Global pandemic preparedness before and during COVID-19: an assessment of changes and financing

COVID-19 exposed weaknesses in health-system readiness and renewed interest in how reported preparedness changed across countries. This paper describes changes in formal preparedness capacity before and during the pandemic, presents health-expenditure and pandemic-response accounting ratios, and examines cross-country associations between reported preparedness changes, fiscal health measures, and international grants. Preparedness is proxied by country-reported International Health Regulations (IHR) monitoring scores. We combine these scores with capital and operating government health expenditure from the WHO Global Health Expenditure Database, selected respiratory-related medical imports from UN COMTRADE, and above-the-line health-sector measures from the IMF COVID-19 fiscal-response dataset. Cross-sectional ordinary least-squares models examine associations between changes in reported IHR scores, fiscal health measures, and grants; the design does not identify causal effects. The unweighted mean reported IHR score increased from 63 to 66, while the population-weighted mean increased from 76 to 78. Larger increases were observed among countries with lower initial scores and among low- and lower-middle-income groups. Health-expenditure-to-score and response-spending-to-score ratios varied widely across countries. In the cross-sectional specifications, fiscal measures and grants were positively associated with reported score changes only through interactions with below-median initial preparedness; these estimates are sensitive to specification and should not be interpreted causally. Reported formal preparedness capacity improved modestly on average, with larger observed gains among countries that began with lower scores. Because IHR scores are self-reported, the measurement instrument changed over time, and the regressions are observational, the results cannot establish that fiscal support or grants caused these changes. The findings nevertheless support continued attention to preparedness financing, transparent measurement, and the needs of countries with limited fiscal space. (1) Reported IHR scores improved modestly on average, with larger observed increases among countries with lower initial scores. (2) Broad expenditure and response-spending ratios show substantial cross-country differences in the fiscal resources recorded relative to reported preparedness; these ratios are descriptive accounting measures and should not be interpreted as the marginal cost of achieving an IHR point. (3) Fiscal health measures and grants are associated with changes in reported preparedness among countries with lower initial scores in some specifications, but the cross-sectional design does not establish causality.