Strengthening the Free Healthcare Initiative Through a Pharmacy and Supply Chain Intervention: Partners In Health’s Experience in Rural Sierra Leone (The Lancet)

The Lancet
April 17, 2017
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Abstract

Background

To improve high maternal and under-5 mortality—among the worst globally—Sierra Leone’s Ministry of Health and Sanitation (MOHS) enacted the Free Healthcare Initiative in 2010. Under this initiative, pregnant and lactating women and children aged younger than 5 years receive medical treatment and essential medicines free of charge at public facilities. However, the availability of medicines remains inconsistent, which results in patients paying for medicines and an undermining of the quality of care and trust in the health-care system. These gaps between services and medicines promised under the Free Healthcare Initiative and actual resources delivered worsened during the 2013–15 Ebola epidemic, which strained an already weak health-care system. Here, we describe an approach to strengthen pharmacy and supply chain systems to improve access to essential medicines at a district hospital in Sierra Leone.

Methods

In 2015, Partners In Health undertook a gap analysis to understand the barriers to drug availability for patients eligible for the Free Healthcare Initiative at Koidu Government Hospital (KGH). A multidisciplinary task force identified priorities and created a partnership with the MOHS. Partners In Health’s Director of Pharmacy led meetings with hospital management, shadowed clinical staff, and performed an inventory of drugs and medical supplies.

Findings

The gap analysis revealed challenges in the areas of human resources, infrastructure, storage, and information systems. The results led to the following interventions: decentralisation of medication distribution from hospital to ward level; the hiring of four pharmacy technicians; expansion of central warehousing; and implementation of electronic reporting tools to improve consumption data. MOHS pharmacy staff were mentored to improve feedback mechanisms between central and district levels. Between November, 2015, and August, 2016, these changes resulted in nearly 100% availability of essential drugs—with 80% provided via the strengthened MOHS system—and elimination of out-of-pocket expenses for patients. Additionally, trust in the public health-care system has improved: compared with a 2012 and 2013 pre-Ebola baseline at KGH, paediatric and maternity admissions have increased by 47%, with a 95% increase in hospital-based deliveries.

Interpretation

The success of the Free Healthcare Initiative is rooted in its shared ownership with the MOHS and the integration of central-level and district-level information systems. The approach described here could be used to guide new interventions to strengthen pharmacy supply chains elsewhere in Sierra Leone and other low-resource settings.

Funding

Partners In Health, Sierra Leone.

Declaration of interests

We declare no competing interests.

The Ebola Suspect’s Dilemma (Harvard Medical School)

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What to do when seeking treatment is more likely to harm than to help?
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Harvard Medical School
March 2, 2017
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West Africa. 2014. The height of the Ebola outbreak sweeping the region. A person experiences sudden onset of fever, vomiting, diarrhea—textbook early symptoms of Ebola.

But there’s a catch. A person with those symptoms is just as likely to have malaria as Ebola, creating a potentially deadly dilemma, said the authors of a newly published essay in Lancet Global Health. Someone with malaria has a 1 in 500 risk of dying if they choose to avoid treatment, while someone without Ebola seeking care at an Ebola treatment unit at the time would have a 1 in 5 chance of getting infected and perishing from the virus.

 

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Partners In Health Survivor Program staffer Gibrilla Sheriff conducts home visits to Ebola survivors in Freetown, Sierra Leone on Sept. 9, 2015. Image: Rebecca Rollins/PIH

 

The 64 percent mortality rate in treatment units, the authors said, stemmed from the fact that many Ebola units were ill-equipped to provide even the most rudimentary resuscitative care like intravenous fluids. What this meant, the authors add, is that even a person already sick with Ebola would be only marginally more likely to survive by seeking what then passed for treatment in such a poorly staffed and stocked facility.

Impossible Choices

In the absence of effective therapy, the authors argue, the choice between going to a clinic and staying home represents a higher-stakes version of the so-called prisoner’s dilemma, a game theory model of collaboration and betrayal that tries to tease out the rational basis for cooperation and altruism.

“You hear this notion that Ebola was driven by selfish ‘superspreaders’ who were unwilling to seek care,” said lead author Eugene Richardson, HMS instructor in medicine at Brigham and Women’s Hospital. “But the reality is that there was very little effective care available for most people, because of the region’s catastrophically underdeveloped health systems.”

“What’s more,” added Paul Farmer, the Kolokotrones University Professor of Global Health and Social Medicine at HMS, “many of the ‘superspreaders’ were caregivers, most of them traditional healers working in precisely those settings bereft of nurses and doctors.”

They nursed the sick and were involved in last rights and burial of the dead, he said.

“These are the main acts of caregiving—including its final act,” Farmer said.

Beyond a deconstruction of the impossible clinical and moral choices facing people with symptoms of Ebola, the essay is a call to action for policy makers, global health organizations and international development institutions to reframe and rethink the persistent misconceptions that the authors say have hamstrung an effective response to the suffering caused by Ebola.  

Diverse Perspectives

The authors of the essay represent a diverse group that includes frontline clinicians who treated Ebola during the outbreak and researchers who conducted extensive studies of the clinicalbiological and social aspects of the disease.

Farmer, who is also co-founder of Partners In Health, is senior author on the commentary. Other authors include faculty and leaders at HMS, Brigham and Women’s, Partners In Health, governmental and nongovernmental agencies in Liberia and Sierra Leone, and other institutions.

Some of the survivors who shared their stories with the authors talked about the heart-rending struggle to care for their loved ones in a place where the already strained health infrastructure was so overwhelmed by Ebola that clinics and hospitals were amplifying the outbreak instead of healing the afflicted, Richardson said.

“The essay is a call to action for policy makers, global health organizations and international development institutions to reframe and rethink the persistent misconceptions that the authors say have hamstrung an effective response to the suffering caused by Ebola.”  

In most cases, the afflicted sought help from caregivers—professional caregivers if they were available and lay caregivers if they were not. It bears noting, the authors added, that the three most affected countries were also the world’s most medically impoverished. There were, in other words, few professional caregivers. And so, the disease was transmitted from patient to caregiver, spreading not just from patient to family members but to nurses and doctors, as well. The story of Ebola in West Africa, Farmer has said, is the story of a “caregiver’s disease in a clinical desert.”

In other cases, people sought help but had to wait days for an ambulance to come.  At that point, Richardson said, their choice was to stand back and watch their sick family members suffer or to try their best to care for them and keep them clean.

“They knew about Ebola, knew how it spread, and they knew their mothers, their brothers, their children were probably infected,” Richardson said. “They weren’t going to sit there and watch their loved ones suffer. It’s a basic human response.”

Discerning Solutions

Ebola doesn’t have to be just about making impossible choices between watching your loved ones suffer without helping or choosing to help and risking a horrible death yourself, Richardson said, adding that the 70 percent mortality rate seen at some points during the epidemic would be more like 5 percent if all patients had access to the kind of intensive resuscitative treatment available with modern health care.

It doesn’t even need to be all that modern. The authors point out that since 1832 intravenous fluids have been known to prevent death from hypovolemic shock, but Richardson said there are still some in the global health community who debate whether IV fluids should be considered part of the standard of care for Ebola, a disease that kills by sending some people into shock due to loss of blood and fluids.

“Not all people who die of Ebola die of hypovolemia,” Farmer said. “With this virus, sepsis kills people without volume loss, too. But the fact that some of those who die do so of shock is good news because there’s a straightforward, easy to implement way of providing effective care. The Ebola suspect’s dilemma arose because that almost never happened in West Africa, alas.”

Any solution that leaves out fundamental clinical aspects of treatment while ignoring the social context where it must function is unlikely to work, the authors said. Blaming patients—who choose to avoid dangerous medical facilities or who choose to take care of their sick loved ones—for the spread of the disease while focusing on attempts to contain Ebola through isolation without providing effective treatment in quarantine is like watching the shadows on the wall of Plato’s cave, the authors argued.

“It is an illusion to believe that any one discipline can deliver a simple solution to a problem as complex as Ebola,” Farmer said. “Understanding the daily lives of the people who have lived with the disease and its aftermath, as well as acknowledging the political, historical and economic forces that shaped those lives and the contours of the Ebola outbreak in West Africa, is every bit as important as understanding the pathophysiology of the disease or identifying new ways to deliver care.”

Sierra Leone to Begin Cholera Vaccination Drive in Disaster-Affected Areas (The World Bank)

The World Bank
September 5, 2017
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 Half a million people in Sierra Leone will be able to access the life-saving cholera vaccine within weeks, the country’s Ministry of Health and Sanitation announced on Tuesday.

The vaccines will be received from the Gavi-funded global stockpile and will target areas particularly affected by August’s floods and deadly landslide, which resulted in over 500 confirmed deaths. Hundreds more people were reported missing in the wake of the disaster, according to the Office of National Security, while thousands were displaced from their homes.

“Cholera is a devastating disease which spreads quickly and kills fast, and risks can increase after severe flooding,” said Dr. Brima Kargbo, Chief Medical Officer at the Ministry of Health and Sanitation. “The oral cholera vaccine is an important tool to better protect the country and affected communities against the disease, which will ultimately save lives.”

Two rounds of vaccination are planned to run from September and will be delivered in 25 affected communities by the Government of Sierra Leone with support from Gavi Alliance, the World Health Organization (WHO), UNICEF, the UK Government and other health partners.

“The devastating floods and landslides which ravaged Sierra Leone throughout August have left the country dangerously vulnerable to water-borne disease outbreaks,” said Dr. Seth Berkley, CEO of Gavi Alliance. “Access to safe water and sanitation is limited, and the public health system, still recovering after the 2014 Ebola outbreak, is stretched. These lifesaving vaccines, alongside urgent support to improve safe water and sanitation, have the potential to prevent a cholera outbreak before it has the chance to bring more misery to a country that has already suffered enough.”

The decision to send cholera vaccines from the global stockpile was taken quickly on 31th August by the International Coordinating Group (ICG) for Vaccine Provision following the deployment of a WHO specialist to the country. The full quantity of the vaccine (1,036,300 doses for two rounds) is set to arrive in Freetown on 7th September through UNICEF’s global Supply Division.

WHO recommends that vaccination against cholera be considered in emergencies and other high-risk scenarios where there are increased threats of outbreaks, when combined with standard prevention and control measures for the disease. These measures include readiness to provide adequate testing and treatment, steps to ensure access to safe water and sanitation, and community mobilization to engage the public in preventing infection.

Sierra Leone’s last major cholera outbreak, in 2012, killed 392 people and infected more than 25,000 others.

Gavi, WHO, UNICEF and partners are working with the Ministry of Health and Sanitation to help plan and implement the campaign, which will make the vaccine available free-of-cost to disaster-affected populations, while supporting ongoing cholera prevention and preparedness.

Donors and Drug Makers Offer $500 Million to Control Global Epidemics (The New York Times)

The New York Times
By Donald G. McNeil Jr. 
January 18, 2017
 
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Stung by the lack of vaccines to fight the West African Ebola epidemic, a group of prominent donors announced Wednesday that they had raised almost $500 million for a new partnership to stop epidemics before they spiral out of control.

The partnership, the Coalition for Epidemic Preparedness Innovations, will initially develop and stockpile vaccines against three known viral threats, and also push the development of technology to brew large amounts of vaccine quickly when new threats, like the Zika virus, arise.

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A child born with microcephaly caused by the Zika virus, during an evaluation at Fundação Altino Ventura in Recife, Brazil. A group of prominent donors announced Wednesday that they had raised almost $500 million for a new partnership to stop epidemics before they spiral out of control.

With enough money and scientific progress, the strategy could bring a drastic change in the way the world tackles pandemics.

Now the global response often resembles a fire department racing from blaze to blaze. The coalition wants something more like a military campaign, with stores of ammunition and different weapons systems ready to be deployed as soon as a threat emerges.

In theory, health officials could even act pre-emptively — inoculating a population against a dangerous new flu or coronavirus circulating in animals before it infects many people, for example.

“We’ll have to make sure we do better than we did against Ebola,” said Bill Gates, founder of the Bill and Melinda Gates Foundation, one of the largest initial donors. He has often predicted that the catastrophe most likely to kill 10 million people in the near future is a pandemic rather than nuclear war, terrorism, famine or natural disaster.

The other donors, besides the Gates Foundation, include the governments of Japan and Norway, and Britain’s Wellcome Trust. Each is putting up $100 million to $125 million over five years; Germany, India and the European Commission are expected to announce donations soon.

Six major vaccine makers — GlaxoSmithKline, Johnson & Johnson, Merck, Pfizer, Sanofi and Takeda — joined in the coalition as “partners” rather than donors, as did the World Health Organization and Doctors Without Borders.

Marie-Paule Kieny, the W.H.O.’s assistant director-general for innovation, said her agency would help by working with governments to streamline regulations.

Ultimately, the coalition will need billions of dollars to fulfill its ambitious plans. Members made their announcement at the World Economic Forumin Davos, Switzerland, in the hopes that the billionaires and corporate leaders in attendance would take notice and chip in.

The announcement was welcomed by Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, which designs vaccines but must partner with private industry to produce large amounts.

“I’ve been pushing for a global health emergency fund for years,” he said, “and half a billion dollars is a good start.”

Dr. Stanley A. Plotkin, a longtime vaccine researcher and scientific adviser to the new coalition, said members debated which of 10 diseases to target first and picked three because “taking a vaccine from soup to nuts costs at least half a billion dollars.”

Even if the United States is not now a donor, he said, it already supports vast amounts of vaccine research through its bioterrorism budget, “so I hope they’ll supplement the coalition’s work with theirs.”

New epidemics can be expected to occur regularly and spread quickly thanks to air travel, public health experts warn. Stopping them early will save lives and billions of dollars.

The long-discussed idea was given new impetus by the back-to-back Ebola and Zika epidemics.

Experimental Ebola vaccines that worked in monkeys had existed for years, but had never been tested in humans or stockpiled because vaccine companies had no financial incentive to make them. Ultimately, the 2014 epidemic killed 11,000 West Africans, and isolated cases reached Britain, France, Germany, Spain and the United States.

No experimental vaccine was ready when Zika exploded across the Western Hemisphere, but many research teams found them easy to create in the lab because there were already vaccines against two close viral relatives, yellow fever and dengue.

The coalition’s first $500 million will be spent pursuing two goals: further development of vaccines against Lassa fever, the Nipah virus and Middle East Respiratory Syndrome (MERS); and improving the latest DNA and RNA vaccine technology, which seems like the best hope to make a true “plug and play” vaccine platform.

Those viruses were chosen, said Dr. Penny M. Heaton, the Gates Foundation’s director of vaccine development, because many experts consider them the biggest threats for which experimental vaccines are already in the works.

Lassa, like Ebola, causes hemorrhagic fevers; rodents — notably the African soft-furred rat — transmit it through urine and feces.

Nipah causes deadly encephalitis and pneumonia; it circulates in Asian fruit bats and is also caught from pigs that eat fruit gnawed by bats. Outbreaks usually begin among hog farmers or people who drink date-palm sap fouled with bat urine.

MERS is a coronavirus related to SARS that also causes acute, deadly pneumonia. It originates in bats and circulates among camels, and can prompt large hospital outbreaks, especially when patients are crowded together and staff members do not wear protective masks.

The coalition will pick two experimental vaccines against each virus and pay vaccine companies to prove they work in monkeys, are safe for humans and induce what are thought to be protective levels of antibodies in humans.

After that, modest amounts will be stockpiled — ideally within five years.

Scientists obviously cannot test vaccines by giving healthy humans lethal doses of incurable diseases. So the ultimate test will be to see if the stockpiled version stops the next outbreak that occurs in nature.

Bringing a new vaccine to market can take 20 years and cost up to $1 billion, and candidates usually disappear in the “valley of death” — the many expensive steps required between showing that a lab-brewed concoction protects mice or monkeys, and rolling out a factory-line version proven safe to inject into millions of humans.

The coalition aims to move candidates far enough across that valley so they can stop an outbreak and see if full-fledged production is justified.

RNA and DNA technology involves injecting a virus’s genes to provoke the immune system to make both antibodies and white blood cells primed to attack the virus.

But RNA and DNA can break down, or fail to penetrate cell membranes or to trigger protein-coding. So various “platforms” are being tried, such as folding them into larger shapes or chemically gluing them onto microscopic beads.

Once the technical issues are solved, the method will have great promise. Large amounts of vaccine could be made much faster than, for example, growing vaccine in fertilized chicken eggs.

Thorny legal issues, however, remain — including who will hold patents on innovations developed with coalition funds and who will be held legally liable if anyone dies or is harmed during vaccine trials.

“We have not sorted out all the intellectual property problems yet, but I’m confident we can,” said Dr. Jeremy Farrar, director of the Wellcome Trust.

Any fund recipient would have to guarantee that its vaccines would be priced for poor countries as well as rich ones, he said.

On the liability issue, Dr. Farrar added, the coalition likes an American model — the National Vaccine Injury Compensation Program, under which vaccine makers cannot be sued but must contribute to a fund that compensates anyone hurt by a vaccine.

Andrew P. Witty, chairman of GlaxoSmithKline, or GSK, who joined the Davos announcement, said the industry preferred protection like that of the United States’ 2005 Public Readiness and Emergency Preparedness Act, which exempts vaccine makers from all liability — except for willful misconduct — once the secretary of health and human services declares a public health emergency.

The United Nations or W.H.O. will have to help protect the industry, Mr. Witty said.

His company is willing to devote a slice of one of its research facilities to the coalition’s goals and to conduct up to $50 million worth of research on a nonprofit basis.

GSK will do so, Mr. Witty said, “first, because it’s the right thing to do when the world is up against it, and, second, because it prevents disruption of our business.”

The world’s vaccine companies have no factories sitting idle for emergencies, he said, “so when a crisis hits, as the biggest company, we get the first call — and we have to stop doing other stuff.”

With assurances that good manufacturing processes would be followed, he said, GSK could be willing during an epidemic to let vaccine companies in India or Brazil, for example, use the company’s patented techniques to make vaccines.

Sierra Leone to begin cholera vaccination drive in disaster-affected areas

More than 1 million doses of Gavi-funded cholera vaccines heading to Sierra Leone after severe flooding and landslides

 

 Half a million people in Sierra Leone will be able to access the life-saving cholera vaccine within weeks, the country’s Ministry of Health and Sanitation announced on Tuesday.

The vaccines will be received from the Gavi-funded global stockpile and will target areas particularly affected by August’s floods and deadly landslide, which resulted in over 500 confirmed deaths. Hundreds more people were reported missing in the wake of the disaster, according to the Office of National Security, while thousands were displaced from their homes.

“Cholera is a devastating disease which spreads quickly and kills fast, and risks can increase after severe flooding,” said Dr. Brima Kargbo, Chief Medical Officer at the Ministry of Health and Sanitation. “The oral cholera vaccine is an important tool to better protect the country and affected communities against the disease, which will ultimately save lives.”

Two rounds of vaccination are planned to run from September and will be delivered in 25 affected communities by the Government of Sierra Leone with support from Gavi Alliance, the World Health Organization (WHO), UNICEF, the UK Government and other health partners.

“The devastating floods and landslides which ravaged Sierra Leone throughout August have left the country dangerously vulnerable to water-borne disease outbreaks,” said Dr. Seth Berkley, CEO of Gavi Alliance. “Access to safe water and sanitation is limited, and the public health system, still recovering after the 2014 Ebola outbreak, is stretched. These lifesaving vaccines, alongside urgent support to improve safe water and sanitation, have the potential to prevent a cholera outbreak before it has the chance to bring more misery to a country that has already suffered enough.”

The decision to send cholera vaccines from the global stockpile was taken quickly on 31th August by the International Coordinating Group (ICG) for Vaccine Provision following the deployment of a WHO specialist to the country. The full quantity of the vaccine (1,036,300 doses for two rounds) is set to arrive in Freetown on 7th September through UNICEF’s global Supply Division.

WHO recommends that vaccination against cholera be considered in emergencies and other high-risk scenarios where there are increased threats of outbreaks, when combined with standard prevention and control measures for the disease. These measures include readiness to provide adequate testing and treatment, steps to ensure access to safe water and sanitation, and community mobilization to engage the public in preventing infection.

Sierra Leone’s last major cholera outbreak, in 2012, killed 392 people and infected more than 25,000 others.

Gavi, WHO, UNICEF and partners are working with the Ministry of Health and Sanitation to help plan and implement the campaign, which will make the vaccine available free-of-cost to disaster-affected populations, while supporting ongoing cholera prevention and preparedness.

Liberian Ebola Fighter, a TIME Person of the Year, Dies in Childbirth (Time)

 

Time
By Aryn Baker 
February 27, 2017

 

The 2014 West African Ebola outbreak killed 11,310 people. Liberian nursing assistant Salome Karwah was not one of them. The disease that tore through her town in August of that year took her mother, her father, her brother, aunts, uncles, cousins and a niece. But by some miracle it left Karwah, her sister Josephine Manley and her fiancé James Harris still alive.

But just because Karwah escaped Ebola, it didn’t mean she was secure against the failures of Liberia’s broken medical system. She died on Feb. 21, 2017, from complications in childbirth and the lingering social stigma faced by many of Ebola’s survivors.

 

Karwah used to joke that survivors had “super powers” — because after overcoming the disease they were forever immune from it. Like any superhero, she often quipped, it was her moral duty to use those powers for the betterment of humankind. So as soon as she recovered, she returned to the hospital where she had been treated — the Médecins Sans Frontières (MSF) Ebola treatment unit just outside of the capital, Monrovia — to help other patients. Not only did she understand what they were going through, she was one of the rare people who could comfort the sick with hands-on touch. She could spoon-feed elderly sufferers, and rock feverish babies to sleep.

When I met Karwah, in November 2014, she, her fiancée, and her sister were already planning to re-open the family medical clinic that had been forced to close when her father, the local doctor, succumbed to Ebola. She envisioned a kind of super-clinic, whose survivor nurses would able to go where other medical personnel feared to tread because of their immunity. “I can do things that other people can’t,” she said then. “If an Ebola patient is in his house, and his immediate relative cannot go to him, I can go to him. I can take [care of] him.”

It was her determination to help Ebola patients when most of the world fled in fear that put her among the Ebola Fighters who were named TIME Magazine’s Person of the Year in 2014.

At the time, Karwah seemed invincible. When the outbreak in Liberia ended, and people could have a party without fear of catching the virus, she finally married her fiancé, changed her name to Salome Harris, and had her third child. She picked the name Destiny. Then she got pregnant again. On Feb. 17 she delivered a healthy boy, Solomon, by cesarian section. She was discharged from hospital three days later.

Within hours of coming home, Karwah lapsed into convulsions. Her husband and her sister rushed her back to the hospital, but no one would touch her. Her foaming mouth and violent seizures panicked the staff. “They said she was an Ebola survivor,” says her sister by telephone. “They didn’t want contact with her fluids. They all gave her distance. No one would give her an injection.”

Karwah died the next day. “My heart is broken,” says Manley. “Salome loves her children, her James. The one-year-old, the newborn, they will grow up never remembering their mother’s face.”

Manley doesn’t know what caused the convulsions, but believes that something went wrong in the surgery. Still, she says, if her sister had been treated immediately, she might have had a chance. Instead, “she was stigmatized.”

News of Karwah’s death rippled far beyond her small community in Liberia. Those who knew her for her tireless cheer in the MSF Ebola treatment clinic were devastated. “To survive Ebola and then die in the larger yet silent epidemic of health system failure… I have no words,” says Ella Watson-Stryker, a MSF health promoter who worked with Karwah in Liberia and was also among the Ebola Fighters on the 2014 cover.

World Bank launches ‘pandemic bond’ to tackle major outbreaks (Reuters)

Reuters
By Claire Milhench
June 28, 2017
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LONDON (Reuters) – The World Bank has launched a “pandemic bond” to support an emergency financing facility intended to release money quickly to fight a major health crisis like the 2014 Ebola outbreak.
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World Bank Group President Jim Yong Kim delivers his speech during the Belt and Road Forum for International Cooperation in Beijing, China May 14, 2017. REUTERS/Lintao Zhang/Pool

 

 

 

 

 

 

 

 

 

 

The catastrophe bond, which will pay out depending on the size of the outbreak, its growth rate and the number of countries affected, is the first of its kind for epidemics. It should mean money is disbursed much faster than during West Africa’s Ebola crisis.

Ebola spread across the region in the early months of 2014. Michael Bennett, head of derivatives and structured finance at the World Bank’s capital markets department, said that if the pandemic emergency financing facility (PEF) had existed in 2014, some $100 million could have been mobilised as early as July.

In reality, money did not begin to flow on this scale until three months later, by which time the number of deaths from Ebola had increased tenfold.

“In the end about 11,000 people died in that pandemic and it’s estimated that the cost to the countries most affected – Guinea, Liberia and Sierre Leone – was about $2.8 billion,” Bennett said.

The PEF will offer coverage to all countries eligible for financing from the International Development Agency (IDA), the arm of the World Bank dedicated to the world’s poorest countries.

It covers outbreaks of infectious diseases most likely to cause major epidemics, including pandemic influenza strains; coronaviruses, including SARS; filoviruses, which include Ebola and Marburg; plus others such as Crimean Congo fever, Rift Valley fever and Lassa fever.

Bennett said the PEF as a whole would provide more than $500 million of coverage against pandemics over the next five years. This includes today’s $425 million transaction, comprising $320 million raised through the bond market and $105 million through swaps transactions.

The transaction was oversubscribed by 200 percent, attracting interest from dedicated cat bond investors, asset managers, pension funds and endowments, the World Bank said.

For the pandemic bond, the World Bank will pay bondholders a coupon that replicates an insurance premium plus a funding spread, in return for a payout if the bond is triggered.

“If a trigger event occurs, instead of repaying the bond in full, some or all of the principal is transferred to the PEF trust fund,” Bennett said. “So essentially the investors are acting like insurance companies.”

Under the swaps transactions, the swaps counterparty pays out if a trigger event occurs.

“The objective of offering the risk in both forms is that the bonds and swaps appeal to different types of investors, and therefore … we are creating the broadest possible investor pool for this risk,” said Bennett. That helped drive down prices. 

A replenishable cash window available from 2018 will provide funding for diseases that may not meet the activation criteria for the bond, whilst future donor commitments may be used to purchase additional coverage from the market.

Munich Re, which helped develop the insurance component of the PEF in conjunction with Swiss Re and catastrophe risk modeller AIR Worldwide, said pandemics were among the most likely uninsured risks to occur.

The annual global cost of moderately severe to severe pandemics is estimated at roughly $570 billion, or 0.7 percent of global income, the World Bank said.