Posted: OCTOBER 13, 2025
The Economics of Preparedness
How the World Bank Thinks About the Next Pandemic
The next piece I’m working on is about the major pandemics in our recent history and how these health crises pushed governments to invest in public health infrastructure.
Across history, major outbreaks have produced similar outcomes. The cholera epidemics of the 19th century led to the creation of modern urban sewer systems, the Spanish Flu resulted in the establishment of emergency hospitals, and COVID-19 prompted the fastest global vaccine rollout in history.
Yet, most of these investments came only after the damage was done. The Spanish Flu killed an estimated 50 million people worldwide – more than the total deaths of World War I – and economists estimate it reduced GDP of most countries by nearly 6% in 1919. The World Bank, meanwhile, estimates that COVID-19 caused global economic losses exceeding $10 trillion in output by 2022.
The real challenge, however, lies not in responding to pandemics but in preventing them. Prevention and preparedness are where societies save the most (both in lives and in money) by avoiding the need for costly emergency responses in the first place. However, investing in readiness is far more difficult than reacting to a crisis that’s already visible. To better understand why this is the case, and how global institutions approach the problem, I reached out to Magnus Lindelow at the World Bank.
Dr. Lindelow leads the World Bank’s Global Program for Pandemic Prevention, Preparedness, and Response where he oversees the institution’s global work on health system resilience and pandemic readiness. Over his career, he has held senior roles across Africa, East Asia, and Latin America, leading major programs on health reform, financing, and emergency preparedness and graciously accepted my request for an interview, during which I asked him the following questions:
Across history, major outbreaks have produced similar outcomes. The cholera epidemics of the 19th century led to the creation of modern urban sewer systems, the Spanish Flu resulted in the establishment of emergency hospitals, and COVID-19 prompted the fastest global vaccine rollout in history.
Yet, most of these investments came only after the damage was done. The Spanish Flu killed an estimated 50 million people worldwide – more than the total deaths of World War I – and economists estimate it reduced GDP of most countries by nearly 6% in 1919. The World Bank, meanwhile, estimates that COVID-19 caused global economic losses exceeding $10 trillion in output by 2022.
The real challenge, however, lies not in responding to pandemics but in preventing them. Prevention and preparedness are where societies save the most (both in lives and in money) by avoiding the need for costly emergency responses in the first place. However, investing in readiness is far more difficult than reacting to a crisis that’s already visible. To better understand why this is the case, and how global institutions approach the problem, I reached out to Magnus Lindelow at the World Bank.
Dr. Lindelow leads the World Bank’s Global Program for Pandemic Prevention, Preparedness, and Response where he oversees the institution’s global work on health system resilience and pandemic readiness. Over his career, he has held senior roles across Africa, East Asia, and Latin America, leading major programs on health reform, financing, and emergency preparedness and graciously accepted my request for an interview, during which I asked him the following questions:
To start, could you please tell me about your role as Global Program Lead for Pandemic Prevention, Preparedness, and Response at the World Bank?
What are your key priorities in this role?
What are your key priorities in this role?
“
Yes, the way the World Bank works, briefly, is that most of our work is to support countries with financing, but also technically. That’s done through regional units, and within regional units there are country teams that work with different country counterparts.
The global unit is, as it sounds, a global unit. It has a function that is external-facing but also deals with issues that are cross-cutting across the Bank. We also work with regional teams to support them as they assist countries. In that sense, it’s a more indirect role.
We’re a team of about 14 to 15 people in the global unit, including staff and consultants. Our priorities reflect the growing interest from countries in the pandemic preparedness agenda or, more broadly, the health emergency preparedness agenda. A major part of our focus is to support that.
There are also several internal efforts to learn from COVID and make the Bank better equipped to support countries by developing the right instruments. We do some work on that as well. In addition, there’s quite a lot of external work: collaborating with the WHO, working with the G20, and other initiatives like that.
The global unit is, as it sounds, a global unit. It has a function that is external-facing but also deals with issues that are cross-cutting across the Bank. We also work with regional teams to support them as they assist countries. In that sense, it’s a more indirect role.
We’re a team of about 14 to 15 people in the global unit, including staff and consultants. Our priorities reflect the growing interest from countries in the pandemic preparedness agenda or, more broadly, the health emergency preparedness agenda. A major part of our focus is to support that.
There are also several internal efforts to learn from COVID and make the Bank better equipped to support countries by developing the right instruments. We do some work on that as well. In addition, there’s quite a lot of external work: collaborating with the WHO, working with the G20, and other initiatives like that.
In a 2021 blog, you wrote about what pandemic preparedness requires, everything from surveillance systems to primary healthcare resilience and legal frameworks.
In your opinion, which of these components tends to be the most underinvested in, especially in developing countries?
In your opinion, which of these components tends to be the most underinvested in, especially in developing countries?
“
It’s a good question. It’s a very tricky question to answer. So, a couple of things. One, on the question of what’s most important to invest in, I think it’s important to acknowledge that strengthening preparedness isn’t just about investment.
There are a number of things that require financing and can be thought of as investments in that way. But many aspects are about governance and institutional arrangements at the country level. That’s not really a financing issue as much as it is one of institutional design and leadership.
In some respects, that kind of leadership and organization of government around a set of priorities is probably the most critical dimension of stronger preparedness. Because it’s not a one-off thing where you simply say, “This is important; we’re going to invest.” It’s complex; it’s a cross-government agenda. It involves many different ministries and levels of government, so you really need political leadership and the structure to support it.
Having said that, there are many things that do require financing. In many of the contexts we work in, the biggest challenge is probably very weak health systems. And with weak health systems, there isn’t much you can do in terms of detecting and responding to outbreaks. So, I would say investment in primary healthcare and stronger health systems is probably the biggest piece.
Some of the other areas (laboratory systems, surveillance systems, or workforce capacity for responding to crises) are also really important, but they’re smaller investments compared to the more fundamental health system weaknesses we see in many places.
There are a number of things that require financing and can be thought of as investments in that way. But many aspects are about governance and institutional arrangements at the country level. That’s not really a financing issue as much as it is one of institutional design and leadership.
In some respects, that kind of leadership and organization of government around a set of priorities is probably the most critical dimension of stronger preparedness. Because it’s not a one-off thing where you simply say, “This is important; we’re going to invest.” It’s complex; it’s a cross-government agenda. It involves many different ministries and levels of government, so you really need political leadership and the structure to support it.
Having said that, there are many things that do require financing. In many of the contexts we work in, the biggest challenge is probably very weak health systems. And with weak health systems, there isn’t much you can do in terms of detecting and responding to outbreaks. So, I would say investment in primary healthcare and stronger health systems is probably the biggest piece.
Some of the other areas (laboratory systems, surveillance systems, or workforce capacity for responding to crises) are also really important, but they’re smaller investments compared to the more fundamental health system weaknesses we see in many places.
If you were advising a developing country with limited resources, what’s the one preparedness related investment you would advise them to prioritize first?
“
I don’t think we can recommend one thing over another. It’s really a package deal.
The one thing you can’t buy is political engagement and leadership – not just in the Ministry of Health, but also in the Ministry of Finance, the Prime Minister’s office, and so on. That’s the most critical piece.
Coming out of COVID, we’ve seen more countries recognize this as an important issue. You’re starting to see leadership emerge, and once that happens, a lot of things can follow. But you really wouldn’t want to go to a prime minister or president and say, “There’s one thing you should do before anything else,” because ultimately, it’s about building a system that holds together.
The one thing you can’t buy is political engagement and leadership – not just in the Ministry of Health, but also in the Ministry of Finance, the Prime Minister’s office, and so on. That’s the most critical piece.
Coming out of COVID, we’ve seen more countries recognize this as an important issue. You’re starting to see leadership emerge, and once that happens, a lot of things can follow. But you really wouldn’t want to go to a prime minister or president and say, “There’s one thing you should do before anything else,” because ultimately, it’s about building a system that holds together.
You’ve worked in many regions across the world. How do local challenges in preparedness differ among regions, and how does the World Bank balance global strategy with tailoring to country-specific needs?
“
I was saying earlier, the Bank’s business model is really country-based. The fundamental decisions around what we do in a particular country are based not on some sort of global strategy, but on dialogue at the country level. That’s built into how we work.
The global strategies play more of a supporting, guiding role, but they don’t determine what happens because, ultimately, we often talk about World Bank projects, but they’re really government projects financed by the World Bank. So that leadership and ownership have to come from the countries themselves.
On the first part of the question – there are quite significant differences across regions, partly in the types of threats they face. For example, when we talk about disease outbreaks, there are particular challenges with Ebola, Marburg, and other diseases in the Africa region that you don’t see to the same extent elsewhere. That doesn’t mean you can’t see them in other regions, but some areas face much greater threats from new outbreaks, especially the Africa region and the East Asia and Pacific region.
There are also differences in baseline capacity when it comes to responding to these threats. Some regions are doing much worse in that respect. Another key factor is the extent of cross-country collaboration, which is much stronger in some regions. You have regional institutions like the Africa CDC or PAHO in the Latin America and Caribbean region. In other contexts, such as South Asia, cross-country coordination and collaboration are much harder because of political and institutional challenges.
Those are some of the main differences that really come into play when we think about pandemic preparedness.
The global strategies play more of a supporting, guiding role, but they don’t determine what happens because, ultimately, we often talk about World Bank projects, but they’re really government projects financed by the World Bank. So that leadership and ownership have to come from the countries themselves.
On the first part of the question – there are quite significant differences across regions, partly in the types of threats they face. For example, when we talk about disease outbreaks, there are particular challenges with Ebola, Marburg, and other diseases in the Africa region that you don’t see to the same extent elsewhere. That doesn’t mean you can’t see them in other regions, but some areas face much greater threats from new outbreaks, especially the Africa region and the East Asia and Pacific region.
There are also differences in baseline capacity when it comes to responding to these threats. Some regions are doing much worse in that respect. Another key factor is the extent of cross-country collaboration, which is much stronger in some regions. You have regional institutions like the Africa CDC or PAHO in the Latin America and Caribbean region. In other contexts, such as South Asia, cross-country coordination and collaboration are much harder because of political and institutional challenges.
Those are some of the main differences that really come into play when we think about pandemic preparedness.
Pandemics hit all countries. What are the biggest challenges in getting countries to coordinate investments and preparedness across regions?
“
I think the biggest challenge, at least in some regions, is the political barriers. While you do see much greater collaboration and existing platforms for that in some regions like Latin America and Africa, in other regions there is very little coordination across neighboring countries. That can have very significant consequences in a pandemic.
From a global perspective, there was recognition, especially in the context of COVID and in its aftermath, that there are several critical agendas around research and development and manufacturing capacity for key products, whether therapeutics, vaccines, or others. Not every country can have that capacity, so the question is how to ensure that all countries can benefit and have equitable access to those products.
That’s a harder challenge to solve. It was a major focus, and continues to be, of the pandemic agreement being negotiated at the WHO with countries. There has been some progress, and there are many different initiatives aimed at ensuring that countries will have access to the products they need in future outbreaks. But it remains a big challenge, and one that we’ll likely keep working on for some time.
From a global perspective, there was recognition, especially in the context of COVID and in its aftermath, that there are several critical agendas around research and development and manufacturing capacity for key products, whether therapeutics, vaccines, or others. Not every country can have that capacity, so the question is how to ensure that all countries can benefit and have equitable access to those products.
That’s a harder challenge to solve. It was a major focus, and continues to be, of the pandemic agreement being negotiated at the WHO with countries. There has been some progress, and there are many different initiatives aimed at ensuring that countries will have access to the products they need in future outbreaks. But it remains a big challenge, and one that we’ll likely keep working on for some time.
You were directly very involved in the development of the Pandemic Fund. What have you learned from establishing that Fund?
“
I think we learned that it’s possible to mobilize many different actors and significant resources. When this process started in 2021–2022, there was a lot of skepticism from various parts. People thought it wouldn’t be possible or that it didn’t make sense, that we didn’t need it. But we reached a point where many key stakeholders saw the value and were willing to contribute resources. That wasn’t obvious to me when we began, so I think one thing we learned is that it’s possible… it just requires building coalitions and engaging a lot of people.
That’s one part. The other part is that it takes time. I think the Pandemic Fund has been successful in starting to operate and getting funding to countries very quickly, which is impressive. At the same time, it’s trying to do something very difficult, and we’re learning a lot of lessons along the way, both in terms of governance and operations.
It just takes time for efforts like this to mature, and that’s natural. But it’s something I hadn’t quite anticipated or foreseen.
That’s one part. The other part is that it takes time. I think the Pandemic Fund has been successful in starting to operate and getting funding to countries very quickly, which is impressive. At the same time, it’s trying to do something very difficult, and we’re learning a lot of lessons along the way, both in terms of governance and operations.
It just takes time for efforts like this to mature, and that’s natural. But it’s something I hadn’t quite anticipated or foreseen.
What makes prevention so difficult to prioritize politically and financially compared to response efforts, and how do we change that?
“
First of all, when people talk about prevention, they sometimes mean different things, right? So you might think of primary prevention is preventing these spillover events from happening. A lot of pandemics result from something hosted by an animal that spills over into humans. Preventing those events from happening is extremely complex, and it’s not purely a health sector agenda. It’s really about natural resource management, where people get their food, and limiting reliance on wild foods. In some regions, that’s a major source of outbreaks.
It also relates to how the livestock industry and the agriculture sector operate. The complexity lies in the fact that this isn’t just a health sector issue. It’s not easy to point to one thing and say, “Do this.” There are fundamental changes needed in agriculture and the management of natural resources. You have many sectors involved, making it difficult to say what is most important in that space.
Another dimension of prevention is stopping these spillover events from becoming large-scale outbreaks. That really comes down to countries having the intelligence, surveillance systems, and health infrastructure to detect when something unusual is happening, investigate quickly, act on it, and contain it.
This is sometimes referred to as the “epidemics that don’t happen.” We don’t hear much about those, but there are many instances where something occurs and is brought under control relatively quickly. That’s what really needs to be celebrated. Ultimately, it comes down to having a functioning health system that can detect these events and the core capacities to respond rapidly – identifying the problem and figuring out how to address it.
It also relates to how the livestock industry and the agriculture sector operate. The complexity lies in the fact that this isn’t just a health sector issue. It’s not easy to point to one thing and say, “Do this.” There are fundamental changes needed in agriculture and the management of natural resources. You have many sectors involved, making it difficult to say what is most important in that space.
Another dimension of prevention is stopping these spillover events from becoming large-scale outbreaks. That really comes down to countries having the intelligence, surveillance systems, and health infrastructure to detect when something unusual is happening, investigate quickly, act on it, and contain it.
This is sometimes referred to as the “epidemics that don’t happen.” We don’t hear much about those, but there are many instances where something occurs and is brought under control relatively quickly. That’s what really needs to be celebrated. Ultimately, it comes down to having a functioning health system that can detect these events and the core capacities to respond rapidly – identifying the problem and figuring out how to address it.
Finally, looking ahead, what innovations, whether in financing, technology, or governance, give you the most hope for strengthening global preparedness in the next decade?
“
I’m not sure I would put a lot of faith solely in innovation. There are a lot of good things happening, and it’s a bit hard to define. Often when we talk about innovation, we think of technology, but as you said, it can take other forms as well.
To me, what’s most important isn’t just the technological side. As in every other area, we’ll see institutional and technological innovations that are important. Some of that is happening in what we call the medical countermeasure agenda: the platforms and readiness needed for research, development, and production when an outbreak occurs.
There are important efforts in that regard, and you can think of them as institutional innovations. Coming out of COVID (and even before that) there has been a realization that we need to put more resources into preparatory research and development. That’s important and can have huge payoffs.
But more importantly, and somewhat to my surprise, there is a lot of political commitment around pandemic preparedness and disease outbreak preparedness more broadly. I wasn’t convinced that commitment would survive this many years after COVID, so I take some comfort in the fact that leadership in many places still seems to be there. That leadership is fundamental for getting these other, more targeted institutional and technological efforts started and sustained.
To me, what’s most important isn’t just the technological side. As in every other area, we’ll see institutional and technological innovations that are important. Some of that is happening in what we call the medical countermeasure agenda: the platforms and readiness needed for research, development, and production when an outbreak occurs.
There are important efforts in that regard, and you can think of them as institutional innovations. Coming out of COVID (and even before that) there has been a realization that we need to put more resources into preparatory research and development. That’s important and can have huge payoffs.
But more importantly, and somewhat to my surprise, there is a lot of political commitment around pandemic preparedness and disease outbreak preparedness more broadly. I wasn’t convinced that commitment would survive this many years after COVID, so I take some comfort in the fact that leadership in many places still seems to be there. That leadership is fundamental for getting these other, more targeted institutional and technological efforts started and sustained.
My conversation with Magnus Lindelow made one thing clear: pandemic preparedness is as much about economics and governance as it is about medicine. The world often reacts to crises only after they inflict immense social and financial damage, but the greatest returns come from investing early – in institutions, governance, and resilient health systems.
As Dr. Lindelow emphasized, prevention is not just a health priority; it’s an economic one. The pandemics we never hear about, the ones quietly contained before they spread, are the true measure of global progress.
Keep an eye out for excerpts from my Zoom interview with Dr. Lindelow in my next video on Economic Origins soon.
As Dr. Lindelow emphasized, prevention is not just a health priority; it’s an economic one. The pandemics we never hear about, the ones quietly contained before they spread, are the true measure of global progress.
Keep an eye out for excerpts from my Zoom interview with Dr. Lindelow in my next video on Economic Origins soon.
Magnus Lindelow is the Global Program Lead for Pandemic Prevention, Preparedness, and Response (PPR) and Public Health at the World Bank, where he oversees the institution’s global work on health system resilience and pandemic readiness. Over his career, he has held senior roles across Africa, East Asia, and Latin America, leading major programs on health reform, financing, and emergency preparedness. He played a key role in establishing the Pandemic Fund.
He holds a DPhil in Economics from Oxford University and has published widely on health systems, public finance, and poverty reduction.
He holds a DPhil in Economics from Oxford University and has published widely on health systems, public finance, and poverty reduction.
Magnus Lindelow
Global Program Lead for Pandemic PPR and Public Health at the World Bank