As the risk of global health threats grows, better tracking of spending on Prevention, Preparedness and Response (PPR) for pandemics and other global health threats is needed to support informed decisions on sustainable investment. This is particularly important in a changing global health financing landscape, where the poorest and most vulnerable countries are both on the frontline for most global health risks and are bearing the brunt of aid cuts.
National PPR spending, financed from both domestic and external sources, is estimated to have fallen from its pandemic peak but remains, on average, above pre‑pandemic levels. Following the sharp increase in spending during the COVID‑19 pandemic, PPR expenditure has, on average, declined across all country income groups. However, in 2023, as a share of GDP, PPR spending remained, on average, 13% above 2019 levels.
High-income countries (HIC) are estimated to spend more on PPR per capita, but low-income countries (LIC) allocate a greater share of total health expenditure to PPR. In 2023, HICs spent on average USD 75 per capita on PPR, representing less than 2% of their overall health expenditure. LICs spent less than USD 4 per capita, which accounted for 10% of their health expenditure.
LICs reliance on external sources to finance PPR creates new risks for preparedness, particularly as aid to health is projected to decline by up to half from 2024 to 2026. In 2023, external sources, such as aid, financed nearly 75% of total PPR expenditure in LICs with available data. At a time when the risk of emerging and re‑emerging health threats remains high, declining aid sources, notably Official Development Assistance, risks further constraining PPR investment in developing countries that are already spending substantially less per capita.
The development of a Global Health and Resilience Tracker helps to strengthen the evidence base by improving monitoring of financing trends and supporting analysis on how countries are investing in PPR and broader health resilience. This work, in collaboration with World Health Organization, World Bank and other organisations, builds upon standards for tracking health spending and development finance, notably the System of Health Accounts and the Creditor Reporting System, while also drawing on the OECD’s cross-sectoral expertise, with an underlying rationale that effective prevention, preparedness and response require investments across and beyond the health sector.
Tracking spending on prevention, preparedness and response to global health threats
As the frequency and complexity of global health threats continue to increase, sustained investment in prevention, preparedness and response (PPR) is essential to strengthen resilience and reduce the risk and impact of future health emergencies (HLIP, 2025[1]).
PPR is a global health framework that comprises the core systems, capacities and capabilities that enable countries to anticipate, prevent, detect and manage emerging health threats. While PPR is often associated with pandemic preparedness, its scope extends beyond pandemics to encompass large‑scale epidemics from emerging and re‑emerging infectious diseases, antimicrobial resistance (AMR), chemical, nuclear and radiological events, and biological risks enabled by advances in biotechnology and artificial intelligence. This brief therefore focusses on core capacities of PPR that combat against this range of global health threats.
Despite their importance, many PPR activities are structurally vulnerable to underinvestment because they exhibit the characteristics of global public goods. Investments in surveillance systems, infection prevention and control, emergency response capacity, and research and development generate benefits that extend beyond national borders by reducing the risk and impact of cross-border disease outbreaks. This creates a collective action problem, as countries may underinvest when many of such benefits accrue globally rather than domestically. The challenge is compounded by the difficulty of measuring or quantifying the benefits of prevention, preparedness and response, making sustained investment politically difficult to prioritise relative to more immediate domestic demands. As a result, financing for PPR has historically fallen short of what is needed to strengthen global health security and resilience, even during periods of relative economic and geopolitical stability (Penn et al., 2025[2]).
These longstanding financing challenges are becoming more acute amid a rapidly changing global health financing landscape. Official Development Assistance (ODA) has historically been one of the most stable and predictable sources of external financing for health systems in developing countries. This is complemented by others flows for development including non-concessional flows, private flows from philanthropic organisations and other international initiatives. However, the aid financing environment is becoming increasingly constrained. ODA for health from countries of the Development Assistance Committee1 is projected to decline by 29‑46% between 2024 and 2026, equivalent to an overall reduction of USD 5‑8 billion. This would place health ODA approximately 63% below its 2022 pandemic peak and return funding levels to those last seen before the global financial crisis of 2008 (OECD, 2026[3]). At a time when the risk of emerging and re‑emerging health threats remains high, declining international financing risks widening already substantial income gaps in global PPR capacity and weakening collective resilience to future pandemics.
PPR spending is not currently tracked in a systematic or internationally comparable manner, in part because relevant activities are embedded across multiple areas of the health and non-health sectors rather than captured as a distinct budget item. This limits the ability to monitor financial support, assess alignment between spending and identified needs, and understand how resources are mobilised domestically and through development assistance. Addressing these gaps requires a consistent approach to routinely estimating expenditure on PPR (Box 1).
The OECD has refined the methodology to estimate PPR expenditure in the health sector using the System of Health Accounts (SHA), an international health accounting framework (OECD/Eurostat/WHO, 2017[4]). The approach maps SHA healthcare functions to PPR technical areas, as defined by the Joint External Evaluation (JEE) framework for the International Health Regulations (WHO, 2022[5]). This mapping was initially developed collaboratively by the OECD and the World Health Organization (WHO) and discussed with global health security experts.
To estimate expenditure, a proportion of each SHA function is attributed to PPR according to its alignment with JEE technical areas. Attribution shares were informed by detailed World Bank case studies in Bangladesh, Indonesia, Pakistan and Viet Nam, and were piloted in the report Smart Spending to combat global health threats (Penn et al., 2025[2]). The attribution shares have since been refined using analyses of national health accounts, budget data, cost-of-illness studies, disease‑specific immunisation expenditure and special SHA reporting items on COVID‑19 expenditure (Table 1).
This provides a consistent and internationally comparable approach for estimating recurrent health-sector spending on PPR using existing expenditure data. However, the estimates do not capture all PPR-relevant expenditure, including capital expenditure, research and development on medical countermeasures, and PPR-related spending outside of the heath sector, including in development, animal health, agriculture and other areas that contribute to global health and resilience. In future, a PPR memorandum item in the SHA will allow countries to regularly report health-related PPR spending directly and help refine the methodology.
Note: Allocation shares estimate the proportion of expenditure within each SHA 2011 category attributable to PPR activities, across all financing sources. Allocation shares were revised in July 2026; further details will be made available in a forthcoming methodological note.
In 2023, high-income countries spent on average USD 75.7 per capita on PPR within the health sector, 20 times higher than low-income countries (USD 3.7), and substantially more than lower-middle (USD 5.5) and upper-middle income countries (USD 11.9).2,3
Although per capita spending was much lower, PPR accounted for a larger share of total health expenditure in low-income countries. In 2023, an estimated 5‑10% of total health spending in low- and lower-middle‑income countries was attributable to PPR, compared to less than 2% in high-income countries (Figure 1).
Health PPR expenditure per capita and as a share of current health expenditure
Note: HIC = high-income countries; UMIC = upper-middle‑income countries; LMIC = lower-middle‑income countries; LIC = low-income countries. Income groupings are based on the World Bank’s income classification. Estimates are based on limited country coverage and will be expanded as data becomes available. Upper and lower bounds indicate the range resulting from different attribution shares; bars show the midpoint of this range.
Source: OECD Health Expenditure and Financing Database and WHO Global Health Expenditure Database.
Relative to the size of their economies, low-income countries also devoted a larger share of GDP to PPR. In 2023, on average, PPR expenditure was equivalent to 0.5% of GDP in low-income and 0.2% in lower-middle income countries, compared to 0.15% in both upper-middle and high-income countries.
Following a peak during the COVID‑19 pandemic, PPR expenditure as a share of GDP declined across all income groups in 2023, although it remained, on average, 13% above 2019 levels (Figure 2).
Health PPR expenditure as a share of GDP, 2018-2023
Note: HIC = high-income countries; UMIC = upper-middle‑income countries; LMIC = lower-middle‑income countries; LIC = low-income countries Income groupings are based on the World Bank’s income classification. Estimates are based on limited country coverage and will be expanded as data becomes available.
Source: OECD Health Expenditure and Financing Database and WHO Global Health Expenditure Database.
Low-income countries continue to rely on external aid to fund PPR. In 2023, external sources financed 74% of total PPR expenditure among low-income countries with available data, while 19% was financed from domestic government resources and 7% from private spending. In addition, vulnerable countries that are most exposed to global health threats (for example, small-island developing states in the Pacific) rely heavily on aid to finance regional PPR mechanisms, alongside national spending (Penn et al., 2026[6]).
Estimates of national PPR expenditure, financed from both domestic and external sources, point to less than USD 4 per capita being spent on average in low-income countries (LICs) and around USD 5.5 in lower-middle income (LMICs) from both domestic and external sources, despite these countries often being the most at risk of global health threats. These estimates do not provide an assessment of the financing needs, nor does the amount of spending alone indicate the level of preparedness, which also depends on spending choices. Nevertheless, the relatively low levels of spending reinforce concerns about low-income countries’ ability to strengthen core prevention and preparedness capacities and respond effectively to future global health threats.
In 2021, the WB, WHO and the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response highlighted a substantial annual financing gap of USD 10.5‑15 billion for PPR (G20 HLIP, 2021[7]; The World Bank/WHO, 2022[8]). Efforts have been made to close this gap, including the creation of the Pandemic Fund, a dedicated multilateral financing mechanism. Despite these efforts, estimates presented here show PPR declining across all income groups between 2021-2023.
The majority of PPR spending in LICs and LMICs is financed through external aid. These findings highlight the potential risks of recent shifts in the global health financing landscape, particularly with regards to external aid. The decline in ODA for health in recent years is rapidly reducing the availability of external financing for PPR (OECD, 2026[9]).This creates a new risk that essential preparedness capacities will deteriorate as external resources contract. These risks have already been highlighted in the Democratic Republic of Congo and Uganda, where the onset of Ebola outbreaks in 2026 coincide with a projected decrease in ODA for health of 47% and 54% respectively in 2026, compared with 2024 levels (OECD, 2026[9]).
These findings reinforce the objectives of international initiatives such as the Lusaka Agenda and the Accra Reset which call for more sustainable, domestically financed health systems, while recognising that many countries will continue to require predictable external support, at least during the transition phase, with some countries continuing to require long-term external support.4,5 They also underscore the importance of improving transparency on both domestic and external financing to identify PPR gaps as they emerge and to help identify alternative sources of support where relevant.
The OECD will be working jointly with the WHO, World Bank and other partners to develop a Global Health and Resilience Tracker to provide a more comprehensive and consistent picture of PPR financing over time (European Commission, 2026[10]). By bringing together different partners and data sources, the tracker will improve the visibility of spending trends, help to identify financing gaps and support more sustainable investment in the capacities needed to prevent, detect and respond to health threats.
The Tracker will be developed using a mixed-method approach, combining data on domestic health expenditure, official development assistance and other relevant sources. It aims to strengthen the measurement of PPR expenditure and better reflect its cross-sectoral nature. Recognising that PPR extends beyond the health sector, the Tracker will progressively expand to capture expenditure in animal health, agriculture, environmental surveillance, defence and other relevant sectors. It will also consider broader investments that underpin health system resilience, including workforce development, infrastructure and health information systems The Global Health and Resilience Tracker can therefore help connect financing across sectors and support a more coherent approach to resilience.
References
[12] Accra Reset (2026), The Accra Reset, https://accrareset.org/ (accessed on 11 September 2026).
[10] European Commission (2026), Reinforcing global health resilience amidst geopolitical change. Brussels, 13.5.2026 COM(2026) 197 final, https://international-partnerships.ec.europa.eu/document/download/c0e94b0c-e9ed-4088-9a7b-1ed94c34df48_en?filename=com-2026-197-1-act-part1-ghri_en.pdf.
[11] Future of Global Health Initiatives [FGHI] (2018), The Lusaka Agenda: Conclusions of the Future of Global Health Initiatives Process – FGHI, https://futureofghis.org/final-outputs/lusaka-agenda/ (accessed on 11 September 2026).
[7] G20 HLIP (2021), A global deal for our pandemic age: Report of the G20 High Level Independany Panel on Financing the Global Commons for Pandemic Prepaaredness and Response, https://nam.edu/wp-content/uploads/2026/01/High-Level-Summary.pdf.
[1] HLIP (2025), Closing the Deal: Financing Our Security Against Pandemic Threats, G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response, https://nam.edu/wp-content/uploads/2025/11/UPDATED_FINAL_Closing-the-Deal_compressed-1.pdf.
[3] OECD (2026), ODA projections for 2026 and the near-term: Implications for vulnerable countries and sectors, OECD Publishing, Paris, https://doi.org/10.1787/d7c74fa2-en.
[9] OECD (2026), The latest 2026 ODA projections reveal aid for health is further at risk, https://www.oecd.org/en/data/insights/data-explainers/2026/06/the-latest-2026-oda-projections-reveal-aid-for-health-is-further-at-risk.html (accessed on 28 August 2026).
[4] OECD/Eurostat/WHO (2017), A System of Health Accounts 2011: Revised edition, OECD Publishing, Paris, https://doi.org/10.1787/9789264270985-en.
[6] Penn, C. et al. (2026), “Increasing volatility in external financing: what it means for health financing and the future of the Pacific”, Paper presented at the 17th Pacific Heads of Health (PHoH) Meeting, https://www.spc.int/DigitalLibrary/Doc/PHD/Meetings/HeadsDirectors_of_Health_meetings/2026/English/WP/PHOH17___WP_3___Item_2.3___Increasing_Volatility_in_External_Financing___OECD.pdf.
[2] Penn, C. et al. (2025), “Smart spending to combat global health threats: Tracking expenditure on prevention, preparedness, and response, and other global public goods for health”, OECD Health Working Papers, No. 175, OECD Publishing, Paris, https://doi.org/10.1787/166d7c57-en.
[8] The World Bank/WHO (2022), Analysis of Pandemic Preparedness and Response (PPR) architecture and financing needs and gaps, G20, Indonesia, https://who-track.phmovement.org/analysis-pandemic-preparedness-and-response-ppr-architecture-financing-needs-gaps-and-mechanisms.
[5] WHO (2022), International Health Regulations (2005) Joint External Evaluation Tool, third edition, https://iris.who.int/server/api/core/bitstreams/f9a1d72f-d8e4-4abe-900f-040829de686d/content.
Contact
OECD Health Division, health.contact@oecd.org
← 1. The Development Assistance Committee (DAC) comprises 34 members and Associates: Australia, Austria, Belgium, Canada, Czechia, Denmark, Estonia, European Union, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Latvia, Lithuania, Luxembourg, Netherlands, New Zealand, Norway, Poland, Portugal, Romania (Associate), Slovak Republic, Slovenia, Spain, Sweden, Switzerland, the United Kingdom and the United States.
← 2. Figures presented in this brief are indicative estimates based on available expenditure data and methodological assumptions and should not be interpreted as estimates of actual PPR spending in individual countries.
← 3. Per capita spending is expressed in USD and is adjusted for inflation, but not for purchasing power parity. Country averages are not weighted by population.
← 4. Accra Reset is an Africa-led political and economic doctrine launched in 2025 to overhaul development co‑operation and shift the Global South from aid dependency to self-determination (Accra Reset, 2026[12]).
← 5. The Lusaka Agenda is a global framework launched in 2023 that outlines strategic shifts to reform global health financing and transition power back to national governments (Future of Global Health Initiatives [FGHI], 2018[11]).