The aforementioned challenges across the global health and international financing architecture should not come as a surprise to anyone studying global health financing. In many cases they are commonplace concerns with long traditions of critique. They are elaborated not necessarily to provide new insights, but to outline a series of general concerns and recognised challenges in global health financing. By doing so, these challenges are then used in this section to assess the emerging governance structure of the Pandemic Fund in order to explore the degree to which they are being addressed in this new instrument. Below we assess the Pandemic Fund against each of the challenges in turn.

Misaligned aid allocation

As discussed, DAH is often criticised for its lack of effective, efficient and/or equitable outcomes that are poorly aligned with national health strategies. This creates vertical health siloes, which focus on singular coverage areas while diminishing efforts to strengthen integrated approaches, local buy-in, and ownership. Moreover, DAH conditionalities often reduce local control, flexibilities and needs-based responsiveness, undermining programme performance and population health outcomes. A focus on international aid priorities in the Pandemic Fund, such as for laboratories and surveillance, can leave vital and complementary system areas for prevention and impact management underfunded, weakening the whole chain of response, particularly for disadvantaged and underserved communities [54,55,56]. Since social and health inequality were risk factors of COVID-19 across different country settings, equity would be important for public health effectiveness [56, 57]. There is, however, no explicit guidance in the Pandemic Fund Governance Framework on how equity will be addressed in either the fund process, with reference to prioritised beneficiaries of programmes, health system or health-related features, or as a key deliverable to be assessed in any proposal. Finally, there is emerging evidence that there are ODA and national budget reallocations away from other health subsystems to PPR activities [4], further threatening to undercut health system strengthening efforts, while exacerbating universal health coverage vulnerabilities.

It is not clear whether challenges of misaligned programming have been suitability addressed by the new Pandemic Fund. What is clear is that eligibility for the first round of funding required countries to be eligible for IDA and IDBR funding and to demonstrate national co-investment and co-financing by at least one of the 13 approved implementing entities. Moreover, the Fund’s Technical Advisory Panel (TAP) scores proposals against a scorecard, with several questions on how well the proposal aligns with country and regional plans, as well as ‘country ownership’ [58]. In theory, the requirement for co-financing and national-level additionality should create opportunities for strategic alignment. However, the Pandemic Fund’s call for proposals did not provide guidance regarding the specific ways, standards, or best practices among global health agencies for co-financing or ensuring additionality. It also remains unclear whether other external sources can qualify as legitimate sources of additionality (such as bi-lateral aid) and whether demonstrated additionality should be measured by improved performance on preparedness, or merely on whether additional funding was secured. This raised concerns that the process relies heavily on the effectiveness of co-financing arrangements, the mechanisms of each implementing agency, and potentially other external funder conditionalities [59].

For the first round of funding, the World Bank received 179 applications from 133 countries with requests for over $2.5 billion in grants. The TAP, chaired by the WHO, selected 49 out of 135 eligible applications for recommended funding. The Governing Board then picked 19 out of these 49 [60]. In terms of programme requirements, the World Bank asserts that proposals will be reviewed by their ability to meet one or more of the following criteria, ‘strengthening comprehensive disease surveillance and early warning, laboratory systems, and human resources/public health workforce capacity’. Although the Pandemic Fund is clear that proposals must align with health security strategies, it is not clear on how far these preparedness activities should be aligned or integrated within wider health system strengthening efforts and/or broader national health strategies, both identified as key for long-term health security [15, 61,62,63]. Moreover, it remains unclear exactly how the Governing Board made their final decisions and with what balance of criteria. Although the TAP has a ‘score card’ with criteria for assessing proposals, there is not something similar for the Governing Board. Since the 179 individual proposals have not yet been released at the time of writing, nor have the scorecards for the 19 successful applications, it is not possible to determine common elements between successful and non-successful proposals.

The concern for better PPR alignment has been echoed by Fan and Smitham, who argue that the Pandemic Fund should not track whether government additionality relates to increases from a specific list of pandemic preparedness activities [59]. Instead, they argue, the Pandemic Fund should focus on the overall increases in government spending on public health activities relative to overall government spending, with this being inclusive of core functions of pandemic preparedness but also wider alignment to health system strengthening. This includes particularly those areas of health system functioning such as the integrated primary health care responses and community health systems that support equity in pandemic responses and health outcomes.

Accountability

A crucial aspect for programme ownership, follow-through and effectiveness is multidirectional accountability in which principles of ‘partnership’ are embedded within DAH processes. External funders should rightfully know that their funds are ‘reaching the ground’ by their implementing partners and thus can be justified to taxpayers as having ‘value for money’, with this in everyone’s mutual interest. Correspondingly, implementing countries should rightfully have a genuine sense of partnership, where localized needs and control are being respectfully reflected in programme design, management, and evaluation. This multidirectional accountability is crucial since asymmetrical processes undermine trust, effective design, programme sustainability, and outcomes [15, 64]. Given the scale, complexity and urgency of the Pandemic Fund mandate, there is a real danger that a lack of appropriate accountability measures could fail to mitigate against unidirectional accountability (only upward to international funders and agencies), which endangers the possibility to break from DAH ‘business-as-usual’ [65].

Multistakeholder participation and representation

An important takeaway from COVID-19 is the realisation that effective pandemic preparedness and response will require the coordination and input of multiple sectors and stakeholders. Multisectoral participation is necessary not only to align policies for more comprehensive and complementary PPR coverage but also to make sure that PPR activities align with local needs, wider policy and system goals, burdens of disease and upstream determinants. This speaks to the importance of public sector leadership in countries, and of a ‘partnership agenda’ in global health, as well as the facilitation of meaningful dialogue between stakeholders, particularly those with local expertise and implementation experience. This is recognised in the language of the Pandemic Fund [1, 58, 60, 66].

Yet, the Pandemic Fund looks as if it will be managed by an exclusionary group of the usual global funders and agencies. Although two CSOs were added to the Governing Board, this was largely in response to growing protests from key actors, after the main designs for the Pandemic Fund were complete, and only after much fanfare [67]. Now, it is unclear to what degree these CSO actors will be able to influence Pandemic Fund decisions and/or whether they will be co-opted into institutional power dynamics, as has happened with past instruments [68].

Community level consultation and engagement is purported to be fostered within the Pandemic Fund during its proposal stage, where the TAP scorecard provides a higher score for proposals that can demonstrate community engagement, input, and ‘co-creation’ [58]. Although the scorecard largely focuses on co-creation between global partners, this emphasis on the community level is found in at least two scoring areas. That said, the level of engagement and meaningfulness of community input will be scored on the narrative presented within the proposal, and it remains to be seen whether engagement will be largely tokenistic or genuine. What is clear is that failure to widen participation could result in ‘travelling models’ that are not fit for purpose and do not promote wider global health security.

Country ownership

Global covenants have increasingly recognised the need for localised ownership and managerial autonomy in the design, implementation, and evaluation of DAH. Although the Pandemic Fund is promoting a ‘horizontally integrated approach’, the concern is that it is replicating traditional top-down approaches where international funders and agencies and high-income countries set the PPR agenda and control how it is implemented [69]. These critiques are not unfounded since CSOs gained seats and representation on the Pandemic Fund Board only after fierce worldwide criticism [67]. As critics suggest, the Pandemic Fund needs a better bottom-up approach that can take account of country and regional level needs [70]. There are concerns that the required use of 13 Implementation Entities embeds hierarchical structures, dependencies, and unidirectional accountability. One suggestion to broaden inclusiveness is to involve regional organisations in governance models, with the African Union Africa Centres for Disease Control and Prevention (CDC) recommended to represent African countries, with its links to regional organisations such as the East African Community, the East Central and Southern African Health Community, West African Health Organisation and Southern African Development Community, who have themselves played a role in supporting country health system capacities and responses to health security issues [15]. However, the African CDC and these partners have recently been left out as an Implementing Entity, despite the former being the coordinating agent for the continent’s disease control and prevention. Since the Africa CDC has only recently been upgraded to an autonomous public health agency under the African Union, their role as implementing partner may be clarified by African member state resolution on their relative disease control role viz. a viz. that of WHO AFRO. Within countries, while the Pandemic fund usefully includes investment in human resources, it is unclear whether this applies beyond specific technical personnel, to include the public sector leadership, co-ordination, and negotiation capacities that have been important for engaging and mobilizing private actors and domestic and international funders for pandemic responses, including for local production of health technologies [15, 54, 56, 71].

External funder coherence and fragmentation

COVID-19 demonstrated that global, regional and national systems were unprepared and unable to suitably respond to the pandemic, with key factors including those identified from the review, particularly historic underfunding and policy fragmentation.

Regarding underfunding, the Pandemic Fund has a remit to generate the estimated $USD 10.5 billion annual funding requirement for PPR. However, as of August 2023, the Fund had thus far only secured financial commitments of $USD 1.9 billion from twenty-six donors, most of whom are G20 countries, the Bill & Melinda Gates Foundation, the Rockefeller Foundation and the Wellcome Trust [66, 72]. In terms of existing demand, the Pandemic Fund in the first round received 179 bids, equating to $USD 2.5 billion, while only committing $USD 338 million to the first round of financing, constituting a demand over eight times the allotted envelope [60]. This suggests that demand for financing is far greater than available capacities, which raises concerns about the Pandemic Fund’s ability to effectively and equitably govern PPR, while foreshowing criticisms that it is built to fail [73].

In terms of strategic financing, the Pandemic Fund has been critiqued for its heavy focus on ‘classic’ pandemic preparation such as surveillance, diagnostic capacity and related personnel and skills [74]. Yet learning from COVID-19 showed that although many of these science-based requirements for pandemic control were met, ‘the global management of the pandemic still failed in many respects’ [75]. This included the failure to ensure adequate global supplies and equitable distribution of key commodities for LMICs and the implementation of top-down approaches in some settings that failed to build on strengths of primary care and community health systems, especially given their important role in leveraging inter-sectoral action (markets, housing, transport and other infrastructures) for pandemic prevention [54, 56, 62, 76].

While the Pandemic Fund refers to ‘One health’ in areas covered, it is not clear if its ‘prediction of disease’ or ‘early detection’ will support upstream capacities and processes for this type of health impact assessment. Nor is it clear whether prediction and detection will also address upstream economic and wider sectoral determinants of health that increase risk or support improved links between technical dimensions of health security and wider health system goals. Although the World Bank has stated that other institutions and financing mechanisms are necessary to support PPR, and they may invest in these areas, the Pandemic Fund has not given them sufficient coverage, demonstrating that other capacities will play a secondary role in PPR and limiting links in building a more integrated systems response. For example, the Pandemic Fund does not contain financing for contingency funds, clear links with the WHO Contingency Fund for Emergencies, links to investments in community or primary health care systems or to One Health, intersectoral investments and funding mechanisms to prevent and manage the socioeconomic impacts of health emergencies, highlighting a gap in vital public health emergency management [55, 77].

Although the planned activities for the fund have been shown as necessary, they are more tailored to ‘strengthening’ and ‘building’, apparently thus geared toward pre-outbreak settings and without enough focus on response capacities. According to Boyce et al. it would require $124 USD billion over 5 years to reach ‘demonstrated capacity on each indicator of the Joint External Evaluation’, a key ‘element’ on the Pandemic Funds ‘results framework’ [77]. As a result, the Independent Panel for Pandemic Preparedness and Response has recommended a matched sum of $100 billion to be available for response efforts [77]. This implies that the Pandemic Fund is unlikely to be able to fund both efforts.

In relation to policy fragmentation, there is little indication of how the Pandemic Fund will interconnect and complement other PPR and global health initiatives. One way that the Pandemic Fund is attempting to increase coherence across international funders and agencies is by partnering with 13 Implementing Entities to channel funds, such as development banks, Global Fund and UNICEF, to complement already established financing mechanisms in LMICs. However, the Pandemic Fund lacks clarity on how funds will be split amongst these organisations, what level of required co-financing is appropriate, on their approach to implementation through these entities, nor on how far these entities will be expected to link with and engage continental and regional economic communities that include LMICs who play a role in supporting, harmonising, and providing capacities for country activities. These details are not available from the brief two-page summaries of the successful applications published by the Pandemic Fund [78]. It is also unclear whether entities such as the Global Fund are appropriate agents to implement PPR system reforms. What remains clear, considering the discussion above, is that not addressing these challenges threatens to render the Pandemic Fund yet another under-coordinated and fragmented institution that lacks meaningful political capacities, country level buy-in, or funds to prepare for the next pandemic [69].

Transparency

The literature reviewed suggests that opacity in transparency mechanisms undermine stakeholders’ trust while also masking asymmetries in policy influence and subvert programme accountability. Widespread ambiguities in the original World Bank white paper signalled a lack of urgency regarding the importance of transparency for programme acceptance and buy-in, ignoring its key role in policy success. For example, the success of the Pandemic Fund will rely on its ability to generate new financing without competing for existing global health funding [4]. Yet, there is no strategy for how the World Bank will assure that existing global health financial commitments are not reallocated to the Pandemic Fund. Although the Pandemic Fund has launched a new financial tracker, it operates under the assumption that commitments are from ‘new sources’ and not reallocations. Moreover, there is a lack of new thinking in how to engage key shareholders toward effectively financing global public goods [4, 73, 77]. As argued by Glassman, this sort of strategy will be crucial to engage prospective funders in a way that can meet the PPR financing gap [73].

The Pandemic Fund has generally lacked transparency in how it prioritizes projects, how it balances between global and local initiatives, and in how it integrates criteria such as equity in funding decisions. The creation of an instrument for the TAP to score proposals [58] should allow for better consistency in decision-making and transparency in how funding decisions were made. Moreover, whereas earlier Pandemic Fund meetings were closed, the Secretariat now organises open meetings to increase transparency and has committed to consistently publish its minutes.

In terms of transparency about prioritizations, PPR is complex and involves global collective action, meaning investment needs a national and international perspective [79]. PPR projects will directly benefit countries and indirectly benefit the rest of the world, and vice versa. For example, surveillance for a low morbidity disease in one country may not directly benefit that country and there could be better uses for that money. Nevertheless, that same investment could be beneficial at the regional and global level to prevent a wider-scale outbreak [79]. A working group has been set up to consider prioritisation frameworks and resource allocation criteria for PPR, but developments have not yet been reported [79]. To increase transparency in decision making, this process will also have to consider governance concerns regarding bias towards external funders and high-income countries.

Power dynamics

Power dynamics, or more accurately, power asymmetries within countries, and between states and non-state actors, particularly those at international level, are pervasive across global health governance. Through such international financing channels, powerful actors can have a tangible and concrete influence over the direction of agencies, national health system priorities in implementing countries and funding channels for selected implementing agencies [15, 80]. This creates a scenario whereby if an implementing country’s government disagrees with the international funder-selected priority area, they risk forgoing financial support. This may encourage adoption of external priorities that do not align well with local needs and priorities. Yet, foregoing needed funds will render larger financial shortfalls, with potential cascading effects. Currently there is little evidence that the Pandemic Fund will stray from this playbook, as it will likely only fund activities endorsed by powerful international agencies, funders and high-income countries, such as in a focus on capacities for surveillance and laboratories versus those for health and community system strengthening and distributed local production of health technologies, with poor or uncertain country ownership. Unsustainable and fragmented initiatives ultimately undermine meaningful strengthening of pandemic preparedness and response, while reinforcing and solidifying the relevancy and influence of the World Bank and traditional powers.

Anti-corruption

Whilst the World Bank’s disbursement of funds may be vital to ensure financial solvency, experience also suggests that without proper transparency mechanisms, money can go unaccounted for and be misappropriated. This poses a threat that funds will be taken away from vital services with longer-term national implications, as corrupt actors enrich and entrench. Although anti-corruption mechanisms remained underspecified in the World Bank whitepaper, there is widespread understanding that robust monitoring and accountability mechanisms are needed. In response, a UN High-level meeting on PPR to discuss and develop an appropriate set of monitoring and accountability mechanisms for the Pandemic Fund was scheduled for September 20, 2023 [81]. Moreover, the World Bank published its Pandemic Fund Conflict of Interest Framework in March 2023, which is aimed to make sure the Fund operates with high standards of transparency and accountability’ [82].

Beyond mechanisms for public domain reporting and oversight by mandated national audit and parliamentary bodies, ongoing debates also need to address the risk of corruption in pandemic financing, whether in the form of bribes, embezzlement, fraudulent contracts, inflated pricing, insider trading or diversion of funds. Given the nature of the Pandemic Fund as a potential global institution dedicated to quickly respond to global threats (if given a role for surge funding), experience (from across countries at all income levels [83, 84]) suggests that the Pandemic Fund and the public bodies involved need to take and publicly report on appropriate measures, such as: open-contracting, pre-registration of suppliers, beneficial ownership information, freedom of-information acts, limits on conflicts of interest, oversight by public bodies, and sufficient investigative resources to bring cases promptly and to protect and reward whistle-blowers to avoid corruption [85].

Limitations

We note several limitations in this research. First, there is a potential bias in the published literature reviewed on challenges in international health financing instruments in that it mostly comes from high-income countries or international institutions, and from international NGOs/CSOs. Importantly therefore, the eight challenges reviewed may not fully represent the perspectives and/or hierarchical prioritization in low-income countries or other traditionally underrepresented contexts. Moreover, only material written in English was reviewed, which excludes perspectives from non-English sources. Second, with the Pandemic Fund still in the process of designing and implementing its policies, many of the issues raised could still be ‘in process’ and may be addressed in due course. The assessment in this article is thus meant to be informative to help reflect on an emerging international health financing instrument at the centre of the PPR agenda. Third, there are changing and emerging lessons involving COVID-19 and PPR, with unclear and evolving evidence on longer term impacts of policy and measures. This assessment thus draws on current knowledge, and further assessment is needed as better evidence materialises. Lastly, effective PPR requires a holistic response beyond the actions of a single international health financing instrument. We have focused on the Pandemic Fund due to its key, and currently monopolizing, financing position in the PPR agenda. By doing so this understates the crucial need for a broader assessment of what a suitable and more holistic PPR global health architecture requires. This has received a more thoroughgoing treatment elsewhere [16]. In this paper we add Pandemic Fund insights to that wider assessment. Notwithstanding these limitations, we consider the themes selected and the analysis given in relation to the current Pandemic Fund design to have provided useful research evidence and information for ongoing policy dialogue.