Responding to outbreaks of infectious diseases involves different norms, processes, and structures from those used when delivering regular healthcare services. Decision making needs to be streamlined; leaders must make no-regrets decisions in the face of uncertainty. But much of our present epidemic-management system goes unused until outbreaks happen, in a “break glass in case of emergency” model. It is difficult to switch on those latent response capabilities suddenly and unrealistic to expect them to work right away.
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A better system might be founded on a principle of active preparedness and constructed out of mechanisms that can be consistently used and fine-tuned so they are ready to go when outbreaks start (Exhibit 3). We see several means of instituting such an always-on system. One is to use the same mechanisms that we need for fast-moving outbreaks (such as COVID-19) to address slow-moving outbreaks (such as HIV and tuberculosis) and antimicrobial-resistant pathogens. Case investigation and contact tracing are skills familiar to specialists who manage HIV and tuberculosis. But few areas have deployed their experts effectively in responding to the COVID-19 pandemic.
Another way to build active preparedness is to form cross-sector partnerships—something that becomes much more challenging during a crisis. The private sector has generally been willing to help during the COVID-19 crisis, but many companies have had trouble finding effective channels. The Coalition for Epidemic Preparedness Innovation (CEPI) represents a model for always-on partnerships across sectors. It was founded in 2017 as a not-for-profit platform to accelerate the development of vaccines against emerging infectious diseases. When the COVID-19 outbreak began, the organization pivoted from studying a wide set of diseases with epidemic potential to focus much of its attention on the new threat. Along with the Gavi alliance and others, CEPI has been an important vehicle for ensuring that vaccine-development efforts for COVID-19 hit the ground running.
Governments can also maintain their information-sharing practices between major outbreaks and then ramp them up when outbreaks start. South Korea, for example, built an always-on disaster- and safety-information system to capture risk information in real time following its experience in responding to MERS. The system brings together data, including localized geospatial information, from 11 existing disaster-management systems and 16 government ministries. It includes a rapid emergency-approval system for diagnostic-testing kits. As COVID-19 spread, South Korea activated that approval system to scale up testing quickly.
The principle of active preparedness might also lead governments to strengthen other aspects of pandemic response, such as the development of diagnostics and therapeutics for emerging infectious diseases (which might focus on known gaps between epidemics), the manufacturing of personal protective and medical equipment, and the sharing of information. Predefining response roles for different stakeholders at the global, national, and local levels is also an important part of active preparedness, since well-defined roles prevent delays and confusion when an outbreak occurs.
Last, governments can keep outbreak preparedness on the public agenda. Iceland offers an example of how to do that effectively. Since 2004, the country has been testing and revising its plans for responding to global pandemics. Authorities there also encourage the public to take part in preparing for natural disasters. The government’s efforts to heighten public awareness of the threat posed by infectious diseases and to engage the public in the necessary response measures aided the country’s successful response to the COVID-19 pandemic.
To build always-on systems around the world, an up-front two-year investment of $20 billion to $30 billion and ensuing annual investments of $5 billion to $10 billion (for a ten-year total of $60 billion to $110 billion) would go into the following areas:
- building and maintaining high-quality, flexible outbreak-investigation capacity in all geographies: most countries have a field-epidemiology-training program of some kind, but many of them are underfunded and place their graduates onto uncertain career pathways; strengthening such programs is likely to be one of the most effective investments that a country can make in developing its outbreak-investigation capacity
- supporting epidemiological-response capacity with emergency operations centers (EOCs) that function during all types of major crises
- maintaining robust stockpiles of medical supplies and emergency supply-chain mechanisms at the subnational, national, or regional levels (depending on the setting)
- conducting regular outbreak simulations and other cross-sectoral preparedness activities