BMJ

Confidential: For Review Only World Bank’s Pandemic Emergency Financing Facility – the Panacea against Pandemics?

Journal: BMJ

Manuscript ID BMJ-2019-050786.R1

Article Type: Analysis

BMJ Journal: BMJ

Date Submitted by the 31-Jul-2019 Author:

Complete List of Authors: Brim, Bangin; London School of Economics and Political Science, Department of Health Policy; London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy Wenham, Clare; London School of Economics and Political Science, Department of Health Policy

Global Health Security, Pandemic Preparedness, World Bank, Emergency Keywords: Funds, Global Health, Financing Facility

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1 2 3 1 Analysis 4 5 2 6 3 World Bank’s Pandemic Emergency Financing Facility – 7 8 4 the Panacea against Pandemics? 9 5 10 6 Bangin Brim1,2,3 11 7 Clare Wenham1 12 Confidential: For Review Only 13 8 14 9 1LSE - London School of Economics and Political Science, London WC2A 2AE UK 15 10 2LSHTM - London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK 16 11 3Charité, Berlin University of Medicine, 10117 Berlin, Germany 17 18 12 19 13 Correspondence to: 20 14 Full Name: Bangin Brim, MD 21 15 Mailing address: Houghton Street, London WC2A 2AE, UK 22 16 Email: [email protected] 23 24 17 Phone: +49 178 44 84 712 25 18 26 19 Word count: 1907 + 151 (key messages) 27 20 References: 74 28 21 29 30 KEY MESSAGES 31 32  The World Bank’s Pandemic Emergency Financing Facility’s (PEF) sought to ensure swift 33 fund allocation to countries and responding agencies to prevent humanitarian and economic 34 35 crises following disease outbreaks. 36  PEF is yet to make a payout through its insurance window, while alternative funds–WHO’s 37 Contingency Fund for Emergencies (CFE) and UN OCHA’s Central Emergency Response 38 39 Fund (CERF)–continuously provide emergency funds. 40  Meanwhile, PEF has paid out US$114.5 million as coupons on catastrophe bonds to 41 42 bondholders. 43  Analyzing past disease outbreaks for which CERF and CFE funds were allocated, PEF’s 44 45 insurance scheme would only have been triggered for the 2014 Ebola-virus-outbreak in West- 46 Africa and 2006 Rift-Valley-Fever-virus-outbreak in East-Africa 47 48  PEF needs to be reformed to contribute to global health security, including the removal of 49 cross-border requirement, broadening the scope of PEF-eligible pathogens, and adapting the 50 51 arbitrary criteria like minimum case numbers or deaths to the given individual context. Co- 52 financing of existing funds should be considered. 53 54 22 55 23 Contributors and sources 56 24 BB conceived the idea, collected and analysed the data, and drafted the initial version of the 57 25 paper. CW helped conceptualise and revise the draft. Both approved the final version. BB is 58 59 26 the guarantor. 60 27

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1 2 3 28 BB is a physician and aspiring health economist, interested in good governance, global health 4 29 security and international humanitarian and development assistance. 5 30 6 31 CW is Assistant Professor of Global Health Policy at LSE. Her research focuses on global 7 32 health security and global health governance. 8 33 9 10 34 Data analysed for the paper include predominantly WHO’s Disease Outbreak News and 11 35 Situation Reports, UN CERF’s and WHO CFE’s grant reports and financial datasets, 12 36 correspondingConfidential: reports from UN OCHA’s ForReliefWeb Review database and trustee Only reports on World 13 37 Bank’s PEF. 14 38 15 39 Acknowledgements 16 40 We thank Philip Evans and Lorcan Clarke for discussions and reflections on PEF and 17 18 41 catastrophe bonds and Jordan Ramacciato for discussions about the CFE. 19 42 20 43 Patient involvement 21 44 No patients were involved. 22 45 23 46 Conflicts of Interest 24 47 We have read and understood BMJ policy on declaration of interests and have the following 25 48 interests to declare: 26 49 BB: None. 27 50 CW: None. 28 51 29 52 Licence 30 53 The Corresponding Author has the right to grant on behalf of all authors and does grant on 31 54 behalf of all authors, an exclusive licence (or non exclusive for government employees) on a 32 55 worldwide basis to the BMJ Publishing Group Ltd ("BMJ"), and its Licensees to permit this 33 56 article (if accepted) to be published in The BMJ's editions and any other BMJ products and 34 57 to exploit all subsidiary rights, as set out in The BMJ's licence. 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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1 2 3 4 58 World Bank’s Pandemic Emergency Financing Facility – 5 59 the Panacea against Pandemics? 6 7 60 8 61 Does World Bank’s Pandemic Emergency Financing Facility have the “speed and flexibility” 9 62 to fight disease outbreaks, as claimed by former president Jim Yong Kim? Bangin Brim and 10 63 Clare Wenham contend that the facility, in its current form, serves private sector interests at 11 12 64 the cost Confidential:of global health security – and call For for its reform.Review Only 13 65 14 15 16 66 INTRODUCTION 17 18 67 The outbreak of Ebola in West-Africa 2014-6 exposed many flaws in the global governance framework 19 20 68 for responding to infectious disease(5-7). One of the key concerns is the implementation gap between 21 22 69 the commitment by states under the International Health Regulations 2005 (IHR) to meet certain core 23 24 70 competencies for outbreak preparedness, detection and response, and the de facto ability for states to 25 26 27 71 do so, owing in part to lack of financing(8, 9). 28 29 72 A second key finding was that the 2014-6 Ebola response suffered from financing delays meaning actors 30 31 73 were on the back foot in control efforts(5, 6). According to the World Bank, early financing of US$100 32 33 74 million could have averted the subsequent socio-economic and human crisis(10, 11), suggesting that 34 35 75 prompt financing during the early stages of outbreaks might limit a pathogen’s spread(12, 13). 36 37 76 In 2016, and as part of its broader role as the largest risk insurance provider for low-and-middle-income- 38 39 77 countries(14), the World Bank, in consultation with the World Health Organization (WHO), the risk 40 41 78 modeling agency AIR Worldwide, the re-insurers Munich Re and Swiss Re(15), and supported by Japan 42 43 79 and Germany, designed the Pandemic Emergency Financing Facility (PEF) to quickly provide funds 44 45 80 for the world’s poorest countries (IDA-eligible countries) and responding agencies to prevent future 46 47 48 81 pandemics and their humanitarian and economic externalities(1, 16, 17). By creating a market for 49 50 82 pandemic risk insurance, drawing on funds from the private sector through (catastrophe) bonds and 51 52 83 swaps, featuring highly lucrative interest rates between 6.5% and 11.1% over LIBOR, reliance on donor 53 54 84 contributions could be averted while also providing an example as to how capital markets can support 55 56 85 global health (Box 1)(18, 19). 57 58 59 60

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1 2 3 Box 1: Actuarial terms explained 4 5  Bonds – temporary loan agreement between the issuer of the bond and the loaning investor, after which 6 the bond issuer returns the investment with an added coupon based on a set interest rate 7 8  Catastrophe Bonds (cat bonds) – bonds linked to a natural disaster (e.g. hurricanes, earthquakes). If the 9 disaster occurs, the investor loses their investment to finance the response. If no disaster occurs, 10 11 investments are returned with an added coupon 12  SwapsConfidential: – temporary agreement between two For parties toReview exchange cash flows Onlyand/or liabilities from other 13 14 financial instruments, often used to reduce one’s financial risk 15  LIBOR – London Interbank Offered Rate; a globally accepted benchmark rate of interest 16 17  Parametric criteria – predefined measurable variables, relating to a triggering event; once met, an 18 insurance pay-out has to be made 19 20  IDA – International Development Association; an institution of the World Bank Group, providing loans 21 to the world’s poorest countries (IDA[-eligible] countries), currently defined as those with a gross 22 23 national income per capita below US$1,145(4) 24  IBRD – International Bank for Reconstruction and Development; an institution of the World Bank 25 26 Group, providing loans to creditworthy low- and middle-income-countries, IBRD[-eligible] countries 27 86 28 However, PEF’s insurance window has not ever been activated while other emergency funds including 29 30 87 WHO’s Central Fund for Emergencies (CFE) and United Nations (UN)’s Central Emergency Response 31 32 88 Fund (CERF) have released funds rapidly to mitigate outbreaks. This has led to widespread criticism of 33 34 89 the financing facility, particularly during the current Ebola outbreak in the Democratic Republic of 35 36 90 Congo (DRC)(20-22), leading the World Bank to deploy US$300 million through the IDA instead(23). 37 38 91 Whilst much of the critique is centered on fundamental flaws of using catastrophe bonds to finance 39 40 92 international responses to pandemics, this paper reviews PEF’s failures from a global health security 41 42 93 perspective. To do so, we examine payments allocated to responses to PEF-eligible pathogens through 43 44 94 other crisis financing mechanisms, the CERF and CFE. This is a pertinent exercise, given that the World 45 46 95 Bank has stated that discussions are taking place around the development of PEF 2.0(24). We 47 48 49 96 demonstrate that only two outbreaks within the last 15 years would have met the parametric criteria to 50 51 97 activate PEF’s insurance pay-out, and in doing so, we call for a re-evaluation of the disbursement 52 53 98 criteria to ensure future global health security. 54 55 99 56 57 100 HOW PEF WORKS 58 59 60

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1 2 3 101 PEF has two distinct payout windows. The insurance window provides up to US$425 million when 4 5 102 defined parametric activation criteria are met, different for flu and five non-flu viral outbreaks, based 6 7 103 on the duration of the outbreak, number of cases, the growth rate and the geographic spread (Box 2). 8 9 10 Box 2: Activation Criteria for PEF’s Insurance Window (available to IDA-eligible countries) (1-3) 11 For Flu (release of US$275 million): 12 Confidential: For Review Only 13 (a) At least 5,000 confirmed cases worldwide within a rolling 42-day period and 14 15 (b) The virus is an influenza A virus which 16 ▪ is a new influenza A virus with a new genetic subtype, and no case of or death relating to such influenza 17 18 A virus has been reported in any WHO Report published prior to July 2017; or 19 ▪ is an influenza A virus whose hemagglutinin gene is antigenically distinct, due to an antigenic shift, 20 21 from those in seasonal influenza viruses circulating in the 35 years prior to July 2017; and 22 ▪ which is experiencing sustained or effective human-to-human transmission; and 23 (c) The Growth Rate is greater than zero after the first 42 days and 24 25 (d) The Growth Rate Mean needs to be greater than or equal to 0.265, for any day after the first 42 days. 26 27 For Non-flu (Filoviridae (e.g. Ebola virus, Marburg virus), Coronaviruses (e.g. MERS, SARS), Rift-Valley- 28 Fever-viruses, Lassa-Fever-viruses, Crimean-Congo-Hemorrhagic-Fever-viruses): 29 30 (a) At least 12 weeks have passed from the date of the start of the event and 31 32 (b) The outbreak needs to be in at least two IDA- or IBRD-eligible countries, with each such country having 33 greater than or equal to 20 confirmed deaths and 34 35 (c) The Growth Rate needs to be greater than zero and 36 (d) The Total Confirmed Death Amount needs to be greater than or equal to 250 and 37 38 (e) The Rolling Total Case Amount needs to be greater than or equal to 250 and 39 (f) The Rolling Confirmed Case Amount needs to comprise a minimum percentage of the Rolling Total Case 40 Amount 41 42 Eligible countries and responding agencies have to submit a request for funds to the PEF coordinator who 43 44 checks whether the criteria have been met and, if so, calculates how much will be provided to each affected 45 country/responding agency (Appendix 3): 46 47  Regional outbreaks affecting two to seven countries would activate payments of Pandemic 48 Bond/Insurance Payout Amounts at three stages as the number of total confirmed deaths increases. 49 50  Global outbreaks affecting eight or more countries also activate payments at three stages but 51 provide access to higher funding levels at the first two triggers 52 104 53 54 55 56 57 58 59 60

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1 2 3 105 PEF’s cash window provides up to US$61 million when the criteria for the insurance window are not 4 5 106 met (Box 3)(1). Germany, Japan and Australia, the countries financially contributing to PEF, govern 6 7 107 this cash window and decide on pay-outs(3). 8 9 Box 3: Possible purposes for which PEF’s Cash Window may allocate money (available to IDA- and 10 11 IBRD-eligible countries) (1-3) 12 (i) to provideConfidential: supplemental financing for an outbreak For of pathogens Review covered by PEF’s Only Insurance Window, that 13 14 clearly merit larger or earlier funding allocation than provided by the activation criteria and PEF’s Insurance 15 Window allocation arrangements; 16 17 (ii) to provide financing to severe single-country outbreaks 18 (iii) to provide coverage for new or unknown pathogens not covered by PEF’s Insurance Window; 19 (iv) to serve as a conduit for efficient and effective surge financing during crisis for development partners to 20 21 channel resources to affected countries; and 22 (v) for all other allocations in line with PEF objectives and as approved by the Steering Body. 23 24 108 25 26 27 109 REVOLUTIONARY MODEL? 28 29 110 PEF joined an already expanding financing landscape in global health security. The WHO established 30 31 111 the Contingency Fund for Emergencies (CFE) in 2015 within the WHO’s Health Emergencies 32 33 112 Programme, “to quickly mount an effective response to disease outbreaks and humanitarian crises” of 34 35 113 up to $500,000 considered Grade 2 or above in the Emergency Response Framework (25-28)Funds are 36 37 114 not earmarked and theoretically, no financial ceiling exists. However, the CFE has not met its 38 39 115 fundraising target (29): As of March 2019, US$70.7 million of the goal of US$100 million had been 40 41 42 116 collected (27, 30). Still, the CFE has allocated more than US$67 million for the current Ebola outbreak 43 44 117 in the DRC, overstraining its own mandate and budget while demonstrating the crucial need for funding 45 46 118 (Appendix 1). As PEF does not rely on voluntary contributions, it was heralded as an innovative 47 48 119 financial instrument to supersede this challenge of capitalization. 49 50 51 52 53 54 55 56 57 58 59 60

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1 2 3 120 The UN OCHA’s Central Emergency Relief Fund (CERF) was created in 2005 to raise and pool 4 5 121 emergency disaster relief funds(31, 32) and provides grants and loans through its underfunded 6 7 122 emergency window and a rapid response window. Whilst US$74.6 million was disbursed for health 8 9 10 123 emergencies in 2018(33), only 55.5% of its annual donor funding target of US$1 billion was met (33). 11 12 124 The WorldConfidential: Bank claims that PEF is an innovative For model Review for bringing private Only sector financing into 13 14 125 pandemic response (34). At the time of writing, PEF’s insurance window has yet to be activated, while 15 16 126 the cash window has released US$11.4 million in May 2018 for DRC’s former Ebola outbreak in the 17 18 127 Équateur province(35), and approved US$20 million in February 2019 for the subsequent, current 19 20 128 outbreak in DRC’s provinces of North Kivu and Ituri(36, 37). However, by the end of 2018, 21 22 129 bondholders had been paid US$114.5 million in return for their investment in this catastrophe bond 23 24 130 (35). 25 26 131 27 28 132 Thus, we sought to understand why this was the case that PEF has not been able to release funds ‘with 29 30 31 133 speed and flexibility’ from the dominant insurance window(38). We examined all outbreaks for which 32 33 134 CERF and CFE funds were allocated prior to PEF’s existence to evaluate whether they would have met 34 35 135 the activation criteria for an insurance claim through the PEF, to assess how suitable the PEF’s criteria 36 37 136 are for real life outbreak events. 38 39 Box 4: Methods 40 41 By performing a retrospective analysis from March 2006 (the creation of CERF) until today (April 42 2019), we evaluated PEF’s insurance windows’ disbursement criteria in relation to all outbreaks 43 44 caused by PEF-eligible pathogens and for which CERF and/or CFE funds were allocated to assess 45 whether the parametric criteria to trigger the payout would have been met in these instances. 46 47 First, we identified and listed CFE’s fund allocation for disease outbreaks and complex 48 49 emergencies and CERF’s grant reports and fund allocation lists of the rapid-response window. We 50 excluded all outbreaks which did not involve PEF-eligible pathogens. We further excluded those 51 52 which did not take place in IDA-countries. 53 Next, we collected further information on these outbreaks from WHO’s Disease Outbreak 54 55 News and Situation Reports and UN OCHA’s ReliefWeb database and policy / media searches 56 covering these outbreaks. From this descriptive data, we were able to ascertain whether these 57 58 outbreaks would have met the criteria for PEF’s insurance window, by measuring against the 59 60 parametric criteria contained within PEF’s prospectus (Box 2).

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1 2 3 137 4 5 138 HIGH HURDLES FOR TRIGGERING PEF’S INSURANCE SCHEME 6 7 8 139 Since CFE’s establishment in late 2015, 66 payouts were due to disease outbreaks, totaling around 9 10 140 US$109.5m (77.1% of all CFE’s allocations). 24 of the outbreaks were PEF-eligible pathogens 11 12 141 (AppendixConfidential: 1). For Review Only 13 14 142 CERF allocated funds more than 1,500 times for health-related events, providing US$900.9 million 15 16 143 (15.3% of all CERF’s allocations(39)). Of all these outbreaks caused by pathogens eligible for PEF 17 18 144 financing, only the 2006 Rift-Valley-Fever-virus outbreak in East-Africa and the 2014 Ebola outbreak 19 20 145 in West-Africa would have met all PEF’s eligibility criteria. 21 22 146 Table 1 - Results for non-flu- and flu-related disease outbreaks, divided between CFE and 23 24 147 CERF payouts and whether the PEF criteria for triggering the payout have been met (see also 25 26 27 148 supplementary material) 28 29 30 31 Outbreak details Emergency funds 32 33 PEF insurance window (non-flu) 34 CFE CERF activation criteria hypothet 35 ical Duration Countries pay-out? pay-out? pay-out? ≥ 250 36 ≥ 2 ≥ 20 deaths + (references) affected + + confirmed ≥ 250 deaths? 37 duration IDA/IBRD in affected total total total cases? ≥ 12 weeks? countries IDA / IBRD amount? 38 amount? amount? (total deaths) affected? countries? 39 (total cases) 40

41 Coronaviridae (MERS, SARS,...) 42 43 44 no cases with CFE and/or CERF payout 45 46 47 Crimean-Congo-Hemorrhagic-Fever virus 48 49 50 51 no cases with CFE and/or CERF payout 52 53 54 Filoviridae – Ebola virus 55 56 August 2007 57 ✓ ✓ ✘ – November DRC ✘ ✘ ✘ ✘ 58 2007 (40) US$ (264) (187) 59 0.9 M 60

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1 2 3 June 2012 – 4 November ✓ ✘ ✘ DRC ✓ ✘ ✘ 5 2012 (41) US$ (57) (29) ✘ 6 0.5 M 7 West Africa 8 (Libera, 9 December Sierra ✓ 2013 – ✓ ✓ ✓ Leone, US$ ✓ ✓ ✓ 10 June 2016 (28,616) (11,310) US$ Guinea, 3.6 M (42) 150 M 11 Nigeria, 12 Confidential:Mali) For Review Only 13 14 July 2014 – November ✓ ✘ ✘ DRC ✓ ✘ ✘ 15 2014 US$ (69) (49) ✘ 16 (43) 1.4 M 17 18 April 2017 – ✓ ✘ ✘ 19 June 2017 DRC ✘ ✘ ✘ (44) US$ ✘ (5) (4) ✘ 20 2.0 M 21 22 April 2018 – ✓ ✓ ✘ ✘ 23 July 2018 DRC ✘ ✘ ✘ (45) US$ US$ (38) (33) ✘ 24 4.6 M 0.8 M 25 26 August 2018 DRC ✓ ✓ ✓ ✓ 27 (ongoing) ✓ ✓ ✘ (46) (Uganda) US$ US$ (2522) (1698) ✘ 28 67.0 M 1.7 M 29

30 Filoviridae – Marburg virus 31 32 33 October 2017 – December ✓ ✘ ✘ 34 Uganda ✘ ✘ ✘ 2017 US$ ✘ (2) (2) ✘ 35 (47-49) 0.5 M 36 37 Lassa-Fever-Virus 38 39 40 Nigeria, August 2015 Benin, ✓ – ✓ ✘ ✘ 41 Liberia, ✓ ✓ (Nigeria, May 2016 ✘ US$ (228) (132) ✘ 42 (50-53) Sierra Benin) 43 Leone 0.4 M 44 January 2018 45 ✓ ✓ ✓ ✘ – April 2018 Nigeria ✓ ✘ ✘ 46 (54, 55) US$ US$ (428) (107) ✘ 47 1.0 M 0.7 M 48 January 2019 49 ✓ ✓ ✘ (ongoing) Nigeria ✓ ✘ ✘ 50 (56) US$ ✘ (622) (140) ✘ 51 0.4 M 52 53 Rift Valley Fever Virus 54 55 56 November Kenya, 2006 – ✓ ✓ ✓ ✓ Tanzania, ✓ ✓ ✓ 57 March 2007 (394) (315) Somalia US$ US$ 58 (57) 1.0 M 22.5 M 59 60

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1 2 3 October 2007 4 – ✓ ✓ ✘ Sudan ✘ ✘ ✘ 5 January 2008 US$ (698) (222) ✘ 6 (58-60) 0.9 M 7 January 2008 8 – ✓ ✘ ✘ Madagascar ✓ ✘ ✘ 9 June 2008 US$ (84) (20) ✘ 10 (61) 0.1 M 11 12 October 2010Confidential: For Review Only – November ✓ ✘ ✘ Mauritania ✘ ✘ ✘ 13 2010 US$ (30) (2) ✘ 14 (62) 0.4 M 15 September 16 2012 – ✓ ✘ ✘ Mauritania ✘ ✘ ✘ 17 October 2012 US$ (34) (17) ✘ 18 (63) 0.4 M

19 August 2016 – 20 ✓ ✘ ✘ November Niger ✓ ✘ ✘ 21 2016 US$ ✘ (17) (32) ✘ 22 (64) 0.5 M 23 24 June 2018 ✓ ✓ ✘ ✘ Kenya ✘ ✘ ✘ 25 (65) US$ US$ (7) (6) ✘ 26 0.2 M 0.7 M 27 28 January 2019 South ✓ ✘ ✘ ✘ ✘ ✘ 29 (66) Sudan US$ ✘ (6) (0) ✘ 30 0.3 M 31

32 Influenza A, H1N1 33 34 35 PEF insurance window (flu) 36 CFE CERF activation criteria hypothet ical 37 Duration Countries pay-out? pay-out? pay-out? ≥ 5000 cases 38 never growth rate + (references) affected + + worldwide positive new genetic occurred mean ≥ 0.265 total 39 total total (within a 42- growth rate subtype? within the after 42- amount? amount? amount? days rolling after 42 days 40 last 35 years? days-period? 41 basis)? 42 March 2017 – 43 ✓ ✘ June 2017 Maldives ✘ ✘ ✘ ✘ ✘ ✘ 44 (67) US$ (277) 45 0.1 M 46 149 47 48 49 150 This analysis shows that only Rift Valley Fever (2006-7) and Ebola (2013-6) would have met the PEF 50 51 151 insurance criteria. This is at odds with a number of notable outbreaks and even Public Health 52 53 152 Emergencies of International Concern (PHEIC). 54 55 153 56 57 58 154 PEF’s raison d'être 59 60

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1 2 3 155 Our analysis shows that PEF’s insurance window does not provide funds to mitigate risks posed to 4 5 156 global health security. What’s more, recent appraisal of the scheme has shown that more money was 6 7 157 paid out to investors in the pandemic bonds than had been to IDA-eligible countries facing outbreaks 8 9 10 158 of disease. US$175.6 million had been paid into the scheme by Australia, Germany, Japan and IDA, 11 12 159 US$31.4 Confidential:million had been disbursed for outbreak For response; Review in contrast, byOnly the end of 2018, $114.5 13 14 160 million had been paid our as coupons on catastrophe bonds (35). As such, the inconvenient truth is that 15 16 161 in its current format, the system appears to favour private sector investors over global health security. 17 18 162 We propose that a key flaw are the stringent parametric criteria. These may make sense from 19 20 163 an insurance perspective, balancing the desire to give insurance coverage whilst needing to deliver 21 22 164 financial returns to investors, they are at odds with the messy reality of epidemic control. Even the cash 23 24 165 window acts as a final safety net preventing the insurance scheme activation – and the investors’ losses. 25 26 166 We propose that the World Bank should reflect on this inconvenient truth and decide whether reform is 27 28 167 needed, or whether its desire to finance pandemics can be better served through other established 29 30 31 168 mechanisms. For example, since CFE and CERF are chronically underfunded, co-financing agreements 32 33 169 between these and PEF for disease outbreaks could enhance the overall efficiency by removing parallel 34 35 170 structures and deploying pandemic financing sooner. Alternatively, if the World Bank seeks to continue 36 37 171 with the PEF, we identify the following changes to improve the current activation criteria: 38 39 172 First, the PEF insurance criteria requires the outbreak to have crossed a border and affect at least 20 40 41 173 people in two IDA/IBRD countries. This criterium places banal limitations on the facility. Outbreaks 42 43 174 may occur in the centre of large countries with limited cross-border traffic, reaching epidemic 44 45 175 proportions before crossing an international border. This is epitomised by the DRC Ebola outbreak, 46 47 176 which was declared a PHEIC in July 2019, and currently is registering 2522 confirmed cases and 1698 48 49 50 177 deaths(46). Whilst the PEF’s cash window has deployed US$20 million (36, 68)., PEF’s insurance 51 52 178 window remains inactivated. The only outstanding criterium is the requirement for 20 deaths in at least 53 54 179 2 eligible countries. In November 2018, all other criteria had already been met and in June 2011, Ebola 55 56 180 was reported across the border in Uganda, but the case numbers still remain below the 20 person 57 58 181 threshold (69, 70). 59 60

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1 2 3 182 The current scale of the humanitarian crisis in Ebola painfully showcases that the cross-border 4 5 183 requirement should be removed entirely if the goal of PEF is ensuring global health security. 6 7 184 Secondly, PEF’s sole focus on viruses is unclear and regressive. The majority of the outbreak-related 8 9 10 185 CFE funds were allocated to [bacterial] cholera outbreaks. PEF’s ambition to solely cover the “six 11 12 186 viruses thatConfidential: are most likely to cause a pandemic” For is short-sighted, Review especially Only considering trends in anti- 13 14 187 microbial resistance, and the all-risk approach to disease embedded within WHO R&D Blueprint and 15 16 188 International Health Regulations(11, 71, 72). 17 18 189 Thirdly, the existence of parametric criteria within an insurance model are fundamentally at odds with 19 20 190 providing proactive intervention in the early stages of an outbreak to prevent transmission. Alternatively, 21 22 191 the insurance window could rely on the same steering committee as the cash window, also, it could be 23 24 192 linked to WHO PHEIC declarations. Whilst there have been problems noted with the WHO’s 25 26 193 Emergency Committee process, including political interference in decision making(73), it would bring 27 28 194 greater synergy to global health security. 29 30 31 195 32 33 196 …and the investors’ interests? 34 35 197 However, we recognise that these options would come at a cost: Liberalizing or jettisoning the criteria 36 37 198 for the insurance window would increase the risk to investors and would need to be reflected in even 38 39 199 higher interest rates. In this instance, aligning PEF with CFE or CERF appears more attractive and 40 41 200 reasonable to the World Bank, Australia, Japan and Germany. 42 43 201 44 45 46 47 202 CONCLUSION 48 49 50 203 PEF was created “to make resources available […] to help prevent rare, high-severity disease outbreaks 51 52 204 from becoming pandemics”(1, 16). However, our analysis has shown that only two outbreaks which 53 54 205 received funds through CFE and CERF would have met the criteria for a payout under PEF’s insurance 55 56 206 window. Accordingly, PEF has failed to deliver on its innovative promise with investor interests silently 57 58 207 underlying the activation criteria. 59 60

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1 2 3 208 4 5 209 Yet, given the challenges CFE and CERF face in failing to ensure sustainable fundraising, PEF financial 6 7 210 capabilities appear to be in position to fill this crucial gap in global health security(74), if these 8 9 10 211 mechansims were to be streamlined. If PEF 2.0 is to be lauched, soul-searching needs to be done to 11 12 212 decide whetherConfidential: this facility prioritises global For health security Review against investor Only interests. 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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1 2 3 213 References 4 5 6 214 1. World Bank. PEF Operations Manual 2016 [Available from: 7 8 215 http://pubdocs.worldbank.org/en/168391509719305386/PEF-Operations-Manual-September-13- 9 216 2017.pdf. 10 11 217 2. World Bank. Operations Manual: Pandemic Emergency Financing Facility. 2017. 12 218 3. WorldConfidential: Bank. Pandemic Emergency Financing For Facility Review Framework. 2017. Only 13 14 219 4. International Development Association. Borrowing Countries 2019 [Available from: 15 220 http://ida.worldbank.org/about/borrowing-countries. 16 17 221 5. Moon S, Sridhar D, Pate MA, Jha AK, Clinton C, Delaunay S, et al. Will Ebola change the game? 18 19 222 Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent 20 223 Panel on the Global Response to Ebola. The Lancet. 2015;386(10009):2204-21. 21 22 224 6. Heymann DL, Chen L, Takemi K, Fidler DP, Tappero JW, Thomas MJ, et al. Global health 23 225 security: the wider lessons from the west African Ebola virus disease epidemic. The Lancet. 24 25 226 2015;385(9980):1884-901. 26 27 227 7. World Health Organization. Report of the Ebola Interim Assessment Panel Geneva: WHO 2015. 28 228 8. World Health Organization. Report of the Review Committee on the Functioning of the 29 30 229 International Health Regulations (2005) in relation to the pandemic (H1N1) 2009. Geneva; 2011. 31 230 9. Gostin LO, Friedman EA. Ebola: a crisis in global health leadership. The Lancet. 32 33 231 2014;384(9951):1323-5. 34 232 10. Boseley S. Escalation of Ebola crisis could have been avoided, says World Bank president. The 35 36 233 Guardian. 2016. 37 38 234 11. World Bank. Pandemic Emergency Financing Facility: Frequently Asked Questions 2017 39 235 [Available from: http://www.worldbank.org/en/topic/pandemics/brief/pandemic-emergency- 40 41 236 facility-frequently-asked-questions. 42 237 12. World Health Organization. Global Capacities Alert and Response. IHR (2005) Monitoring and 43 44 238 Evaluation framework. Joint External Evaluation tool (JEE tool) 2016 [ 45 46 239 13. Nkengasong J, Djoudalbaye B, Maiyegun O. A new public health order for Africa's health security. 47 240 The Lancet Global Health. 2017;5(11):e1064-e5. 48 49 241 14. World Bank. Annual Report 2018. 2018. 50 242 15. Munich Re. Press release: Munich Re is a partner to PEF, a World Bank initiative to contain 51 52 243 pandemic outbreaks in developing countries 2017 [Available from: 53 244 https://www.munichre.com/en/media-relations/publications/press-releases/2017/2017-06-29- 54 55 245 press-release/index.html. 56 57 246 16. Pandemic Emergency Financing Facility (PEF) Framework (2016). 58 247 17. Tyson J. Inside the World Bank's Pandemic Emergency Facility. Devex 2016 23rd May 2016. 59 60

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1 2 3 248 18. Stein F, Sridhar D. Health as a "global public good": creating a market for pandemic risk. BMJ. 4 5 249 2017;358:j3397. 6 250 19. Stein F, Sridhar D. The financialisation of global health. Wellcome Open Res. 2018;3(17):17. 7 8 251 20. Allen K. World Bank’s ‘pandemic bonds’ under scrutiny after failing to pay out on Ebola. Financial 9 10 252 Times 2019 Feburary 21st 2019. 11 253 21. Igoe M. World Bank pandemic facility 'an embarrassing mistake,' says former chief economist. 12 Confidential: For Review Only 13 254 Devex. 2019 12th April 2019. 14 255 22. foreignpolicy.com. The World Bank Has the Money to Fight Ebola but Won’t Use It 2019 15 16 256 [Available from: https://foreignpolicy.com/2019/07/22/the-world-bank-has-the-money-to-fight- 17 257 ebola-but-wont-use-it/ 18 19 258 23. World Bank. World Bank Mobilizes US$300 Million to Finance the Ebola Response in Democratic 20 21 259 Republic of Congo 2019 [Available from: https://www.worldbank.org/en/news/press- 22 260 release/2019/07/24/world-bank-mobilizes-us300-million-to-finance-the-ebola-response-in- 23 24 261 democratic-republic-of-congo. 25 262 24. Selection of Expert Risk Modeling Engagement for PEF 2.0 [press release]. 2019. 26 27 263 25. World Health Organization. Health Emergencies Programme 2016 [Available from: 28 264 https://www.who.int/westernpacific/about/how-we-work/programmes/who-health-emergencies- 29 30 265 programme. 31 32 266 26. World Health Organization. Contingency Fund for Emergencies 2017 [Available from: 33 267 https://www.who.int/emergencies/funding/contingency-fund/CFE_Impact_2017.pdf. 34 35 268 27. World Health Organization. Contingency Fund for Emergencies (CFE) Geneva2017 [Available 36 269 from: http://origin.who.int/about/who_reform/emergency-capacities/contingency-fund/en/. 37 38 270 28. World Health Organization. 2014 Ebola virus disease outbreak and follow-up to the special session 39 40 271 of the Executive Board on Ebola: options for a contingency fund to support WHO’s emergency 41 272 response capacity. Report by the Director-General. 2015. 42 43 273 29. World Health Organization. Contingency Fund for Emergencies - 2018 annual report. 2019. 44 274 30. Organization WH. Contingency Fund for Emergencies (CFE) contributions and allocations 2019 45 46 275 [Available from: https://www.who.int/emergencies/funding/contingency-fund/allocations/en/. 47 276 31. Amos V. UN OCHA. Tsunami: Ten years on, what have we learned? 2014. 48 49 277 32. Resolution adopted by the General Assembly on 15 December 2005: Strengthening of the 50 51 278 coordination of emergency humanitarian assistance of the United Nations (2006). 52 279 33. UN CERF. About CERF - Invest in Humanity. 2019. 53 54 280 34. World Bank. PEF Operational Brief. 2019. 55 281 35. World Bank. Pandemic Emergency Financing Facility: Financial Report (December 2018). 2019. 56 57 282 36. Ebola Escalated Response: US$80 Million Commitment to the Democratic Republic of the Congo 58 59 283 [press release]. 2019. 60

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1 2 3 284 37. World Bank. Statement: The Pandemic Emergency Financing Facility (PEF) released an additional 4 5 285 $10 million for Ebola response activities in the Democratic Republic of Congo 2019 [Available 6 286 from: https://www.worldbank.org/en/news/statement/2019/05/09/the-pandemic-emergency- 7 8 287 financing-facility-pef-released-an-additional-10-million-for-ebola-response-activities-in-the- 9 10 288 democratic-republic-of-congo. 11 289 38. Kim JY. World Bank Group’s Pandemic Emergency Financing Facility (PEF) Makes First $12 12 Confidential: For Review Only 13 290 million Commitment to Bridge Financing Gap For Ebola Response in DRC. 2018. 14 291 39. UN CERF. Total CERF Funding by Sector - Summary (2006 - 2019) 2019 [Available from: 15 16 292 https://cerf.un.org/what-we-do/allocation-by-sector/total_to_date. 17 293 40. WHO Regional Office for Africa. DRC: Government announces end of Ebola outbreak. 2007. 18 19 294 41. World Health Organization. Ebola virus disease - key facts 2018 [Available from: 20 21 295 https://www.who.int/en/news-room/fact-sheets/detail/ebola-virus-disease. 22 296 42. World Health Organization. Ebola data and statistics, situation summary. 2016. 23 24 297 43. Maganga GD, Kapetshi J, Berthet N, Kebela Ilunga B, Kabange F, Mbala Kingebeni P, et al. Ebola 25 298 virus disease in the Democratic Republic of Congo. N Engl J Med. 2014;371(22):2083-91. 26 27 299 44. World Health Organization. Ebola Virus Disease: Democratic Republic of the Congo, External 28 300 Situation Report 26. 2017. 29 30 301 45. Ebola outbreak in DRC ends: WHO calls for international efforts to stop other deadly outbreaks in 31 32 302 the country [press release]. 2018. 33 303 46. World Health Organization. Disease Outbreak News: Ebola virus disease – Democratic Republic 34 35 304 of the Congo. 2019. 36 305 47. World Health Organization. WHO supports containment of rare virus on Uganda-Kenya border. 37 38 306 2017. 39 40 307 48. European Commission's Directorate-General for European Civil Protection and Humanitarian Aid 41 308 Operations. Uganda – Marburg Virus Disease (DG ECHO, Ministry of Health) (ECHO Daily Flash 42 43 309 of 6 November 2017). 2017. 44 310 49. World Health Organization. Uganda ends Marburg virus disease outbreak. 2017. 45 46 311 50. World Health Organization. Disease Outbreak News: Lassa Fever – Nigeria. 2016. 47 312 51. World Health Organization. Disease Outbreak News: Lassa Fever – Benin. 2016. 48 49 313 52. World Health Organization. Disease Outbreak News: Lassa Fever – Liberia. 2016. 50 51 314 53. World Health Organization. Lassa virus - Epidemic focus. 2019. 52 315 54. Nigerian Centre for Disease Control. Situation Report: 2018 Lassa Fever Outbreak in Nigeria. 53 54 316 2018. 55 317 55. World Health Organization. Nigeria's Lassa fever outbreak contained, but continued vigilance 56 57 318 needed. 2018. 58 59 319 56. Nigerian Centre for Disease Control. Situation Report: 2019 Lassa Fever Outbreak Situation 60 320 Report - July 14th. 2019.

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1 2 3 321 57. World Health Organization. Disease Outbreak News: Rift Valley Fever – Kenya, Somalia, United 4 5 322 Republic of Tanzania. 2007. 6 323 58. World Health Organization. Disease Outbreak News: Rift Valley Fever – Sudan - update 5. 2008. 7 8 324 59. World Health Organization. Disease Outbreak News: Rift Valley Fever – Sudan. 2007. 9 10 325 60. UN CERF. 2007 Annual Report of the Humanitarian Coordinator on the use of CERF Grants to 11 326 Sudan 2008. 12 Confidential: For Review Only 13 327 61. UN Country Team in Madagascar. Madagascar: Rift Valley Fever - OCHA Situation Report No. 14 328 1. 2008. 15 16 329 62. Faye O, Ba H, Ba Y, Freire CC, Faye O, Ndiaye O, et al. Reemergence of Rift Valley fever, 17 330 Mauritania, 2010. Emerg Infect Dis. 2014;20(2):300-3. 18 19 331 63. World Health Organization. Disease Outbreak News: Rift Valley fever – Mauritania. 2012. 20 21 332 64. World Health Organization. Disease Outbreak News: Rift Valley fever – Niger. 2016. 22 333 65. Organization WH. Disease Outbreak News: Rift Valley Fever – Niger. 2016. 23 24 334 66. World Health Organization; Government of the Republic of South Sudan. South Sudan: Integrated 25 335 Disease Surveillance and Response (IDSR) - Epidemiological Update, Week 04 (January 21 - 27, 26 27 336 2019). 2019. 28 337 67. World Health Organization. Situation Report: Emergency type Influenza Outbreak. 2017. 29 30 338 68. The Pandemic Emergency Financing Facility approves up to US$ 20 million contribution to Ebola 31 32 339 response in the Democratic Republic of Congo [press release]. 2019. 33 340 69. World Health Organization - Health Emergency Programme. Weekly bulletin on outbreaks and 34 35 341 other emergencies - Week 48: 24 - 30 November 2018 2018 [Available from: 36 342 https://apps.who.int/iris/bitstream/handle/10665/276298/OEW48-2430112018.pdf. 37 38 343 70. World Health Organization. Disease Outbreak News: Ebola virus disease – Republic of Uganda. 39 40 344 2019. 41 345 71. MacIntyre CR, Bui CM. Pandemics, public health emergencies and antimicrobial resistance - 42 43 346 putting the threat in an epidemiologic and risk analysis context. Archives of public health = 44 347 Archives belges de sante publique. 2017;75:54. 45 46 348 72. Fidler DP, Gostin LO. The new International Health Regulations: an historic development for 47 349 international law and public health. The Journal of Law, Medicine & Ethics. 2006;34(1):85-94. 48 49 350 73. Eccleston-Turner M, Kamradt-Scott A. Transparency in IHR emergency committee decision 50 51 351 making: the case for reform. BMJ Global Health. 2019;4(2):e001618. 52 352 74. World Health Organization. Financing the WHO Contingency Fund for Emergencies. 2016. 53 54 353 55 56 57 58 59 60

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1 2 3 Supplementary files for online publication 4 5 6 APPENDIX 1 7 8 9 Table 1 – CFE fund allocations since its launch until June 30th, 2019. Disease outbreaks due 10 11 to PEF-eligible pathogens are highlighted in orange; disease outbreak preparedness 12 Confidential: For Review Only 13 measures, kept in italic, were not considered in the final analysis. 14 15 16 Amount of Date Affected Country Emergency Type of Emergency 17 allocated funds 18 Jun 2019 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 50,000 19 20 Jun 2019 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 2,000,000 21 Jun 2019 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 5,000,000 22 Jun 2019 Pakistan HIV outbreak Disease Outbreak $ 5,000,000 23 24 May 2019 Iran Flooding Natural Disaster $ 498,025 25 Tropical Cyclone Apr 2019 Comoros Natural Disaster $ 50,000 26 Kenneth 27 Apr 2019 Libya Conflict Complex Emergency $ 500,000 28 29 Apr 2019 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 15,000,000 30 Apr 2019 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 8,000,000 31 IDP Response 32 Apr 2019 Ethiopia Complex Emergency $ 484,942 33 (Gedeo-West Guji) 34 Mar 2019 Iran Flooding Natural Disaster $ 223,971 35 Mar 2019 Mozambique Tropical Cyclone Idai Natural Disaster $ 4,000,000 36 Mar 2019 Mozambique Tropical Cyclone Idai Natural Disaster $ 50,000 37 38 Feb 2019 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 10,000,000 39 Feb 2019 Nigeria Lassa fever Disease Outbreak $ 400,000 40 Feb 2019 Pakistan Nutrition Emergency Complex Emergency $ 466,000 41 42 Jan 2019 Madagascar Measles Disease Outbreak $ 180,000 43 Jan 2019 Sudan Rift Valley Fever Disease Outbreak $ 300,000 44 Jan 2019 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 10,500,000 45 46 Nov 2018 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 680,000 47 Nov 2018 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 6,000,000 48 Nov 2018 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 100,000 49 Nov 2018 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 3,500,000 50 51 Oct 2018 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 200,000 52 Oct 2018 Uganda Ebola (Preparedness) Disease Outbreak $ 500,000 53 Oct 2018 Philippines Typhoon Mangkhut Natural Disaster $ 75,000 54 55 Sep 2018 Libya Measles Disease Outbreak $ 500,000 56 Sep 2018 Niger Cholera Disease Outbreak $ 689,872 57 Sep 2018 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 4,000,000 58 Sep 2018 Zimbabwe Cholera Disease Outbreak $ 1,100,000 59 60 Sep 2018 Cameroon Cholera Disease Outbreak $ 150,000 Aug 2018 Namibia Hepatitis E Disease Outbreak $ 195,000

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1 2 3 Aug 2018 Democratic Republic of Congo Cholera Disease Outbreak $ 476,629 4 Sep 2018 Lao People's Democratic Republic Flooding Natural Disaster $ 50,000 5 6 Aug 2018 Lao People's Democratic Republic Flooding Natural Disaster $ 50,000 7 Aug 2018 Democratic Republic of Congo Ebola (North Kivu) Disease Outbreak $ 2,000,000 8 Jul 2018 Venezuela Regional Crisis Complex Emergency $ 1,000,000 9 Jul 2018 Liberia Flooding Natural Disaster $ 50,000 10 11 Jul 2018 Nigeria Malaria Disease Outbreak $ 1,241,000 12 Jul 2018Confidential:Nigeria For ChoIeraReviewDisease Only Outbreak $ 100,000 13 Jul 2018 Kenya Rift Valley Fever Disease Outbreak $ 200,000 14 15 Jun 2018 Democratic Republic of Congo Ebola (Équateur) Disease Outbreak $ 1,622,534 16 Jun 2018 Tanzania Cholera Disease Outbreak $ 162,000 17 May 2018 Regional Africa Ebola (Preparedness) Disease Outbreak $ 1,550,000 18 May 2018 Democratic Republic of Congo Ebola (Équateur) Disease Outbreak $ 3,000,000 19 20 May 2018 Nigeria Malaria Disease Outbreak $ 1,100,000 21 May 2018 Somalia Flooding Natural Disaster $ 489,500 22 Apr 2018 Venezuela Regional Crisis Complex Emergency $ 50,000 23 24 Mar 2018 South Africa Listeriosis Disease Outbreak $ 380,791 25 Mar 2018 Uganda Cholera Disease Outbreak $ 225,000 26 Mar 2018 Papua New Guinea Earthquake Natural Disaster $ 135,000 27 28 Mar 2018 Mozambique Cholera Disease Outbreak $ 100,000 29 Feb 2018 Regional Pacific Cyclone Gita Natural Disaster $ 108,385 30 Feb 2018 Bangladesh Rohingya Crisis Complex Emergency $ 2,000,000 31 Feb 2018 Nigeria Lassa fever Disease Outbreak $ 950,459 32 33 Jan 2018 Nigeria Botulism Disease Outbreak $ 60,000 34 Jan 2018 South Africa Listeriosis Disease Outbreak $ 15,000 35 Cholera 36 Jan 2018 Republic of Congo Disease Outbreak $ 50,000 37 (Preparedness) 38 Jan 2018 Democratic Republic of Congo Cholera Disease Outbreak $ 1,250,000 39 Jan 2018 Angola Cholera Disease Outbreak $ 40,000 40 Jan 2018 Bangladesh Rohingya Crisis Complex Emergency $ 1,500,000 41 42 Nov 2017 Democratic Republic of Congo Conflict Complex Emergency $ 500,000 43 Marburg Virus 44 Oct 2017 Kenya Disease Outbreak $ 123,000 (Preparedness) 45 46 Oct 2017 Uganda Marburg Virus Disease Outbreak $ 500,000 47 Sep 2017 Madagascar Pneumonic Plague Disease Outbreak $ 1,451,248 48 Sep 2017 Bangladesh Rohingya Crisis Complex Emergency $ 1,500,000 49 50 Sep 2017 Syria Conflict Complex Emergency $ 292,000 51 Sep 2017 Pakistan Dengue Fever Disease Outbreak $ 282,159 52 Aug 2017 Sierra Leone Mudslides Natural Disaster $ 107,000 53 Aug 2017 Central African Republic Conflict Complex Emergency $ 360,867 54 55 Jul 2017 Nigeria Malaria Disease Outbreak $ 296,000 56 Jul 2017 Kenya Cholera Disease Outbreak $ 300,000 57 Jul 2017 Burundi Malaria Disease Outbreak $ 328,830 58 59 Jul 2017 Iraq Conflict Complex Emergency $ 1,500,000 60 Jun 2017 Sudan Suspected cholera Disease Outbreak $ 500,000 Jun 2017 Philippines Conflict (Marawi) Complex Emergency $ 48,760

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1 2 3 Jun 2017 Iraq Conflict Complex Emergency $ 1,500,000 4 Jun 2017 Democratic Republic of Congo Cholera Disease Outbreak $ 280,000 5 6 May 2017 Vanuatu Cyclone Donna Natural Disaster $ 80,000 7 May 2017 Somalia Famine response Complex Emergency $ 1,442,339 8 Famine 9 May 2017 Regional Africa Complex Emergency $ 995,000 (Horn of Africa) 10 11 May 2017 Occupied Palestinian Territories Conflict Complex Emergency $ 362,000 12 Apr 2017Confidential:Democratic Republic of Congo For ReviewEbola Disease Only Outbreak $ 2,000,000 13 Apr 2017 Nigeria Meningitis Disease Outbreak $ 540,400 14 15 Apr 2017 Ethiopia Suspected cholera Disease Outbreak $ 2,300,000 16 Apr 2017 Burundi Malaria Disease Outbreak $ 100,000 17 Mar 2017 South Sudan Famine response Complex Emergency $ 625,545 18 Mar 2017 Somalia Cholera Disease Outbreak $ 99,940 19 20 Mar 2017 Maldives Influenza Disease Outbreak $ 100,000 21 Feb 2017 Sao Tomé and Principe Necrotising Cellulitis Disease Outbreak $ 150,000 22 Feb 2017 Chad Hepatitis E Disease Outbreak $ 100,000 23 24 Feb 2017 Cameroon Conflict Complex Emergency $ 500,000 25 Dec 2016 Yemen Conflict Complex Emergency $ 1,000,000 26 Dec 2016 United Arab Emirates Legionnaires' Disease Disease Outbreak $ 20,000 27 28 Oct 2016 Yemen Cholera Disease Outbreak $ 506,000 29 Oct 2016 Haiti Hurricane Matthew Natural Disaster $ 250,000 30 Sep 2016 Niger Rift Valley Fever Disease Outbreak $ 500,000 31 Aug 2016 Nigeria Conflict Complex Emergency $ 5,445,189 32 33 Jul 2016 Democratic Republic of Congo Cholera Disease Outbreak $ 1,839,880 34 May 2016 Uganda Yellow Fever Disease Outbreak $ 100,000 35 May 2016 Papua New Guinea El Niño Natural Disaster $ 483,000 36 37 Feb 2016 Libya Conflict Complex Emergency $ 350,000 38 Feb 2016 Global Zika Virus Disease Outbreak $ 3,600,000 39 Feb 2016 Fiji Cyclone Winston Natural Disaster $ 487,840 40 Yellow Fever 41 Feb 2016 Regional Africa Disease Outbreak $ 4,844,986 42 (Angola, DRC) 43 Nov 2015 Ethiopia El Niño Natural Disaster $ 1,082,560 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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1 2 3 APPENDIX 2 4 5 6 Table 2 – CERF rapid-response fund allocations for PEF-eligible events. Included funds from 7 8 the human health cluster, excluding others covering e.g. animal health 9 10 11 Amount of 12 Date Confidential:Affected Country ForEmergency ReviewType Only of Emergency 13 allocated funds 14 Feb 2007 Kenya Rift Valley Fever $ 756,811 07-WHO-001 15 16 Apr 2007 Tanzania Rift Valley Fever $ 271,045 07-WHO-023 17 18 Dec 2007 Sudan Rift Valley Fever $ 941,163 07-WHO-072 19 20 Mar 2008 Democratic Republic of Congo Ebola virus $ 900,004 08-WHO-020 21 Jun 2008 Madagascar Rift Valley Fever $ 149,907 08-WHO-032 22 23 Mar 2011 Mauritania Rift Valley Fever $ 389,425 11-WHO-001 24 25 Sep 2012 Democratic Republic of Congo Ebola virus $ 489,515 12-WHO-069 26 27 Dec 2012 Mauritania Rift Valley Fever $ 445,108 12-WHO-083 28 Apr 2014 Guinea Ebola virus $ 519,313 14-RR-WHO-034 29 30 Jun 2014 Sierra Leone Ebola virus $ 103,608 14-RR-WHO-040 31 32 Jul 2014 Liberia Ebola virus $ 311,200 14-RR-WHO-053 33 34 Aug 2014 Nigeria Ebola virus $ 1,063,443 14-RR-WHO-055 35 36 Oct 2014 Democratic Republic of Congo Ebola virus $ 1,419,887 14-RR-WHO-069 37 May 2016 Nigeria Lassa virus $ 399,741 16-RR-WHO-024 38 39 Jun 2016 Guinea Ebola virus $ 1,649,011 16-RR-WHO-025 40 41 May 2018 Nigeria Lassa virus $ 655,049 18-RR-WHO-016 42 43 May 2018 Democratic Republic of Congo Ebola virus $ 798,502 18-RR-WHO-019 44 Jun 2018 Kenya Rift Valley Fever $ 747,374 18-RR-WHO-020 45 46 Aug 2018 Democratic Republic of Congo Ebola virus $ 1,701,255 18-RR-WHO-029 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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1 2 3 APPENDIX 3 4 5 PEF’s insurance window pays out different amounts depending on which pathogen causes the 6 outbreak. Caps exist and limit the maximum amount paid out (Figure 1). Further, except for flu 7 8 outbreak (influenza virus), the numbers of countries affected from the outbreak and confirmed 9 10 deaths also play a pivotal role in defining how much will be paid out (Figure 2). 11 12 Figure 1.Confidential: Maximum payment amounts For through Review PEF’s insurance Only window (diameters 13 proportional) (RVFV = Rift-Valley-Fever-Virus; LFV = Lassa-Fever-Virus; CCFV = Crimean- 14 Congo-Hemorrhagic-Fever-Virus) 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Figure 2. Based on which pathogen causes the outbreak, different amounts might be paid 36 out; further, the number of IDA- and IBRD-eligible countries affected and confirmed deaths 37 contribute to the sum which will be paid out. 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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