Healthcare System & Services and Public & Social Sector Practices

Not the last pandemic:

Investing now to reimagine
public-health systems
The COVID-19 crisis reminds us how underprepared the world was to
detect and respond to emerging infectious diseases. Smart investments
of as little as $5 per person per year globally can help ensure far better
preparation for future pandemics.

by Matt Craven, Adam Sabow, Lieven Van der Veken, and Matt Wilson

© Skaman306/Getty Images

May 2021
 This article was originally published in July 2020 Correcting these weaknesses won’t be easy.
to make an economic case for investments in Government leaders remain focused on navigating
infectious-disease surveillance and preparedness. the current crisis, but making smart investments
The overall message remains as clear now as it was now can both enhance the ongoing COVID-19
a year ago: the returns from smart investments in response and strengthen public-health systems
preparedness and response are likely to be large to reduce the chance of future pandemics.
multiples of their costs. We have refined the article Investments in public health and other public goods
with three updates that build on our prior work: are sorely undervalued; investments in preventive
measures, whose success is invisible, even more so.
— We sharpened some cost estimates based Many such investments would have to be made in
on further analysis and new information that countries that cannot afford them.
has become available over the past year.
For example, the importance of genomic Nevertheless, now is the moment to act. The world
sequencing, “ever warm” vaccine manufacturing has seen repeated instances of what former World
capacity, and R&D platforms has been Bank president Jim Kim has called a cycle of “panic,
made ever clearer by the trajectory of the neglect, panic, neglect,” whereby the terror created
COVID-19 pandemic. by a disease outbreak recedes, attention shifts,
and we let our vital outbreak-fighting mechanisms
— We have included more detail on our line-item atrophy.1 The Independent Panel for Pandemic
cost estimates and a deep dive on surveillance Preparedness and Response published its findings
costing (available for download on McKinsey.com). in May 2021, describing the COVID-19 pandemic as
the 21st century’s “Chernobyl moment” and making
— We have included new cost analyses, including clear that if investment doesn’t occur now, “we will
cost per capita and the share of spend at the condemn the world to successive catastrophes.”2
global, regional, and country levels.
While some are calling the COVID-19 crisis a
The COVID-19 pandemic has exposed 100-year event, we might come to see the current
overlooked weaknesses in the world’s infectious- pandemic as a test run for a pandemic that arrives
disease-surveillance and -response capabilities— soon, with even more serious consequences.
weaknesses that have persisted in spite of the Imagine a disease that transmits as readily as
obvious harm they caused during prior outbreaks. COVID-19 but kills 25 percent of those infected
Many countries, including some thought to have and disproportionately harms children.
strong response capabilities, failed to detect or
respond decisively to the early signs of SARS-CoV-2 The business case for strengthening the world’s
outbreaks. That meant they started to fight the virus’s pandemic-response capacity at the global, national,
spread after transmission was well established. and local levels is compelling. The economic
Once they did mobilize, some nations struggled to disruption caused by the COVID-19 pandemic could
ramp up public communications, testing, contact cost more than $16 trillion3—many times more than
tracing, critical-care capacity, and other systems the projected cost of preventing future pandemics.
for containing infectious diseases. Ill-defined or We have estimated that spending approximately
overlapping roles at various levels of government $85 billion to $130 billion over the next two years
or between the public and private sectors resulted and approximately $20 billion to $50 billion annually
in further setbacks. And the challenges, including after that could substantially reduce the likelihood
difficulties with vaccine rollouts, lingering vaccine of future pandemics (Exhibit 1). This equates to an
hesitancy, and difficulties in managing second and average of about $5 per person per year for the
third surges, have continued as the pandemic has world’s population. Approximately 30 percent of this
entered its second year. spend would take place at the global and regional

1
Sophie Edwards, “Pandemic response a cycle of ‘panic and neglect,’ says World Bank president,” Devex, April 5, 2017, devex.com.
2
COVID-19: Make it the last pandemic, Independent Panel for Pandemic Preparedness and Response, May 2021, theindependentpanel.org.
3
“Crushing coronavirus uncertainty: The big ‘unlock’ for our economies,” May 2020, McKinsey.com.

2 Not the last pandemic: Investing now to reimagine public-health systems

Web <2020>
<COVID-LastPandemic>
Exhibit
Exhibit <1>1 of <10>

Assuming
Assuming aa COVID-19-scale
COVID-19-scale epidemic
epidemic isis aa 50-year
50-year event,
event,the
thereturn
returnon
on
preparedness investmentisisclear,
preparedness investment clear,even
evenififititonly
onlypartly
partly mitigates
mitigates the
thedamage.
damage.

Estimated costs, $ billion

Epidemic preparedness Minimum economic loss from COVID-19 pandemic

We estimate that an initial

2-year investment of ...

~85–130

... followed by annual

maintenance investments of ...

~20–50
~16,000

... over 10 years could

dramatically reduce the
risks of future outbreaks
~285–430

$5 per person per year could substantially

reduce the likelihood of future pandemics.

levels, and about 70 percent would take place strengthening agenda. Cost estimates will continue
at the country level (8 percent in high-income to evolve as new information emerges. We hope the
countries and 62 percent in middle- and low- overall message is clear: infectious diseases will
income countries). continue to emerge, and a vigorous program
of capacity building will prepare the world to
These are high-level estimates with wide error bars. respond better than we have so far to the
They include pandemic-specific strengthening COVID-19 pandemic.
of health systems but not the full health-system-

Not the last pandemic: Investing now to reimagine public-health systems 3

 In this article, we describe and estimate the cost of From ‘break glass in case of emergency’
five areas that such a program might cover: building response systems to always-on systems
“always on” response systems, strengthening and partnerships that can scale rapidly
mechanisms for detecting infectious diseases, during pandemics
integrating efforts to prevent outbreaks, developing Responding to outbreaks of infectious diseases
healthcare systems that can handle surges while involves different norms, processes, and structures
maintaining the provision of essential services, and from those used when delivering regular healthcare
accelerating R&D for diagnostics, therapeutics, and services. Decision making needs to be streamlined;
vaccines (Exhibit 2). Details of the costing analysis leaders must make no-regrets decisions in the face
are available for download on McKinsey.com. of uncertainty. But much of our present epidemic-
management system goes unused until outbreaks
We estimate that these five pillars of preparedness happen, in a “break glass in case of emergency”
can be achieved at a total cost of $357 billion over model. It is difficult to switch on those latent
10 years (Exhibit 3). response capabilities suddenly and unrealistic to
expect them to work right away.

Web <2020>
<COVID-LastPandemic>
Exhibit <2 > of <10>
Exhibit 2
Five shifts in healthcare systems can help reduce the chance of future
Five shifts in healthcare systems can help reduce the chance of future pandemics.
pandemics.
From To Rationale
“Break glass in case “Always on” systems and Outbreak response is most effective
of emergency” partnerships that can scale when it uses regularly applied
response systems rapidly during epidemics mechanisms

Uneven disease Strengthened global, national, Effective detection capacity is

surveillance and local mechanisms for needed at all levels
detecting infectious diseases

Waiting for Integrated epidemic- Targeted interventions can reduce

outbreaks prevention agenda pandemic risk

Scramble for Systems ready to surge while Epidemic management requires ability
healthcare capacity maintaining essential services to divert healthcare capacity quickly
without lessening core services

Underinvestment in Renaissance in Response to COVID-19 pandemic has

R&D for emerging infectious-disease R&D shown speed possible in moving against
infectious diseases infectious diseases when motivated

4 Not the last pandemic: Investing now to reimagine public-health systems

 Web <2020>
<COVID-LastPandemic>
Exhibit 3 of <10>
Exhibit <3 >

Five
Five pillars
pillarsof
ofpreparedness
preparedness can be built
built for
for $357 billion, in
$357 billion, inour
ourestimate.
estimate.

Epidemic-preparedness costs over 10 years by pillar and initiative,

$ billion (midpoint of estimated range ±20%)

Border health  Supply-chain preparation Emergency

(global stockpile) operations  56
“Always on” 4 14 23 15
systems
Communication and messaging  Regular simulations and other cross-sector exercises <1

Pathogen surveillance/sequencing Notifiable- Population-

disease and representative
IDSR¹-like surveillance 96
Disease surveillance foundation
surveillance 3 48 4 19 19 4

US National Public Health Institutes Specialized surveillance programs  Data integration

Global Limited human- Contained antimicrobial

immunization wildlife interactions resistance 88
Prevention
agenda 15 34 2 37

Mapped global virome

Closed pandemic-specific gaps

54
54
Healthcare
capacity
Assessed gaps in healthcare systems 1

Scaled vaccine-manufacturing capacity Closed known

vaccine/therapeutic 62
6 42 gaps  14
R&D
New antiviral, antibody, and vaccine platforms

Note: Figures may not sum to listed totals, because of rounding.

¹Integrated Disease Surveillance and Response (framework from US Centers for Disease Control and Prevention).

A better system might be founded on a principle Both the public and private sectors have played
of active preparedness and constructed out of major roles in the response to the COVID-19 crisis,
mechanisms that can be consistently used and but collaboration has not always been as smooth
fine-tuned so they are ready to go when outbreaks as it might have been if collaboration channels had
start (Exhibit 4). We see several means of instituting been preestablished. There have been notable
such an always-on system. One is to use the exceptions, including collaborations to increase
same mechanisms that we need for fast-moving access to ventilators.4
outbreaks (such as COVID-19) to address slow-
moving outbreaks (such as HIV and tuberculosis) The principle of active preparedness might also
and antimicrobial-resistant pathogens. Case lead governments to strengthen other aspects of
investigation and contact tracing are skills familiar pandemic response. For example, the past year
to specialists who manage HIV and tuberculosis. But has highlighted gaps in the manufacturing and
few areas have deployed their experts effectively in stockpiling of personal protective equipment, the
responding to the COVID-19 pandemic. sharing of information with the public through

4
“Special bulletin: Public-private effort launched to help distribute existing ventilators to high-need areas of the U.S.,” American Hospital
Association, April 14, 2020, aha.org.

Not the last pandemic: Investing now to reimagine public-health systems 5

 Web <2020>
<COVID-LastPandemic>
Exhibit
Exhibit <4>4of <10> also encourage the public to take part in preparing
for natural disasters. The government’s efforts to
Building‘always
Building ‘alwayson’
on’epidemic-
epidemic-
heighten public awareness of the threat posed by
management systemsmeans
management systems meansthey
theyare
are
infectious diseases and to engage the public in the
ready as soon as outbreaks start.
ready as soon as outbreaks start. necessary response measures aided the country’s
successful always-on early-response systems to the
Summary of estimated epidemic-preparedness
initiatives and investments, $ billion COVID-19 pandemic.

To build always-on systems around the world, an

up-front two-year investment of $15 billion to
$25 billion and ensuing annual investments of
$3 billion to $6 billion (for a ten-year total of
45–70 $45 billion to $70 billion) would go into the
15–25 following areas:
3–6
— supporting epidemiological-response capacity
First 2 years Annual after 10-year total
with emergency operations centers (EOCs) that
● Support epidemiological-response capacity
function during all types of major crises

● Maintain robust medical-supply stockpiles and emer- — maintaining robust stockpiles of medical
gency supply-chain mechanisms
supplies and emergency supply-chain
● Conduct regular outbreak simulations and cross-sector mechanisms at the subnational, national, or
preparedness activities regional levels (depending on the setting)
● Improve communications and messaging
— conducting regular outbreak simulations and
● Implement effective public-health responses at points other cross-sectoral preparedness activities
of entry

Source: Gavi, the Vaccine Alliance; Georgetown University; Global Virome Project; — strengthening communications and messaging
National Academy of Medicine; Nature; The Lancet; US Centers for Disease
Control and Prevention; World Bank; World Health Organization; World through established risk-communication
Organisation for Animal Health
systems, internal and partner communication
and coordination, public communication
and engagement with affected communities,
dynamic listening, and rumor management

— ensuring national border health by establishing

risk-communication systems, and the different routine capabilities and effective public-health
stakeholders’ capability of maintaining border responses at points of entry
health at points of entry. Predefining response roles
for different stakeholders at the global, national,
and local levels is also an important part of active From uneven disease surveillance
preparedness, since well-defined roles prevent to strengthened global, national,
delays and confusion when an outbreak occurs. and local mechanisms to detect
infectious diseases
Last, governments can keep outbreak preparedness Retrospective analysis shows that SARS-CoV-2 was
on the public agenda. Iceland offers an example circulating in a number of countries well before it
of how to do that effectively. Since 2004, the was first recognized. Failures to detect the disease
country has been testing and revising its plans for meant that chains of transmission had been firmly
responding to global pandemics. Authorities there established before countries began to respond.

6 Not the last pandemic: Investing now to reimagine public-health systems

 Such problems occur in part because disease to the COVID-19 pandemic in many parts of the
surveillance is often based on old-fashioned world (Exhibit 5). The past year has also highlighted
practices: frontline health workers noticing the critical role that genomic sequencing can play in
unusual patterns of symptoms and reporting them the management of outbreaks.
through analog channels. Most countries are far
from realizing the potential of data integration Stopping individual chains of transmission requires
and advanced analytics to supplement traditional strong detection and response capabilities at
event-based surveillance in identifying infectious the national and local levels. Those capabilities
disease risks so that authorities can initiate efforts are important to have in place across the globe,
to stop individual chains of transmission. Data especially in parts of the world where frequent
fragmentation has hindered the efforts to respond human–wildlife interactions make zoonotic events
(transmission of pathogens from animals to people)
more likely. Many developing countries will need
external funding and support to build up their
Web <2020> disease-surveillance systems. Donor countries
<COVID-LastPandemic>
Exhibit
Exhibit <5>5of <10> might think of their investments in those systems as
investments in their own safety.
Strong disease-surveillance
Strong disease-surveillance
mechanisms help stop
mechanisms help stopchains
chainsof
of Recognizing that one country’s infectious-disease
transmission sooner.
transmission sooner. threat is a threat to all nations—a lesson reinforced
by outbreaks of SARS in Toronto, cholera in
Summary of estimated epidemic-preparedness Haiti, MERS in South Korea, and Zika across the
initiatives and investments, $ billion
Americas—previous generations created the
International Health Regulations (IHR) to promote
cooperation and coordination on outbreak response.
However, compliance with the IHR has been
imperfect because countries may be reluctant to
75–115 suffer the economic consequences of admitting to
a major outbreak. Weak cooperation efforts were
25–40
6–10 identified as a factor in the slow initial response to
the West Africa Ebola outbreak. As the COVID-19
First 2 years Annual after 10-year total crisis continues, leaders are finding reasons to
renew their commitments to global and regional
Close gaps in foundational surveillance
mechanisms for coordinating outbreak responses—
●

● Build and maintain high-quality outbreak-investigation for example, through the proposed new international
capacity pandemic treaty, currently under discussion.5
● Increase IDSR¹-like surveillance of notifiable diseases
Such an agenda might include closing gaps
● Develop strong pathogen surveillance in population-representative foundational
surveillance; strengthening notifiable disease,
● Support serosurveillance
lab-based, and pathogen surveillance; and
● Strengthen data integration and analysis improving data integration and the use of data.
An investment program of $25 billion to $40 billion
¹Integrated Disease Surveillance and Response (framework from US Centers for
Disease Control and Prevention). for the first two years and $6 billion to $10 billion
Source: Gavi, the Vaccine Alliance; Georgetown University; Global Virome Project;
National Academy of Medicine; Nature; The Lancet; US Centers for Disease per year thereafter (for a ten-year total of $75 billion
Control and Prevention; World Bank; World Health Organization; World
Organisation for Animal Health to $115 billion) would pay for the following:

5
“Global leaders unite in urgent call for international pandemic treaty,” WHO, March 30, 2021, who.int.

Not the last pandemic: Investing now to reimagine public-health systems 7

 — closing the gaps in foundational surveillance, — developing strong pathogen surveillance,
such as through civil-registration and vital including through genomic sequencing
statistics, sample registration systems, and
mortality surveillance — supporting serosurveillance and vaccine-
effectiveness monitoring
— building and maintaining high-quality,
flexible outbreak-investigation capacity in — strengthening data integration and analysis,
all geographies: most countries have a field- such as by US National Public Health Institutes
epidemiology-training program of some kind,
but many of them are underfunded and place
their graduates onto uncertain career pathways; From waiting for outbreaks to an
strengthening such programs is likely to be integrated epidemic-prevention agenda
one of the most effective investments that a While we cannot prevent all epidemics, we can use
country can make in developing its outbreak- all the tools in our arsenal to prevent those we can.
investigation capacity Four approaches to doing so stand out: reducing
the risk of zoonotic events by discovering unknown
— increasing the use of notifiable disease viral threats, reducing the risk of zoonotic events
surveillance, such as the US Centers for Disease by limiting human and wildlife interactions, limiting
Control and Prevention’s Integrated Disease antimicrobial resistance (AMR), and administering
Surveillance and Response framework vaccines more widely (Exhibit 6).

Zoonotic events, in which infectious diseases make

Web <2020>
<COVID-LastPandemic>
the jump from an animal to a human, touched off
Exhibit
Exhibit <6>6of <10> some of the most dangerous recent epidemics,
including of COVID-19, Ebola, MERS, and SARS.
Outbreak
Outbreak prevention
prevention calls
calls for
for new
new
Zoonosis can’t be eliminated, but their occurrence
approaches
approaches toto zoonosis,
zoonosis,antimicrobial
antimicrobial
can be reduced. Areas with high biodiversity
resistance, and immunization.
resistance, and immunization. and places where humans frequently encounter
wildlife present the greatest risk of zoonotic
Summary of estimated epidemic-preparedness
initiatives and investments, $ billion events and therefore require special attention to
and investment in research. Another root cause
is ecosystem degradation, which makes zoonotic
events more likely by increasing interactions
between humans and wildlife. Scientists have
estimated that a large portion of zoonotic-disease
70–105 outbreaks can be linked to changes in agriculture,
land use, and wildlife hunting over the past 80 years.
14–21
7–11 Economic incentives, legal changes, and public
education can lessen contact between humans and
First 2 years Annual after 10-year total wildlife and help protect forests and wilderness
areas, thereby decreasing the likelihood of zoonosis.
● Reduce human–wildlife interactions
There is also much more to learn about the threats
● Discover unknown zoonotic viral threats, including map- we face through wider mapping of the viruses that
ping global virome exist in animal populations.
● Limit antimicrobial resistance
Limiting AMR—the evolution of pathogens to be
● Close the global immunization gap less susceptible to antimicrobial agents—is another
important way to prevent epidemics. AMR is a
Source: Gavi, the Vaccine Alliance; Georgetown University; Global Virome Project;
National Academy of Medicine; Nature; The Lancet; US Centers for Disease public-health crisis to be managed in its own right.
Control and Prevention; World Bank; World Health Organization; World
Organisation for Animal Health It is also a potential accelerant of future outbreaks:

8 Not the last pandemic: Investing now to reimagine public-health systems

 as pathogens become resistant, diseases that coverage of all of the vaccines in our arsenal would
are currently controllable can spread more widely. save millions of lives over the coming decades. It
Conveniently, managing AMR requires many of the will be especially important to jump-start immuni-
same tools and techniques that support responses zation efforts after the current pandemic with
to acute outbreaks, including surveillance, case catch-up campaigns for children who have missed
investigation, information sharing, and special scheduled vaccines.
protocols for healthcare settings. Efforts to improve
AMR management, therefore, not only strengthen The approaches we have described represent
outbreak-response capabilities but also help important steps toward preventing outbreaks. We
prevent outbreaks in the first place. estimate that it would cost approximately $14 billion
to $21 billion for two years and then $7 billion to
Finally, the unprecedented R&D effort that has been $11 billion per year thereafter (for a ten-year total of
launched to develop a vaccine against COVID-19 $70 billion to $105 billion) to limit human exposure
serves as a reminder that we are not realizing the to wild animals, map more of the global virome,
full benefit of existing vaccines. Recent outbreaks slow the spread of AMR, and close the global
of measles, for example, show that places with lower immunization gap.
vaccination rates are more susceptible to diseases
that vaccines can prevent. Achieving full global
From a scramble for healthcare
capacity to systems ready to surge
Web <2020> while maintaining essential services
<COVID-LastPandemic>
Exhibit <7>7of <10>
Exponential case growth during some phases of
Exhibit
the COVID-19 pandemic has compelled officials
Localhealthcare
Local healthcare systems
systems can
can be
be made
made in some countries to rapidly redirect much of their
ready to
ready to handle surges
surges in demand while healthcare capacity to treating patients with
still
still delivering
deliveringessential
essential services.
services. COVID-19. The current challenges in India and
elsewhere highlight the need to ensure that
Summary of estimated epidemic-preparedness healthcare systems are prepared to respond to
initiatives and investments, $ billion demand surges (Exhibit 7). Some gaps, such as the
need for ad hoc conversions of spaces to care for
patients with highly contagious diseases, have been
common across many countries. Others, such as a
lack of oxygen concentrators, have been especially
acute in low- and lower-middle-income countries.
45–65
24–38
To prepare, health systems can establish plans
2–4 detailing how capacity can be diverted to pandemic
First 3 years Annual after 10-year total management and how additional capacity can
be added quickly (for example, by converting
● Conduct assessments to highlight gaps in healthcare nonmedical facilities to temporary healthcare
systems facilities and by establishing field hospitals).
● Target strengthening of health systems to address Some places used existing plans of that type to
largest gaps respond to the COVID-19 pandemic; others created
emergency plans during the outbreak. More can
Source: Gavi, the Vaccine Alliance; Georgetown University; Global Virome Project;
National Academy of Medicine; Nature; The Lancet; US Centers for Disease be done to codify and improve such plans. While
Control and Prevention; World Bank; World Health Organization; World
Organisation for Animal Health universal healthcare is an important long-term goal,

Not the last pandemic: Investing now to reimagine public-health systems 9

 we consider only the portion of health-system- and routine services. An initial three-year outlay of
strengthening costs that are most relevant to $24 billion to $38 billion and yearly spending of
pandemic preparedness. Tools such as Service $2 billion to $4 billion thereafter (for a ten-year
Availability and Readiness Assessment (SARA) and total of $45 billion to $65 billion) would pay for the
joint external evaluations (JEEs) can help assess following actions:
overall system readiness and identify the highest-
priority needs for pandemic preparedness. — conducting relevant assessments (such as
SARA and JEEs) to highlight gaps and address
Surge-capacity plans for pandemics should account the challenges identified in scaling health-
for the need to maintain essential healthcare care capacity
services (Exhibit 8). It is becoming increasingly
clear that the secondary impacts of the COVID-19 — strengthening health systems in targeted ways
pandemic on population health are of a similar to prepare for future pandemics: while building
magnitude to those directly attributable to the resilient health systems around the world is a
disease. This is caused by crowded-out urgent-care multidecade agenda, closing the largest gaps
resources for other conditions, delayed screening in care capacity offers disproportionate benefit
and health maintenance, and increased burden on (the total cost of building high-quality, resilient
mental health.6 health systems will be far higher than the cost
of closing capacity gaps and goes beyond the
Certain investments can help prepare healthcare scope of the analysis presented in this article)
systems to handle surges while delivering essential

Web <2020>
Exhibit 8
<COVID-LastPandemic>
Exhibit <8> of <10>
To mitigate
To mitigate the
the secondary
secondary health
health effects
effectsof
ofpublic-health
public-healthcrises,
crises,health
healthsystems
systems
need to plan for surges and continuation of essential services.
need to plan for surges and continuation of essential services.
Example secondary health effects of health crises

Under-5 mortality Immunization rates Maternal mortality Deaths occurred in excess of

progress stalled during dropped after the 2010 increased across 3 West expected rates across a
Nigeria’s economic crisis earthquake in Haiti and African countries during number of states in the US
in the 1980s and 1990s subsequent cholera the 2014–16 Ebola crisis during COVID-19 crisis
outbreaks
The under-5 mortality Maternal mortality in US Centers for Disease
rate had been dropping Low baseline coverage Guinea, Liberia, and Control and Prevention
steadily prior to the crisis and temporary Sierra Leone was estimated 5–10% excess
in the 1980s and 1990s, suspension of correlated with a deaths above expected
then stalled for 15 years campaigns resulted decrease in skilled birth baseline, excluding
before resuming a in lowered DTP3 attendance and prenatal COVID-19-related deaths that
downward trajectory immunization coverage care, with additional were not fully attributable to
after the crisis and a concurrent disruptions in family the disease itself, with
diphtheria outbreak planning > 5,000 deaths in New York
City alone at peak crisis

Source: Academic articles; expert/field interviews; ministries of health; news reports; US Centers for Disease Control and Prevention; World Bank data sets; World
Health Organization

6
“There have been 7m-13m excess deaths worldwide during the pandemic,” Economist, May 15, 2021, economist.com.

10 Not the last pandemic: Investing now to reimagine public-health systems

 From underinvestment in R&D for threat posed by emerging infectious diseases. Even
emerging infectious diseases to a before the COVID-19 outbreak, the pandemic threat
renaissance posed by known pathogens such as influenza and
Humans have done more to overcome the threat by an unknown “pathogen X” was well understood.7
posed by infectious diseases in the past 100 years The pace of innovation in antibiotics is not keeping
than during the previous 10,000. The widespread pace with the increases in antimicrobial resistance.
availability of antibiotics allows us to manage most Current regulatory and incentive structures fail
bacterial infections. HIV remains a serious condition, to reward innovations that can help counteract
but it isn’t usually an immediately life-threatening emerging infectious diseases or resistant bacteria.
one for people with access to antiretroviral therapy, It is difficult for companies to project the financial
thanks to the innovations of the past 35 years. And returns from interventions for diseases that emerge
the past decade has seen remarkable progress in sporadically and may be controlled before clinical
our ability to cure hepatitis C. trials are complete (as happened during the West
Africa Ebola outbreak). That is especially true of
However, important gaps remain. Public-health interventions for diseases that mainly affect people
leaders have frequently called attention to the in low-income countries.

R&D efforts in response to the COVID-19 pandemic

have been unprecedented. Vaccine-development
Web <2020>
<COVID-LastPandemic> records have been smashed, both for time to
Exhibit <9> of <10>
Exhibit 9 market and for the number of candidates advanced
in a short period of time. The bar for vaccine
The
Theefforts
efforts behind
behind the
the COVID-19
COVID-19 development during a crisis has been raised: CEPI
response may start
response may start aa renaissance
renaissancein
in (Coalition for Epidemic Preparedness Innovations)
infectious-disease R&D.
infectious-disease R&D. has suggested that for a future pandemic, it may be
possible to develop a vaccine within 100 days.8 On a
Summary of estimated epidemic-preparedness
less positive note, the limits of what can be achieved
initiatives and investments, $ billion
through drug repurposing have become clearer. No
one expects that we will go back to the prepandemic
R&D model, but it will be important to ensure that the
product-development lessons of the pandemic are
fully internalized.
50–75
16–24 Building on the momentum created by COVID-19-
4–6 related R&D, there is potential to spark a
renaissance in infectious-disease R&D (Exhibit 9).
First 2 years Annual after 10-year total
The renaissance might focus on several necessities
that the response to the COVID-19 pandemic has
● Accelerate development of diagnostics, therapeutics,
and vaccines against known threats highlighted. One necessity is closing gaps in the tool
kit to respond to known threats, such as influenza.
● Scale vaccine-manufacturing capabilities A second is maintaining platforms that will allow us
● Invest in new vaccine, antibody, antiviral, and therapeutic to respond rapidly to newly discovered diseases (as
platforms mRNA has done for SARS-CoV-2, for example). A
third is sustaining the ability to manufacture billions
Source: Gavi, the Vaccine Alliance; Georgetown University; Global Virome Project;
National Academy of Medicine; Nature; The Lancet; US Centers for Disease of vaccine doses quickly to ensure equitable access
Control and Prevention; World Bank; World Health Organization; World
Organisation for Animal Health to the fruits of innovation.

7
“Prioritizing diseases for research and development in emergency contexts,” WHO, who.int.
8
Kate Kelland, “Vaccine ‘revolution’ could see shots for next pandemic in 100 days,” Reuters, March 10, 2021, reuters.com.

Not the last pandemic: Investing now to reimagine public-health systems 11

 Delivering such necessities will require building happening again. We estimate that an initial global
on the early success of initiatives such as CEPI investment of $85 billion to $130 billion over
to reimagine product-development pathways, the next two years ($40 billion to $65 billion per
from funding models and collaboration platforms year), followed by an investment of $20 billion to
to regulatory review and access agreements. $50 billion per year to maintain always-on systems,
Spending $16 billion to $24 billion in the first two would significantly reduce the chance of a future
years and $4 billion to $6 billion per year thereafter pandemic. Those figures, totaling $285 billion
(for a ten-year total of $50 billion to $75 billion) to $430 billion over the next decade, include
would fund these activities: spending at the global, country, and subnational
levels (Exhibit 10).
— closing gaps in vaccine and therapeutic
arsenals against known threats, including
influenza, for which effective R&D might yield
significant advances The playwright Edward Albee once said, “I find most
people spend too much time living as if they’re never
— scaling vaccine-manufacturing capabilities to going to die.”9 So it is with the global response to
produce 15 billion doses in a six-month period infectious diseases: we have spent too much time
to provide sufficient coverage to immunize the behaving as though another deadly pathogen won’t
global population emerge. Outbreaks of SARS, MERS, Ebola, and Zika
led to some investments in pandemic preparedness
— investing in the development of new vaccine, over the past 20 years, but few of them are the
antibody, antiviral, and therapeutic platforms lasting, systemic changes needed to detect, prevent,
against emerging infectious diseases and treat emerging infectious diseases. And now,
even with all of humanity’s knowledge and resources,
millions of people have been killed by a disease
Bringing it all together that was discovered less than 18 months ago. The
As we continue to respond to the COVID-19 COVID-19 pandemic won’t be the last epidemic to
pandemic, countries should make deliberate threaten the world. By taking action and funding
investments to reduce the chance of such a crisis changes now, we can better withstand the next one.

We have spent too much time behaving

as though another deadly pathogen
won’t emerge.

9
David Richards, “Edward Albee and the road not taken,” New York Times, June 16, 1991, nytimes.com.

12 Not the last pandemic: Investing now to reimagine public-health systems

Web <2020>
<COVID-LastPandemic>
Exhibit 10
Exhibit <10> of <10>

Fundingfor
Funding forepidemic
epidemic preparedness
preparedness requires
requires an
an up-front
up-front investment
investment to
toclose
close
current gaps.
Illustrative funding needed to invest in epidemic preparedness, $ billion

1 Aepidemic-preparedness
“ramp up” phase is needed to close
gaps 2 Steady-state preparedness reduces the likelihood
and average severity of future outbreaks

Ramp-up Steady state

85–130 for 2 years 20–50 annually

“Always on” 15–25

systems

Disease 25–40
surveillance
3–6
6–10
Prevention
14–21 7-11
agenda
2–4
4–6

Healthcare Year 3 Year 4 Year 5 Year 6

24–38
capacity¹

Research and
development 16–24

Year 1 Year 2

¹Initial investment in healthcare capacity takes place over 3 years.

Matt Craven, MD, is a partner in McKinsey’s Silicon Valley office; Adam Sabow is a senior partner in the Chicago office;
Lieven Van der Veken is a senior partner in the Geneva office; and Matt Wilson is a senior partner in the New York office.

The authors wish to thank Gaurav Agrawal, Xavier Azcue, Marie-Renée B-Lajoie, Zoe Fox, Erika LaCasse, and Vignesh Vetrivel
for their contributions to this article.

Designed by McKinsey Global Publishing

Copyright © 2021 McKinsey & Company. All rights reserved.

Not the last pandemic: Investing now to reimagine public-health systems 13