legal status funds.22 to prevent, detect, and respond to public health threats. It no longer requires the mediation of MOH to engage with MOF Preparedness. Due to its “intangible nature,” states fre- to request external financial assistance. These changes endow quently invest very little in preparedness. The REDISSE project, NCDC with greater responsibility for and authority to respond with its surveillance dimension, integrates the preparedness to outbreaks and other public health threats. function in a financing tool. This innovative combination makes for easier, more prompt procurement. Going forward, Efficient financing. Findings from this study reveal that suf- an analysis of the long-term socioeconomic impacts of Lassa ficient resources were mobilized,20 but the request for CERC Fever would help guide policy on domestic public financing activation by the Federal Government of Nigeria (FGON), and and contingency budgeting and program design, as well as the subsequent disbursement of CERC funds was delayed for rationalize and improve the cost-effectiveness of prevention procedural, interministerial reasons (Figure 3). Although CFE and preparedness. and CERC were touted as game changers in agile financing, respondents highlighted the impact of centralized processes and lack of familiarity with new instruments for contract sign- ing and disbursements. Instances were reported when the 21 Accidental omission of certain reagents from the submitted emergency plan. 22 An example is the use of vouchers for fuel (in collaboration with major oil 20 CERC was activated to cover the financing gap from Lassa Fever SRP. and gas companies) instead of financing of fuel.   17 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA FIGURE 3  Nigeria Lassa Outbreak, 2018: Epidemiological Curve, Key Events, and Funding Commitments WHO grades outbreak as Level 2 on February 10, 2018; NCDC writes to MOH to WHO CFE request MOF to ask EOC activated on disburses money WB to activate CERC January 22, 2018, ALIMA effective on on March 12, 2018 helps in EOC setting up February 13, 2018 Lassa Response Plan created by March 2, 2018 565,000 US$ disbursed to UNICEF NCDC begins response on CERC activated on January 14, 2018 April 6, 2018, after GoN declares Lassa NOJ from WB outbreak on February 6, 2018 70 60 MOF requests WB to Outbreak declared over activate CERC May 10, 2018 March 29, 2018 Number of cases 50 MOU signed by 40 UNICEF and NCDC Week 24 and Week 26, June 11, 2018, 30 MOU signed by WHO and NCDC 1.935 million US$ 20 disbursed to WHO 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Epidemiological week Alive Dead BOX 3  Regional Disease Surveillance Systems Enhancement (REDISSE) Program REDISSE is an interdependent series of projects to strengthen emergencies); (4) workforce training, deployment, and reten- national and regional capacity for disease surveillance and tion; and (5) institutional capacity building for project man- response in West Africa. This program is at the heart of the agement, coordination, and advocacy. World Bank’s post-emergency response to the 2014–15 The REDISSE Program currently supports 11 countries Ebola outbreak. The REDISSE Program has two objectives: in West Africa as well as the West African Health Organi- (1) to address systemic weaknesses within the animal and zation (WAHO), including Guinea, Senegal, Sierra Leone, human health systems that hinder effective cross-sectoral WAHO (REDISSE Phase 1); Togo, Guinea-Bissau, Liberia, and cross-border collaboration for disease surveillance and Nigeria (REDISSE Phase 2); and Benin, Niger, Mauritania, response; and (2) in the event of an eligible emergency, to Mali (REDISSE Phase 3). Present financing for the REDISSE provide immediate and effective response to said eligible Program is US$390.8 million. REDISSE Phase 4 is under emergency. The REDISSE Program has five components: preparation and will expand the program to five countries in (1) surveillance and information systems; (2)  strengthened neighboring Central Africa (Angola, Central African Republic, laboratory capacity; (3) epidemic preparedness and rapid Chad, Congo, and Democratic Republic of Congo (DRC). response (including a CERC or “zero-dollar component” for 18  The Epidemics  FIGURE 4  DRC 9th Ebola Outbreak: Epidemiological Curve, Key Events, and Funding Commitments, 2018 WHO upgraded outbreak to Level 3 May 22—Pandemic Emergency Facility (PEF) cash May 21—Strategic Response Plan (SRP) window becomes operational, activated on May 31 costed for US$56.05 M and is fully May 25—World Bank Group (WBG) receives request funded for financing from Ministry of Finance (MOF) May 25—US$15 M reallocated by PDSS WBG Project May 8—DRC declares EVD May 25—Contingency Emergency Response May 8—World Health Organization (WHO) Component (CERC) activation for US$80 M • Outbreak declared by assigns Grade 2, Contingency Fund for DRC/WHO within 13–15 Emergencies (CFE) disburses US$3 M days of first confirmed case 16 • Strong coordination, June 7—PEF funds rapid mobilization 14 disbursed to WHO • Gamechangers (US$6.86 M) compared to 2014–15 12 West Africa Ebola Number of cases 10 June 21—PEF funds Outbreak: pre-existing disbursed to UNICEF IDA investment in 8 (US$4.54 M); Delay surveillance, PEF, SRP 6 due to disparity in institutional agency 4 fees July 24—DRCs 9th Ebola outbreak declared over 2 0 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Week of onset Confirmed Probable Ebola, Outbreaks #9 and #10, Democratic Tenth Ebola outbreak in DRC. The 10th Ebola outbreak in Republic of Congo (DRC), 2018–19 the North Kivu and Ituri provinces of DRC was declared by the Ministry of Health on August 1, 2018 (WHO 2019a) and Strong coordination, rapid resource mobilization, but was determined to be distinct in origin from the 9th outbreak. some delays in disbursements Ebola transmission was ongoing at the time that this report was published. In contrast to the 9th outbreak in Equateur, this outbreak occurred in an area of ongoing insecurity and BACKGROUND humanitarian crises. Being in this environment led to delays in Ninth Ebola outbreak in DRC. The first confirmed cases of outbreak detection, declaration, and response (Munster and Ebola in DRC were recorded on April 23–25, 2018, followed others 2018). by a cluster of 21 cases reported on May 3, 2018, by the Equa- While community deaths started occurring in April 2018, teur Provincial Health Division. MOH, WHO, and Médecins the alerts were received only in late July due to difficulty in Sans Frontières (MSF) carried out a joint field investigation on accessing the region and frequent health care worker strikes May 5, 2018. Following positive test results at the national lab- for nonpayment of salaries (Gostin, Kavanagh, and Cameron oratory in Kinshasa, on May 8, 2018, MOH officially declared 2019; Fanning 2018). The 10th Ebola outbreak is the second the 9th outbreak of Ebola in DRC since the disease had been largest Ebola outbreak to date with 1,400 confirmed and identified in the country 40 years ago. The 9th Ebola outbreak, 66 probable cases, including 92 health workers; and over graded as a WHO Level 3 outbreak (that is, requiring WHO HQ 957  deaths as of May 1, 2019. After the outbreak was con- intervention), was declared ended on July 24, 2018. In total, firmed in eastern DRC, on August 8, 2018, officials began there were 54 cases resulting in 33 deaths, and it took 77 days Ebola vaccination of at-risk populations. As of May 1, 2019, to contain the outbreak (WHO 2018b). The epidemiologic over 106,872 people have been vaccinated (WHO Situation curve of the 9th Ebola outbreak is shown in Figure 4. Report 39, 2019).   19 20  FIGURE 5  DRC 10th Ebola Outbreak: Epidemiological Curve, Key Events, and Funding Commitments Oct 22— CFE releases US$10 M European Union Dec 18—SRP 2 launched for $62.2 M, fully funded. gives 7.3 M Euros 42.2 M–WBG CERC (68% SRP) for EVD response Dec 22—SRP (2.1) $23 M; DFID funded 60 Aug 9—GCRP meeting Aug 10—SRP for $43.8 M Feb 8—3rd SRP launched for US$147.9 M Aug 1—EVD10 50 launched Feb 14—MOH requests US$20 M PEF outbreak Financing cash window declared Feb 25—Additional Financing (AF)3 for Aug 16—SRP PDSS—$120 M (including $40 M for CERC 40 fully funded: replenishment) approved Aug 3—Start $19.6 M via WBG fund GBP CERC (45% SRP) 30 350K to $6.3 M via Oxfam/Save Number of cases WHO CFE the Children 20 Early detection of EVD10 was a challenge 10 0 Global Crisis Risk Platform pr ay ay un un ul ul g g ep ep ct ct ct ov ov ec ec an an eb eb ar (GCRP), Health System -A - M - M -J -J 9 -J 3-J - Au - -S 1 -O 5 -O 9 -O -N -N -D -D 7 -J 1 -J -F -F -M 0 1 5 0 2 Au 3-S 0 1 7 0 1 2 1 2 2 6 1 0 2 4 0 2 0 4 1 8 0 4 Strengthening for Better 3 14 28 1 2 06 20 Maternal and Child Health Week of illness onset Results Project (PDSS) Probable Confirmed The Epidemics  The outbreak has not yet spilled across international bor- prepared three-month Strategic Response Plan and costed it ders. Nevertheless, extensive Ebola preparedness efforts–– at US$56 million. planning, identifying, and prepositioning financial and technical resources, and vaccinating health care workers–– Activation of World Bank emergency financing mecha- are being conducted in the countries bordering the affected nisms. On May 22, 2018, the World Bank activated for areas, in particular Rwanda, South Sudan, and Uganda. the first time the cash window of the PEF.26 The payout of Despite the availability of financing and extensive national US$11.4 million occurred on June 1, 2018, and was financed and international efforts to curb transmission, the response by the German government. At MOH’s request, the funds has been hampered by insecurity, weak community engage- were disbursed to WHO ($6.86 million) on June 17, 2018, and ment, limited coordination with the humanitarian sector, to UNICEF ($4.54 million) on June 18. These disbursements and poor infection prevention and control (IPC) implemen- were made considerably more quickly than the disbursements tation leading to health care worker infections. Since August made to WHO and UNICEF during the Lassa Fever outbreak in 2018, over 237 security incidents23 (as of December 22, Nigeria. Notably, the Bank requested to activate the PEF cash 2018)––including several attacks on first responders––have window during the World Health Assembly (WHA), which had impacted the response (DRC Ministry of Health 2018b). Com- drawn many of the key PEF stakeholders on-site, thus facilitat- munity mistrust and poor access to rebel-held regions have ing communication and coordination. made contact tracing and vaccination extremely difficult. The On May 25, 2018, the World Bank activated a CERC impact of financing and responding to outbreaks in insecure mechanism, making an additional US$80 million available for areas is further explored in Box 3. The epidemiologic curve of emergency use. Although these funds were not engaged27 for the 10th Ebola outbreak is shown in Figure 5. Because the out- the 9th Ebola outbreak response, they were effectively pre-­ break was ongoing at the time of this study, the data cut-off positioned to contribute to the 10th outbreak response in was selected at the time that the third SRP was launched, with North Kivu and are being used during this outbreak. According subsequent World Bank additional financing made available to the UNOCHA tracking system, for the 9th Ebola outbreak, to support the efforts. a total of US$63 million was committed to the DRC from var- ious external sources. Of this total, the World Bank provided US$26.4 million, and US$36 million of the external contribu- FINANCING THE OUTBREAK tions was channeled via WHO. Unspent funds were allocated WHO disbursed the first US$1 million (of US$3 million total to to the 10th Ebola outbreak.28 DRC for the 9th Ebola outbreak) from CFE on May 8, 2018–– For the 10th outbreak, both the 1st SRP (US$43.8 million) the same day that the 9th Ebola outbreak was declared.24 and 2nd SRP ($61.2 million) appeals were fully funded. The Also on May 8, 2018, the World Bank authorized the use of World Bank funded 45 percent of the 1st SRP ($19.6 million, US$15 million from the existing Health System Strengthening of which US$10.5 million went to the UN agencies),29 and for Better Maternal and Child Health Results Project (PDSS), 68 percent of the 2nd SRP ($42.8 million, of which US$30 mil- which included a component on disease surveillance. Domes- lion went to the UN agencies).30 Other donors also leveraged tic emergency government funding included US$500,000 pooled funds to finance the response, including EU’s Emer- from the DRC MOH, and an additional US$4 million in spe- gency Aid Reserve, WHO’s Contingency Fund for Emergencies cial emergency funds were disbursed by the DRC Treasury.25 On May 21, 2018, MOH, WHO, and partners finalized a jointly 26 On May 22, 2018, Germany, as the first bilateral donor, contributed Euro 10 million to the PEF cash window. Germany has since become the largest contributor to the PEF Cash Window, having contributed US$57 million. 27 In the absence of the 10th Ebola outbreak, any non-engaged funds or 23 As per the Human Rights Watch data on https://kivusecurity.org, there remaining balance from CERC activation would have been returned to the have been 823 security incidents in the Kivu region between August 31, donor project and respective components. 2018, and April 30, 2019. 28 For the 10th Ebola outbreak, World Bank CERC funding ($80 million) was 24 Another US$1.5 million from WHO CFE was disbursed for preparedness in activated to cover a US$20 million funding gap. neighboring countries. 29 US$6.5 million to WHO; US$3.7 million to UNICEF. 25 Based on verbal report. 30 US$17.2 million to WHO; US$12.8 million to UNICEF.   21 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA (CFE), and UN Central Emergency Response Fund (CERF). disbursement of US$950,000 from WHO’s CFE, was immedi- Insecurity, lack of infection prevention and control measures, ate. World Bank funding (US$15 million via the PDSS project) and weak community engagement have prolonged the 10th also was committed promptly with a June 1, 2018, payout outbreak, leading to an exponential increase in cost. The 3rd from the PEF cash window of US$11.4 million. The PDSS proj- SRP estimated a cost of US$147.9 million to address the con- ect provided an immediate, agile financial response using tinuing outbreak (DRC Ministry of Health 2018a). US$20 mil- previously allocated health funding. CERC was activated in lion of CERC money is available for the 3rd SRP, and the World response to the 9th outbreak (but later redirected to respond Bank prepared additional financing of US$120 million in IDA to the 10th Ebola outbreak in DRC). grants to replenish PDSS project activities and add US$40 mil- With the confirmation of the 10th Ebola outbreak, lion to the CERC. The Government of DRC also has requested unspent funding from financing the 9th Ebola outbreak was that US$20 million be mobilized for the PEF Cash Window to redirected. Donors responded swiftly to the outbreak, and the contribute to the 3rd SRP funding gaps. availability of more agile financing tools enabled prompt pre- positioning and repurposing of funds. In particular, the inclu- sion of CERC in the PDSS project enabled WBG to leverage an STUDY FINDINGS uncommitted US$80 million from the project for the Ebola 10 Governance. The leadership and country ownership evi- response. Unspent funds from the ERRTF grant also were dent in the DRC government-coordinated 9th Ebola outbreak repositioned to support these efforts. stands in contrast to those in the West Africa Ebola crisis. The DRC outbreak alert was investigated; confirmatory laboratory Effective use of resources. Lack of pre-negotiated agree- tests completed; and outbreak declared all within five days. ments with implementing partners contributed to delays in Although the response to the 10th outbreak was delayed, funding. International implementing agencies often carry sig- the country evidenced strong country ownership, and the SRP nificantly higher costs for contracting and organizational over- tool was used to coordinate and align donors under a single heads. These overheads suggest potential cost savings from plan. However, the absence of high-level decision makers,31 increased domestic implementation capacity and local pro- and key implementation partners (including international curement. However, these would need to be balanced against nongovernmental organization [INGOs] and NGOs) miss- domestic absorptive and implementation capacity. ing from the strategic planning process has been viewed as impeding effective leadership of the response. Community Preparedness. DRC has experienced periodic Ebola out- distrust of the central government, compounded by national breaks and already has established and tested its detection elections, also has resulted in résistance to, and often violence capacity, which was tapped in the 9th Ebola outbreak. In the against, outbreak workers in the communities and hampered ongoing 10th outbreak, MOH has been able to deploy many response efforts. highly experienced domestic experts in every technical area to work with external partiers in Kivu. Operational readiness Efficient financing. The mobilization of domestic response is being strengthened in other provinces and in areas at risk of funding of an initial US$4.5 million for the 9th outbreak, was border transmission. relatively prompt and coordinated. The financial response of the international community, starting with the swift 31 Stakeholders and implementing agencies, including humanitarian partners. 22  The Epidemics  BOX 4  Impact of Insecurity on Outbreak Detection, Response, and Financing Over 1.8 billion, or 24 percent, of the world’s population are the largest recorded cholera outbreak in the country, which living in fragile and conflict-affected situations (FCAS). This affected over 1.2 million people (Federspiel and Ali 2018). figure is projected to grow to 2.3 billion by 2030, when an The 10th Ebola outbreak was severely exacerbated and estimated 80 percent of the world’s extreme poor will be liv- lengthened in DRC. Following every episode of violence, the ing in a FCAS (Ovadiya and others 2015; World Bank 2011; number of newly detected Ebola cases spiked (Figure 6). This OECD 2018). There is a significant overlap between FCAS and spike in new cases likely was due to the lag time in detecting global hotspots for infectious diseases, especially in Sub-Sa- and confirming new cases, which drives increased disease haran Africa (Wise and Barry 2017; Moore and others 2016).32 transmission. These scenarios have the potential to be repli- These countries typically spend less on health as a percent- cated in other countries. The international community needs age of their GDP.33 As a result, they have weaker health sys- to be prepared to support outbreak response in uncertain tems and are less able to prevent, detect, and respond to environments. outbreaks (Graves, Haakenstad, and Dieleman 2015). FCAS Not every scenario can be anticipated prior to a dis- also have limited ability to mobilize domestic resources for ease outbreak. Nevertheless, operational and financing health due to the limited presence of the private sector; inse- systems can be developed to limit lag times in securing curity-driven conflict; and weak governance (OECD 2018; resources to respond to public health emergencies in inse- Witter 2012). cure environments. Insecurity compounds the threat of outbreaks in extremely fragile and conflict-affected situations and com- • Putting the “agile in fragile” to finance rapid response plex emergencies.34 Globally, conflict situations have tripled in extreme FCAS though risk-layering is essential for since 2010, and more countries experienced violent conflict a timely response to public health emergencies. As in 2016 than in the last 30 years (World Bank 2017b; OECD detailed in this report, the World Bank and other 2018). Outbreaks in insecure and conflict-affected environ- development partners have optimized their range of ments are becoming the new normal. However, humanitarian crisis response financing instruments to become more aid, technical assistance, access to services, and community agile and responsive to health emergencies (Table 2). engagement frequently are hindered in responding effec- The risk-layering of multiple funds and instruments tively to health emergencies (Culver, Rochat, and Cookson enables meeting epidemic financing needs of differ- 2017; Spiegel and others 2007). Additional challenges asso- ent scale, frequency, and severity in extreme conflict ciated with conflict such as forced mass displacement, food situations (Cummins and Mahul 2008; WBG 2018). insecurity, interruption of essential services, and shortage of • Multi-Donor Trust Funds (MDTFs) and Country-Based vaccines and drugs further elevate the risk of both escalation Pooled Funds (CBPF) can provide an umbrella for of outbreaks and spillover events (via interaction with wild- diverse donor participation for a “neutral” and effi- life) (World Bank 2017b; Wise and Barry 2017). cient response in extreme FCAS. Although not yet In Syria, the interruption of routine immunization due to used for pandemic financing, solidarity levies (such as the destruction of health care infrastructure, shortage of vac- air ticket levies for UNITAID), and social impact bonds cines, lack of functional roads, and breakdown in the cold that pay for success (such as Humanitarian Impact chain resulted in the re-emergence of polio in the country Bonds) also have potential to enhance agility for pan- (WHO 2014; Culver, Rochat, and Cookson 2017). In the late demic financing. 1990s, war in Congo exacerbated an ongoing measles out- • Prepositioned agreements, contracts, and agile pro- break resulting in 3.3 million people being infected (Burki cesses specifically designed for FCAS can improve 2013). In Yemen, lack of access to safe water and health care timely response. facilities for 16 million people due to relentless conflict led to • Private sector actors can be leveraged to respond to crises. Firms often have technical expertise, crisis (continues) 32 A majority of the FCAS are in Sub-Saharan Africa, and 22 of the 25 most outbreak-vulnerable countries are in the same region (OECD 2018; Moore and others 2016). 33 FCAS spend an average of 6.98 percent of GDP on health, in comparison to the global average of 9.94 percent. 34 A “complex emergency” is defined as “. . . a humanitarian crisis in a country, region, or society where there is a total or considerable breakdown of authority resulting from civil conflict and/or foreign aggression.”   23 24  BOX 4  Continued FIGURE 6  Insecurity and Weak Community Engagement Hindered Ebola 10 Response Efforts, DRC Oct 21—Violent community carried Aug 1—EVD10 dead bodies to Beni mayor’s office outbreak Oct 11—First responders Nov 11—Vaccination suspended in declared in Kalungata attacked & Beni after attacks 60 stripped Dec 27—Ebola treatment center (ETC) attacked Sept 24—Contact tracing Dec 29—Oxfam, International Rescue 50 & vaccination halted Committee suspend operations Major Instances of Violence due to attacks Dec 31—Elections; Beni and 40 Butembo not allowed to vote Elections Feb 27—ETCs in Katwa and Oct 2—Red Cross Butembo attacked and burnt down 30 attacked Number of cases 20 10 0 pr ul ul g g ep ep ct ct ct ov ov ec ec a n an e b e b ar ay ay un un J -J u u S S O O O -N -N -D -D -J -J -F -F -M 0 -A - M -M -J -J 9- -A -A 3- 7- 1- 5- 9- 3 14 28 11 25 0 23 06 20 0 1 0 1 2 12 26 10 24 07 21 04 18 04 Week of illness onset Probable Confirmed The Epidemics  response tools, and logistics networks that can be can help incentivize and mobilize the private sector to leveraged to improve access to vulnerable popula- respond to an epidemic in crisis. tions. Local businesses can act as intermediaries with • Improving governance and coordination for rapid NGOs and humanitarian partners to improve access response financing is critical to ensure swift deci- and logistics. The Maximizing Finance for Develop- sion making and the ability to coalesce partners ment (MFD) approach adopted by WBG in 2017 pur- during outbreaks. Established in September 2016, sues private sector solutions to improve the efficiency the Global Crisis Risk Platform (GCRP)35 has enabled of development aid. MFD also holds the potential to WBG to leverage the entire suite of agile financing leverage the private sector for emergency response. instruments to support countries to manage crises, Insecurity and access to finance are the top con- including epidemics in extreme FCAS. GCRP played a straints to private sector operations in crises. Contin- critical role in facilitating WBG’s response to both the gent contracting arrangements and MIGA guarantees famine and cholera emergency in Yemen, as well as the 9th and 10th Ebola outbreaks in DRC (WBG 2018). TABLE 2  Selected World Bank and Other Development Public Health Emergency Financing Tools and Contingency Instruments MAJOR SOURCE INSTRUMENT DESCRIPTION ACTIVATION IN AFRICA OF FUNDING World Bank Pandemic Emergency Parametric outbreak insurance Has not been activated Germany, Japan, WBG Financing Facility financed by pandemic bond36 (PEF)—Insurance Pandemic Emergency Ad-hoc cash grants to fund the 2018/DRC—US$11.4 million Germany, Japan, Australia Financing Facility (PEF)— financing gap in national emergency Cash Window response plan to outbreak Contingent Emergency Instrument to reallocate WBG • Lassa Fever/Nigeria—US$2.5 million Country portfolio, REDISSE Response Component Investment Project uncommitted • 2018/DRC—US$80 million Project/Nigeria and PDSS (CERC) funds among emergency response Project/DRC components Crisis Response Window International Development • Emergency Response Project/West Africa IDA—multi-donor (CRW) Association (IDA) instrument to Liberia, Senegal, Sierra Leone—US$390 provide funding to projects to million EERP address recovery and reconstruction. CRW complements core IDA allocations IDA Catastrophe Deferred Cat DDO disburses immediate • Not used yet IDA fund Drawdown Options liquidity and budget support to a (Cat DDO) country following a natural disaster and/or health-related events To qualify, country needs adequate macroeconomic policy framework and a satisfactory Disaster Risk Management (DRM) Program (continues) 35 GCRP is a network of WBG units that leverages the Bank Group’s expertise, products, and services; and pioneers innovative financing solutions to provide crisis risk management support to countries. 36 Parametric triggers for certain high-impact diseases. Criteria used in PEF parametric triggers include outbreak size (number of cases or deaths), outbreak growth, and outbreak spread. Defined set of viruses covered by the insurance window: New Orthomyxoviruses (does not cover seasonal flu), Coronavirus (SARS, MERS), Filoviridae (Ebola Marburg), and other viral hemorrhagic fevers (CCHF, RVF, Lassa Fever).   25 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA BOX 4, TABLE 2  Continued MAJOR SOURCE INSTRUMENT DESCRIPTION ACTIVATION IN AFRICA OF FUNDING Developments Partners UN Central Emergency UN global emergency response • 2014/West Africa—US$15.3 million UN—multi-donor Response Fund (CERF) pooled fund to provide financing • 2018/DRC—US$2.8 million for health (Germany, Netherlands, for rapid response or underfunded rapid response; US$12.3 million for rapid Norway, Sweden, UK and emergencies response (UN CERF 2018) others) WHO Contingency Fund for WHO emergency fund to respond • 2018/DRC and neighboring countries— WHO—multi-donor Emergencies (CFE) immediately to disease outbreaks US$4.5 million (Australia, Denmark, and humanitarian crises • $16.4 million—10th Ebola outbreak Germany, Japan, UK, and others) Start Fund Pooled rapid response fund for • 10th DRC Ebola outbreak for financial Belgium, Ireland, INGOs/NGOs to respond to small and support to INGOs Netherlands, UK, and EC medium scale emergencies37 • GB£250,000 to Oxfam (Alert 233) • GB£350,000 Save the Children/Oxfam (Alert 250); GB£300,000 ALIMA • GB£300,000 disbursed to Relief International for Cholera outbreak in Somalia within 48h (Start Network 2016) EU Emergency Aid Reserve €280 million Euro earmarked each • €7.3 million provided to INGOs and UN EU year as reserve fund for rapid agencies for 10th Ebola response response to unforeseen events and major crises in non-EU country crises (priority given to humanitarian crises). Funds are provided to NGOs, INGOs, UN agencies, Red Cross EU Humanitarian Humanitarian aid by EU added • Initial allocation of €1.8 million for the ECHO Implementation Plan (HIP) provision for earmarked funds for Epidemics Tool in 2018 was used to European Civil Protection small-scale epidemic response with: respond to Lassa Fever in Nigeria and to and Humanitarian • Epidemics Tool Ebola 9 outbreak in DRC (€1.2 million) Operations (ECHO) • Acute Large Emergency Response Emergency Tool Box Tool (ALERT) Funds are provided to UN agencies, NGOs, Red Cross, and INGOs AU Africa Risk Capacity • Pooled sovereign risk insurance • Not used yet Rockefeller Foundation, (ARC) product for O&E product for outbreaks and Switzerland, Africa CDC epidemics (non-funding technical • Modelled after ARC insurance partner), Metabiota • Piloting in Uganda and Guinea (technical partner), for Ebola, Marburg, Lassa virus Columbia University outbreaks, and Meningitis outbreaks 37 Fund run by 42 partners of Start Network. Disburses funds within 72 hours of an alert. Fastest, collectively owned early response mechanism in the world. 26  BOX 5  Financial Ownership of Preparedness and Response Efforts A number of key challenges are associated with country ownership, particularly in fragile economies. There are often inade- quate domestic financial and other resources; competing developmental and political priorities; and systemic weaknesses in governance and leadership, human capital, and management systems. The economic and social shocks from extended disease outbreaks such as the Ebola epidemic in West Africa exacerbate these structural challenges. As detailed in this report, the international community has paid considerable attention to developing financing mecha- nisms for outbreak response. However, financing preparedness programs through domestic and international resources have lagged far behind. If preparedness and emergency response continue to be funded largely through discrete mechanisms, this lack of attention to preparedness will persist. Some health systems programs have moved toward more integrated planning for preparedness and response through tools such as the National Action Plans for Health Security and the WHO Benchmarks for International Health Regulations Capacities. These plans enable greater country ownership in identifying priorities and direct- ing domestic and international resources to fill the gaps. When an outbreak hits, there often is not continuity of resources to transition from “peace time” development support to “war time” emergency response. Shorter term resource inputs are made available for acute, and often extended, response through the PEF, CFE, CERC, and other mechanisms. However, these resources were not designed to support longer term out- break and recovery efforts, and their flexibility is being tested in the 10th DRC Ebola outbreak. As part of sustainable systems capacity, longer term response and recovery efforts need to be linked to preparedness programs. Frequently, this funding is not built into country plans or domestic budgets. The dependence on external support during outbreaks significantly affects who drives the decision making. The entity holding the purse often has the most control. Instead of perpetuating a cycle of panic and neglect, financing for preparedness and response should be seen as a continuum of support at both the national and subnational levels. Financing initiatives for emergencies will come and go. It is the health systems programs that were there before the crisis occurred and that will help to contain the current outbreak and prevent or mitigate the next one (Figure 7). The Global Preparedness Monitoring Board (GPMB) was established to monitor, among other areas, the state of pandemic pre- paredness financing. The board has documented that many of the lessons learned from the West Africa Ebola outbreak still have not translated to institutionalizing preparedness financing on the domestic or international level. Other initiatives to improve monitoring include adding a financing action package in the Global Health Security Agenda and new financing indicators in the JEE. Nevertheless, monitoring alone will have little impact without dedicated domestic and international commitments to pre- paredness implementation. The World Bank REDISSE program in West Africa is one example that has substantially invested in country-led programs that support the continuum of activities from detection to response to systems recovery. Similar regional and country-level projects are coming online through the World Bank and other development partners. However, there is still a critical gap in both demand and mechanisms to fund health systems programs. Until these gaps are addressed, countries will continue to manage disease threats reactively, and priorities will continue to be set often by external stakeholders rather than by the countries. FIGURE 7  Selected Funding Sources during Stages of an Outbreak and Recovery Acute outbreak Extended outbreak Recovery (0–3 months) (3–6 months) (6–24 months) Significant drop-off in funds Event with influx of for longer term response and new funds recovery WB: PEF cash WB: PEF insurance UN: CFE UN: CFE WB: CERC Health systems funds   27 WHAT HAS CHANGED IN THE EPIDEMICS OF 2018? CONTINUING CHALLENGES 4 © 2018 The World Bank/Dasan Bobo What Has Changed in the Epidemics of 2018? Continuing Challenges  According to the Prevent Epidemics ReadyScore, based on GOVERNANCE Joint External Evaluations of 19 of the technical capacities Positive Changes required by the IHR, Liberia and Sierra Leone have “work to do;” whereas DRC, Guinea, and Nigeria are “not yet ready” • Organizational reforms introduced in the wake of the (Figure 8). This lack of preparedness, even in countries that West Africa Ebola crisis are helping to develop more have demonstrated the need for these capacities, has implica- autonomous public health institutes, such as Africa tions for global readiness––particularly with respect to severe CDC, recently established as a health security asset pandemics. Many of the interviewees for this study had a pos- in the region. These public health institutes include a itive, but nuanced, perspective on progress. They cited signifi- headquarters in Addis Ababa; five regional coordinat- cant improvements and continuing challenges in the countries ing centers (RCCs); and a National Public Health Insti- that have experienced severe infectious disease epidemics as tute or its equivalent in each country. The National well as in the policies and financing modalities developed by Public Health Institutes, such as the Nigerian Cen- external stakeholder organizations. ter for Disease Control, have demonstrated strong FIGURE 8  “Readiness” Score Based on Joint External Evaluations in Sub-Saharan Africa, 2019 Guinea Nigeria Sierra Liberia Leone ReadyScore External assessment of a country’s ability to nd, stop, and prevent health threats. Better prepared Work to do Not ready In progress Unknown Source: preventepidemics.org.   29 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA leadership, preparedness, and response capacity; and • Some countries have increased domestic financing to have overcome bureaucratic delays. respond to health emergencies. The Nigeria Health • The three countries that experienced the West Africa Act provides for a limited contingency fund earmarked Ebola outbreak have since strengthened their overall for outbreak response, and the DRC government emergency response. Sierra Leone has established a has provided up to US$5 million for the recent Ebola Directorate of Health Security and Emergencies. Libe- outbreaks. ria has instituted a One Health Steering Committee and a National Preparedness Response Committee. Continuing Challenges The role of all national militaries to support logistics, • Country leadership and response coordination remain security, and treatment centers has been strength- a challenge. Donor and country priorities do not always ened. Emergency Operations Centers (EOC) have been align. Weak leadership and emergency management established and strengthened in all three countries. capacity can result in ad hoc funding, inter-donor com- • Reforms within WHO include, first, the establishment petition, and duplication of effort. of the CFE, a catalytic investment tool that can deliver • Effective development and implementation of the out- initial funds within hours. WHO also implemented the break Strategic Response Plans require strong country Health Emergencies Program (WHE), an operational ownership and coordination, which in turn require branch of WHO that leads and coordinates the inter- transparency and compliance. national outbreak response and helps countries detect • The dominant role of external implementing organi- and respond to health emergencies. zations, although helpful, needs to be complemented • WHO’s introduction of the SRP, which includes costing by stronger country ownership and oversight. Ad outbreak response efforts, has increased coordination hoc funding contributions and lack of reporting from and joint planning. This tool was used to facilitate the donors often made it difficult for national govern- activation of CERC to disburse emergency assistance ments to determine the level and type of support that to DRC. they could expect from external stakeholders. • As of the writing of this report, 39 African countries • Effective governance of outbreaks in complex emer- have completed the JEEs, and six more are in the pipe- gencies in fragile states is a major challenge that car- line to do so (WHO 2019b). ries implications for increased conflict, distrust, and • A growing number of countries have developed spread of disease. National Action Plans for Health Security (NAPHS), • A critical gap in planning and country ownership is to which strengthen country health system monitoring adequately fund response plans that will enable the and planning capacities. Liberia, Nigeria, and Sierra essential role of community engagement. Leone have completed their NAPHS, and Guinea is • Regional coordination among countries of prepared- planning to develop one. ness and response planning is needed. The establish- • The jointly developed Global Preparedness Moni- ment of the Africa CDC as well as the development toring Board (GPMB) is dedicated to strengthening by the West African Health Organization (WAHO) policy-level coordination and trust among interna- and partner countries of the West Africa Regional tional and country stakeholders. Response Plan are important moves forward. • Other development frameworks, such as the Global • Persuading public finance and economic authorities Health Security Agenda, which includes 50 participat- that investments in health security are both beneficial ing countries, also strengthen the global framework and cost effective is a critical step in advocating for to finance important dimensions of preparedness and sustainable country ownership of financing prepared- response. ness and response. 30  What Has Changed in the Epidemics of 2018? Continuing Challenges  EFFICIENCY OF FINANCING • Similarly, once funds are disbursed, agreements with implementing agencies and related procurement pro- Positive Changes cedures constitute an additional layer of constraint on • The mobilization and disbursement of both domes- timely delivery of often desperately needed goods and tic and external financing in the successful response services. to the 9th Ebola outbreak in DRC demonstrated clear • Improving management practices, including for pro- improvements in the timeliness, flexibility, and suffi- curement, financial management, and accountabil- ciency of new financing instruments such as WHO’s ity, is just as critical as providing the right technical CFE and the World Bank’s CERC and PEF cash window. support. • In Liberia, recent responses to meningitis (2017 and • “No-regrets financing” (early deployment of excessive 2018), and yellow fever (2018) included small injec- financial and other resources) remains an organizing tions of domestic funds. Rapid access to domestic principle––not policy––and carries the risk of political financing is a key factor in agility. backlash from perceived overfunding. • The available menu of World Bank instruments now • Organized engagement of the private sector, including enables a risk-layered approach to suit the range of citizen communities, holds potential for both resource needs (Table 2). New World Bank health projects mobilization and implementation. now routinely include a CERC and have adapted CERC • Channeling PEF resources through governments guidelines to activate in public health emergencies. presents potentially time-consuming procedural con- The trigger is based on WHO’s event grading system straints, depending on the government’s procurement as an alternative to WHO or government declaration and contracting capacity within the overall constraint of a public health emergency. WHO’s grading system of World Bank procedures. Low government capacity permits prompter access to available project funds. At in these two areas could slow financing during emer- least half of African countries now have provisions for gencies, but this could be mitigated through prepo- CERC activation of existing project funding to respond sitioned contracts for emergency commodities and to outbreaks. services. • Efforts underway to scale up private sector support of • The PEF insurance window trigger parameters and lim- outbreak response include the Global Private Sector itations on included diseases are viewed by many as Roundtable and the Nigerian Alliance for Health Emer- too restrictive for all but catastrophic outbreaks. gencies, which was established in 2018. Continuing Challenges EFFECTIVE USE OF FINANCIAL RESOURCES • Sufficient and timely domestic emergency financing Positive Changes remains a challenge in all the countries considered in • To enable a more effective outbreak response, the this study. Procedural improvements are possible at World Bank regional REDISSE project strengthens each stage of preparedness and response. Availability overall health system absorptive capacity as well as of domestic and external financing at subnational, pro- fiduciary and management capacity. The use of private vincial, and local levels is particularly scarce. sector managers and accounting entities as cosignato- • Even when funds for outbreak response are pledged ries on procurement actions increased transparency early, the mechanisms leading to disbursement often and reduced misuse of response financing but also are overly complex and too inflexible to meet the could add an additional layer of bureaucracy on mov- requirements and demands of an emergency. Ulti- ing funding quickly. mately, timeliness and flexible disbursement are more important than the amount pledged.   31 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA Continuing Challenges Positive Changes • Insufficient domestic resources and continued depen- • The development and activation of the new National dence on external support constrains many aspects of Action Plans for Health Security (NAPHS) enable all systems strengthening, preparedness, and response stakeholders to subscribe to a single preparedness (training and retaining health workers for surveillance, plan based on coordinated planning across all health contact tracing, infection prevention and control, security program areas. finance and management specialists.). • Initiatives including GHSA, JEE, Coalition for Epi- • The concept of “country ownership” must refer not demic Preparedness Innovations (CEPI), and WBG’s only to ownership of country financial resources, but REDISSE,38 with its regional approach using the One also to increased decision making concerning pro- Health model, all contribute to multi-stakeholder sup- curement and effective use of various local resources. port of preparedness. Stronger country engagement and capacity building • The systematic inclusion of the World Bank’s CERC to increase local procurement could reduce costs and mechanism in the health portfolio and streamlining39 increase efficiency. of the CERC implementation instrument to address • Hazard incentive management systems for health care eligible health emergencies significantly improve workers need to be standardized with prepositioned resource mobilization. guidance. • Awareness is growing that it is more cost effective • Human resource capacity, while stronger than in 2014, to maintain prepositioned preparedness capacity is limited in all specialties, particularly at the subna- than it is to scale up response during out-of-control tional level. emergencies. • Country capacity for financial management and reten- tion of qualified managers is a continuing constraint. Continuing Challenges • Financing plans need to include community engage- • A global financing mechanism to incentivize invest- ment aspects. ment in preparedness is required. A key challenge is to • Reporting tools need to be standardized and significantly increase investment in sustainable financ- streamlined. ing of preparedness at country, regional, and global levels. Mechanisms for such investment can be built into broader country development and business and FINANCING PREPAREDNESS global sustainability agendas and “sold” to public and Preparedness, or readiness for response, is a continuous private policy and financing decision makers. function including prevention and early detection for contain- • The opportunity cost of not funding preparedness is ment. Investment in preparedness at the country, regional, easier to appreciate against the experience of not only and global levels is commonly and consistently limited due to the US$6 billion cost of the international response to competing budgetary and political priorities. There is no lobby the West Africa crisis but also the US$53 billion cost to or effective advocacy for preparedness, resulting in periodic the society and economy of the region. mobilization of funding during a public health emergency, • Human capital can be the entry point to a cultural shift followed by neglect––until the next crisis hits and the cycle to investment in preparedness. The private business begins again. Both political and financial resource mobiliza- tion typically react to outbreaks that arguably could have been prevented or much reduced in impact through effective pre- 38 REDISSE often was very positively described by interviewees as a “game changer.” vention, planning, and prepositioned readiness for response. 39 Such as, adapting CERC triggers and positives list for greater sensitivity to health emergencies. 32  What Has Changed in the Epidemics of 2018? Continuing Challenges  community needs to be activated by an appeal to safe- financing outbreaks in the Africa region, it was not designed guard markets and profits (such as travel and tourism). to evaluate the direct impact of specific financing modalities. Better and more visible metrics are needed. Instead it describes the various systems and how they have • The experience gained and systems structures devel- been applied under different circumstances over time. oped during the West Africa crisis must be strength- The data were collected retroactively from stakehold- ened to “enable a rapid and effective national ers, sometimes more than three years after the event. The response to outbreaks, while providing a global safety team reduced the impact of recall bias by interviewing a large net for response when national efforts fail”(Coltart cross-section of stakeholders, looking for common themes and others 2017). Such systems strengthening is crit- between the interviews, and triangulating findings with litera- ically dependent on establishing adequate domestic ture reviews. The team also tried to identify interviewees who and international financing, which must give higher were key actors during the outbreak and not only people who shared priority to both prevention and “readiness” for were currently stationed in the countries where data collec- containment response. tion took place. • The World Bank has the opportunity to lead in devel- This report is limited by the ongoing epidemic in DRC, oping and supporting investment in prevention and which restricted both the fieldwork and complete analysis preparedness. of lessons from the 10th Ebola outbreak there. The study • Prepositioning contingencies, contracts and agree- focused on a subset of the overall timeline, ending at the third ments, supplies, and human resources would stream- SRP, and was unable capture all the lessons learned due to line emergency response management operations. the evolving course of the outbreak. Further work including AARs will be critical for documenting the lessons learned in financing this outbreak, including activation of PEF and CERC LIMITATIONS OF STUDY mechanisms. This report presents a qualitative analysis of the lessons learned in financing response to recent outbreaks in West and Central Africa. While the study examines many of the facets of   33 CONCLUSION AND RECOMMMENDATIONS 5 © 2019 The World Bank/Vincent Tremeau Conclusion and Recommmendations  This report confirms improvements in the timeliness and effi- International development and public health agencies ciency of financing to contain outbreaks of infectious disease such as the World Bank and WHO have also demon- at all levels––country, regional, and global. Today, Guinea, strated significantly greater agility in their institutional Liberia, Sierra Leone, Nigeria (Lassa Fever outbreak, 2018), responses due, in part, to the development of several and the Democratic Republic of Congo (DRC) (9th and 10th new and improved funding instruments and planning outbreaks of Ebola) have demonstrated improved capacity tools that enable more timely and flexible financing of for governance and operational response to outbreaks. This outbreaks. Other national and regional entities includ- capacity growth, in turn, has contributed to the more efficient ing NPHIs and the Africa CDC are also poised to pro- use of domestic and external financing. vide increased indigenous support as their institutions In response to comprehensive recommendations from mature. multiple assessments, the international development com- • Strengthening institutional management capacities munity has taken several institutional and operational steps will result in improved country ownership and use of to improve the efficiency and effectiveness of financing public funds. More streamlined planning and coordination health emergencies. These include the adaptation of policies systems including the SRPs and nationally-led EOCs and procedures that increase the agility of financing while have efficient resource management during outbreak decreasing the processing time, as well as developing new response. Prepositioning agreements and contracts, planning tools and financing mechanisms. Some examples streamlining processes, and providing financial man- include incorporating instruments that permit rapid access agement training prior to the onset of an emergency to funds into World Bank–financed projects and establishing will diminish bottlenecks in receiving and moving new financing mechanisms such as the World Bank Group funds quickly and efficiently, particularly when human (WBG)’s Pandemic Emergency Financing Facility (PEF), World resources are already stretched. WBG and other proj- Health Organization (WHO)’s Contingency Fund for Emergen- ects in epidemic-prone regions can be designed to cies (CFE), and African Union (AU)’s Africa Risk Capacity (ARC) include contingency instruments and legal agreements for outbreaks. There have also been efforts to establish and that permit financing a broad range of activities. AARs strengthen institutions with global, regional, and national and workshops to familiarize countries and key stake- mandates for preparedness and response such as the WHO holders with financing mechanisms will improve the Health Emergencies Program (WHE), Africa Centres for Dis- efficiency of financing outbreak response. ease Control and Prevention (Africa CDC), and National Public • Disease outbreaks will become increasingly common Health Institutes (NPHIs). in insecure environments as transmission patterns Although financing routine systems to prevent and detect shift, disease detection improves, and rapid response health threats has lagged behind initiatives to respond to remains hindered. Agile and flexible approaches to emergencies, new disease surveillance and response pro- outbreak support are even more critical in these situ- grams have been introduced in the African subregion. One ations and may require risk-layering of multiple funds such example is the WBG’s Regional Disease Surveillance Sys- and instruments. tems Enhancement (REDISSE) Program which leverages effi- • Improved transparency in budgeting, domestic and ciency gains of scale by strengthening disease surveillance, international financial commitments, and reporting detection, and response systems across 11 countries in West will improve accountability and reduce duplication of Africa. resources. Standardized reporting tools can facilitate However, there are still critical bottlenecks to overcome efforts to improve transparency and timely reporting. in improving global and national epidemic financing. • Adequate domestic investment in outbreak preven- tion and preparedness remains a critical challenge. • Without a shared, continued commitment of both The barriers to such investment stem from a combi- domestic and external financing it will be difficult to nation of scarce resources and competition across sec- sustain gains in securing funding for outbreak response. tors in prioritizing the resources available. Following   35 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA the West Africa Ebola outbreak, although interna- • Given its financing mandate, convening authority, and tional investments have proved adequate to address access to economic/financial policy decision makers, acute outbreak needs, funding for preparedness has the World Bank is well positioned to lead a scaled-up, severely waned. multi-stakeholder initiative on innovative financing • Leveraging the private sector can both increase to strengthen country-owned and country-led capacity domestic resource mobilization and enhance the agil- for preparedness. ity of emergency financing. Organized engagement • In the context of the demonstrated importance of of the private sector, including citizen communities, global health security, the time is also opportune for holds potential for rapid resource mobilization and international development partners to systemati- implementation of emergency response. Collabora- cally examine their overall strategies. These strate- tion with the International Finance Corporation, con- gies encompass the flexibility, agility, and efficiency of tingent contracting arrangements, and the use of Mul- existing financing tools for emergency response and tilateral Investment Guarantee Agency (MIGA) guar- building country-owned capacity for financing pre- antees could help incentivize and mobilize the private paredness and emergency response. sector to respond to a crisis. 36  APPENDIX LIST OF ORGANIZATIONS INTERVIEWED © 2019 The World Bank/Vincent Tremeau LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA TABLE A1  List of Organizations Interviewed ORGANIZATION LOCATION/S International Organizations World Bank HQ, Guinea, Liberia, Nigeria, Sierra Leone World Health Organization (WHO) HQ, Liberia, Sierra Leone, Guinea, Nigeria United Nations Children’s Fund (UNICEF) Sierra Leone, Guinea, Nigeria United Nations Office for Project Services (UNOPS) Sierra Leone, Guinea United Nations Population Fund (UNFPA) Sierra Leone Bilateral Institutions Department for International Development (DFID) UK, Sierra Leone/DRC GIZ Germany Liberia Japan International Cooperation Agency (JICA) Liberia United States Agency for International Development (USAID), US Government US, Liberia, Nigeria United States Centers for Disease Control (US CDC) US, Liberia, Sierra Leone, Nigeria European Civil Protection and Humanitarian Aid Operations DRC Local/International NGOs/Private Sector Alliance for International Medical Action (ALIMA) Guinea International Federation of Red Cross (IFRC) Guinea, Sierra Leone Expertise France Liberia Riders for Health Liberia Médecins Sans Frontières Liberia, Sierra Leone Plan International Liberia Jhpiego Liberia International Rescue Committee Liberia Clinton Health Access Initiative (CHAI) Liberia The Carter Center Liberia African Field Epidemiology Network (AFENET) Nigeria Irrua Specialist Teaching Hospital Nigeria GOAL Sierra Leone BDO Sierra Leone Government Institutions Ministry of Health (MOH) Democratic Republic of Congo Agence Nationale de Sécurité Sanitaire (ANSS), Ministry of Health, Ministry of Finance Guinea and Economic Affairs (MOFEA) National Public Health Institute of Liberia (NPHIL), Ministry of Health, National Disaster Liberia Management Agency (NDMA), Ministry of Internal Affairs (MIA), Armed Forces Liberia (AFL), Ministry of Defense (MOD), Ministry of Finance and Development Planning (MFDP) Nigeria Centre for Disease Control (NCDC), Ministry of Finance (MOF) Nigeria Ministry of Finance and Economic Development (MOFED), Ministry of Health and Sierra Leone Sanitation (MOHS), Integrated Health Projects Administration Unit (IHPAU), Ministry of Social Welfare, Gender, and Children’s Affair (MSWGCA), National Ebola Response Centre (NERC), MOD, Ministry of Foreign Affairs and International Cooperation 38  REFERENCES Audit Services, Sierra Leone. 2015a. Report on the audit of DuBois, Marc, Caitlin Wake, Scarlett Sturridge, and Christina the management of Ebola funds. Bennett. 2015. The Ebola response in West Africa: Audit Services, Sierra Leone. 2015b. Report on the audit exposing the politics and culture of international aid. of the management of the Ebola funds by the NERC Overseas Development Institute. (November 2014–April 2015). Elmahdawy, Mahmoud, Gihan H. Elsisi, Joao Carapinha, Bali, Sulzhan, Kearsley A. Stewart, and Muhammad Ali Pate. Mohamed Lamorde, Abdulrazaq Habib, Peter Agyie- 2016. “Long shadow of fear in an epidemic: fearonomic Baffour, Redouane Soualmi, Samah Ragab, Anthony W. effects of Ebola on the private sector in Nigeria.” BMJ Udezi, and Cyril Usifoh. 2017. “Ebola virus epidemic in Global Health 1 (3):e000111. West Africa: global health economic challenges, lessons Beaubien, J. 2018. “Nigeria Faces Mystifying Spike learned, and policy recommendations.” Value in Health in Deadly Lassa Fever.” https://www.npr.org/ (regional issue) 13:67–70. sections/goatsandsoda/2018/03/19/587603462/ Elston, J. W. T., C. Cartwright, P. Ndumbi, and J. Wright. 2017. nigeria-faces-mystiifying-spike-in-deadly-lassa-fever “The health impact of the 2014–15 Ebola outbreak.” Burki, Talha. 2013. “Infectious diseases in Malian and Syrian Public Health 143:60–70. conflicts.” The Lancet Infectious Diseases 13 (4):296–297. Evans, David K., Markus Goldstein, and Anna Popova. Cangul, Mehmet, Carlo Sdralevich, and Inderjit J. Sian. 2017. 2015. “Health-care worker mortality and the legacy “Beating back Ebola: nimble action on the economic of the Ebola epidemic.” The Lancet Global Health 3 front was key to overcoming the health crisis.” Finance (8):e439-e440. and Development 54 (2):54–57. Fanning, Emma. 2018. “The Ebola Outbreak in DRC: CDC. 2015. “Ebola Report: Timeline.” https://www.cdc.gov/ Strengthening the response.” about/ebola/timeline.html Federspiel, Frederik, and Mohammad Ali. 2018. “The cholera CDC. 2016. Cost of 2014 Ebola Epidemic. outbreak in Yemen: lessons learned and way forward.” Coltart, Cordelia E. M., Benjamin Lindsey, Isaac Ghinai, BMC Public Health 18 (1):1338. Anne M. Johnson, and David L. Heymann. 2017. “The Fielding, J., T. Allen, B. Chu, J. Galdo, and H. Gayle. 2016. Ebola outbreak, 2013–2016: old lessons for new Report of the Independent Panel on the US Department epidemics.” Philosophical Transactions of the Royal of Health and Human Services (HHS) Ebola Response. Society B: Biological Sciences 372 (1721):20160297. In Washington, DC: United States Department of Health Commons, House of. 2016. UK lessons from Ebola outbreak. Human Services, Office of the Assistant Secretary for Culver, Amanda, Roger Rochat, and Susan T. Cookson. 2017. Preparedness Response. “Public health implications of complex emergencies and Flessa, Steffen, and Michael Marx. 2016. Ebola fever natural disasters.” Conflict Health 11 (1):32. epidemic 2014: a call for sustainable health and Cummins, J. David, and Olivier Mahul. 2008. Catastrophe risk development policies. Springer. financing in developing countries: Principles for public Frost L., Pratt B. A. 2015. The World Bank’s Rapid Response intervention. The World Bank. to the 2014 Ebola Outbreak in West Africa. DRC Ministry of Health. 2018a. National Plan for the Global Ebola Response. 2014. Ebola Outbreak—Updated Response to the Ebola Virus Disease Epidemic in North overview of needs and equirements for January–June Kivu Province. 2015. DRC Ministry of Health. 2018b. “Strategic Response for Ebola Global Ebola Response. 2019. “Timeline.” https:// in DRC (SRP II).” ebolaresponse.un.org/timeline   39 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA Gostin, Lawrence O., and Eric A. Friedman. 2015. “A Jeggo, Martyn, and John S. Mackenzie. 2014. “Defining the retrospective and prospective analysis of the west future of one health.” One Health: People, Animals, and African Ebola virus disease epidemic: robust national the Environment:255. health systems at the foundation and an empowered Kikwete, Jakaya, Celso Amorim, Micheline Calmy-Rey, Marty WHO at the apex.” The Lancet 385 (9980):1902–1909. Natalegawa, Joy Phumaphi, and Rajiv Shah. 2016. Gostin, Lawrence O., Matthew M. Kavanagh, and Elizabeth Protecting Humanity from Future Health Crises: Report Cameron. 2019. “Ebola and War in the Democratic of the High-level Panel on the Global Response to Health Republic of Congo: Avoiding Failure and Thinking Crises. New York: United Nations. Google Scholar. Ahead.” JAMA 321 (3):243–244. Loewenson, R., A. Papamichail, and I. Ayagah. 2015. “African Gostin, Lawrence O., Carmen C. Mundaca-Shah, and responses to the 2014/5 Ebola Virus Disease Epidemic.” Patrick W. Kelley. 2016. “Neglected dimensions of global EQUINET. security: the global health risk framework commission.” Lupel, Adam, and Michael Snyder. 2017. “The Mission to Stop JAMA 315 (14):1451–1452. Ebola: Lessons for UN Crisis Response.” Gostin, Lawrence O., Oyewale Tomori, Suwit Wibulpolprasert, Moon, Suerie, Jennifer Leigh, Liana Woskie, Francesco Ashish K. Jha, Julio Frenk, Suerie Moon, Joy Phumaphi, Checchi, Victor Dzau, Mosoka Fallah, Gabrielle Fitzgerald, Peter Piot, Barbara Stocking, and Victor J. Dzau. Laurie Garrett, Lawrence Gostin, and David L. Heymann. 2016. “Toward a common secure future: four global 2017. “Post-Ebola reforms: ample analysis, inadequate commissions in the wake of Ebola.” PLoS Medicine 13 action.” BMJ Global Health 356:j280. (5):e1002042. Moon, Suerie, Devi Sridhar, Muhammad A. Pate, Ashish K. Govindaraj, Ramesh, Christopher H. Herbst, and John Paul Jha, Chelsea Clinton, Sophie Delaunay, Valnora Edwin, Clark. 2017. Strengthening Post-Ebola Health Systems: Mosoka Fallah, David P. Fidler, and Laurie Garrett. 2015. From Response to Resilience in Guinea, Liberia, and “Will Ebola change the game? Ten essential reforms Sierra Leone. World Bank Publications. before the next pandemic. The report of the Harvard- Graves, Casey M., Annie Haakenstad, and Joseph L. LSHTM Independent Panel on the Global Response to Dieleman. 2015. “Tracking development assistance Ebola.” The Lancet 386 (10009):2204–2221. for health to fragile states: 2005–2011.” Globalization Moore, Melinda, Bill Gelfeld, Adeyemi Okunogbe, and Paul Health 11 (1):12. Christopher. 2016. Identifying future disease hot spots: Grépin, K. 2015. “International donations to the Ebola virus Infectious Disease Vulnerability Index. Rand Corporation. outbreak: too little, too late?” BMJ 350:h376. Munster, Vincent J., Daniel G. Bausch, Emmie de Wit, Robert Harman, Sophie. 2014. “Ebola and the politics of a global Fischer, Gary Kobinger, César Muñoz-Fontela, Sarah H. health crisis.” E-International Relations 36. Olson, Stephanie N. Seifert, Armand Sprecher, Francine Heymann, David L., Lincoln Chen, Keizo Takemi, David P. Ntoumi, Moses Massaquoi, and Jean-Vivien Mombouli. Fidler, Jordan W. Tappero, Mathew J. Thomas, Thomas A. New England Journal of Medicine Ntoumi. 2018. Kenyon, Thomas R. Frieden, Derek Yach, and Sania “Outbreaks in a rapidly changing Central Africa—lessons Nishtar. 2015. “Global health security: the wider lessons from Ebola.” 379 (13):1198–1201. from the west African Ebola virus disease epidemic.” The NCDC. 2018a. “Honourable Minister of Health Announces Lancet 385 (9980):1884–1901. End of Emergency Phase of Nigeria’s Lassa Fever Huber, Caroline, Lyn Finelli, and Warren Stevens. 2018. “The Outbreak.” May 11, 2018. https://ncdc.gov.ng/ economic and social burden of the 2014 Ebola outbreak news/142/honourable-minister-of-health-announces- in West Africa.” The Journal of Infectious Diseases 218 end-of-emergency-phase-of-nigeria%5C%27s-lassa- (suppl_5):S698–S704. fever-outbreak IEG. 2013. Responding to Global Public Bads: Learning from NCDC. 2018b. Lassa Fever After Action Review. Evaluation of the World Bank Experience with Avian NCDC. 2018c. Reported Cluster of Lassa Fever Among Health Influenza 2006–13. World Bank. Care Workers in Ebonyi State. 40  References  NCDC. 2018d. Weekly Epidemiology Report (49). Start Network. 2016. “Alert 087.” https://startnetwork.org/ OECD. 2018. States of Fragility 2018. start-fund/alerts/087-somalia-cholera#ig Office of the UN Special Envoy on Ebola. 2014. Resources for UN CERF. 2018. “CERF Allocations—DRC.” Results I. UNMPTF. 2017. UN Ebola Response Multi-Partner Trust Fund Office of the UN Special Envoy on Ebola. 2016. Resources for Lessons Learned Exercise. Results V (September 1, 2014 to October 31, 2015). USAID. 2016. “West Africa—Ebola outbreak factsheet.” Oleribe, Obinna O., Babatunde L. Salako, M. Mourtalla Ka, https://www.usaid.gov/sites/default/files/ Albert Akpalu, Mairi McConnochie, Matthew Foster, and documents/1866/west_africa_fs07_01-21-2016.pdf Simon D. Taylor-Robinson. 2015. “Ebola virus disease USAID, OFDA. 2018. “Evaluation of Ebola Virus Disease epidemic in West Africa: lessons learned and issues Response in West Africa 2014–2016: Objective 4, arising from West African countries.” Clinical Medicine Coordination of the Response.” 15 (1):54–57. WBG. 2010. Fifth Global Progress Report on Avian and Ovadiya, Mirey, Adea Kryeziu, Syeda Masood, and Eric Pandemic Influenza—A Framework for Sustaining Zapatero Larrio. 2015. Social protection in fragile and Momentum. conflict-affected countries: trends and challenges. The WBG. 2018. “Global Crisis Risk Platform.” World Bank. WHO. 2014. “WHO statement on the meeting of the Parpia, Alyssa S., Martial L. Ndeffo-Mbah, Natasha S. Wenzel, International Health Regulations Emergency Committee and Alison P. Galvani. 2016. “Effects of response to concerning the international spread of wild poliovirus.” 2014–2015 Ebola outbreak on deaths from malaria, HIV/ 5:2014. AIDS, and tuberculosis, West Africa.” Emerging Infectious WHO. 2015a. “Report of the Ebola Interim Assessment Diseases 22 (3):433. Panel.” Pring, Coralie. 2015. People and corruption: Africa survey WHO. 2015b. WHO leadership statement on the Ebola 2015: Transparency International. response and WHO reforms (corrected text). Geneva. Ravi, Sanjana J., Michael R. Snyder, and Caitlin Rivers. 2019. WHO. 2016. “Ebola Situation Reports | Ebola.” http://apps “Review of international efforts to strengthen the global .who.int/ebola/ebola-situation-reports outbreak response system since the 2014–16 West WHO. 2017. Emergency Response Framework (ERF). Africa Ebola Epidemic.” Health Policy Planning. WHO. 2018a. “CFE Allocations (December 19, 2018).” Rey, C. 2018. Ebola Recovery and Reconstruction Trust Fund WHO. 2018b. Situation report 17: declaration of the end of Evaluation. the Ebola outbreak in Équateur Province. Reynolds, C. 2015. “World Bank Group’s support to the Ebola WHO. 2019a. DRC Ebola External Situation Report 27. virus response effort” BMJ 350:h1283. December 5, 2019. Ross, Emma, Gita Honwana Welch, and Philip Angelides. WHO. 2019b. “JEE Dashboard.” 2017. “Sierra Leone’s Response to the Ebola Outbreak.” WHO AFRO. 2018. Weekly report on outbreaks and other Chatham House Report. health emergencies (Week 7, 2018). Spengler, Jessica R., Elizabeth D. Ervin, Jonathan S. Towner, Wise, Paul H., and Michele Barry. 2017. “Civil War & the Pierre E. Rollin, and Stuart T. Nichol. 2016. “Perspectives Global Threat of Pandemics.” Dædalus 146 (4):71–84. on West Africa Ebola virus disease outbreak, Witter, Sophie. 2012. “Health financing in fragile and post- 2013–2016.” Emerging Infectious Diseases 22 (6):956. conflict states: what do we know and what are the Spiegel, Paul B., Phuoc Le, Mija-Tesse Ververs, and Peter gaps?” Social Science Medicine 75 (12):2370–2377. Salama. 2007. “Occurrence and overlap of natural World Bank. 2011. World development report 2011: Conflict, disasters, complex emergencies and epidemics during security, and development. World Bank. the past decade (1995–2004).” Conflict Health Policy 1 World Bank. 2014a. Project Appraisal Document, Ebola (1):2. Emergency Response Project.   41 LESSONS LEARNED IN FINANCING RAPID RESPONSE TO RECENT EPIDEMICS IN WEST AND CENTRAL AFRICA World Bank. 2014b. Project Paper on Proposed additional World Bank, UN. 2017b. Pathways for Peace: Inclusive grants from IDA CRW for the EERP. Approaches to Preventing Violent Conflict. World Bank. 2015a. ERRTF FAQs. Yamey, Gavin, Marco Schäferhoff, Ole Kristian Aars, Barry World Bank. 2015b. Update on the economic impact of the Bloom, Dennis Carroll, Mukesh Chawla, Victor Dzau, 2014–15 Ebola epidemic on Liberia, Sierra Leone, and Ricardo Echalar, Indermit Singh Gill, and Tore Godal. Guinea. 2017. “Financing of international collective action for World Bank. 2017a. “From panic and neglect to investing in epidemic and pandemic preparedness.” The Lancet health security: financing pandemic preparedness at a Global Health 5 (8):e742–e744. national level.” World Bank. 2018. “ERRTF Annual Report: From crisis response to recovery and resilience.” 42