An investment too good to be true?: Reassessing the World Health Organization and World Bank return-on-investment estimates for pandemic preparedness.

The World Health Organization, World Bank, G20 and related health agencies have requested annual investments of US$31.1 billion in pandemic prevention, preparedness and response. To justify these unprecedented costs, they rely on a return-on-investment case developed by WHO and World Bank. Any investment in one area of public health will have knock-on effects on others, through diversion of funds and human resources. Intended outcomes must outweigh alternate investments and be likely to achieve the results on which such comparisons are predicated. This perspective examines the assumptions underlying the WHO and World Bank return-on-investment estimates and outlines implications for equitable and evidence-based global health financing. The examination reveals several problematic assumptions and crude baselines used for comparison - inflating return-on-investment estimates and undermining its use for policymaking. The case is based on improbable assumptions of 100% mitigation of pandemic economic impacts, including rapid vaccine development completely blocking transmission. WHO/World Bank do not disaggregate direct and indirect costs, while the economic impact of comparator diseases appears significantly undervalued. Thus, the return-on-investment case underpinning the current pandemic agenda appears under-evidenced and unreliable, and the apparent over-valuation of pandemic interventions over existing investment in high-burden infectious diseases raises equity concerns, suggesting a reassessment is needed.