The Failure of Preparedness Monitoring

This is a study about pandemic preparedness monitoring, the practice of evaluating, assessing, and measuring those capacities of health systems which are believed to enable countries to better manage epidemic and pandemic events. For many years, pandemic preparedness has been at the center of the global governance effort of global health security. Ever since the 1990s, the notion of pandemic preparedness and health security has shifted priorities in the field of international health collaboration, reformed international health law and the role of the World Health Organization, initiated new networks and institutions of global public health, and reoriented priorities for charities and NGOs. Within the governance and diplomacy arenas of the international community, pandemic preparedness has been established as an important obligation of countries. Accordingly, the monitoring of the development of preparedness capacities has become an important cornerstone of the multi-actor project of global health security. Global health security is imagined to unfold as a decentralized but concerted process of closing those infrastructural gaps in health systems which might threaten a swift and competent response to health events and thereby endanger lives as well as economic stability all over the globe. Preparedness monitoring is supposed to be the means of informing and steering this successive process of infrastructural build-up. By now, a variety of actors engage in the practice of assessing the preparedness capacities of countries, using different measures of monitoring and producing different forms of knowledge and data. The overall goal of this practice is to foster accountability for countries’ efforts to prepare for pandemics and to achieve a development towards more resilient health systems. This research investigates this preparedness accountability practice – its means, effects, failures, successes, and misunderstandings – as part of global health security governance.

Although the COVID-19 pandemic disrupted and catalyzed a variety of developments in the field of global health, especially the practice of preparedness monitoring has gained attention. This was the case because the established measures of preparedness seemed to have failed rather spectacularly: the countries ranked highest on the preparedness scales also ranked highest for numbers of infections and deaths of COVID-19. Being evaluated as “well prepared” did not seem to coincide with a pandemic response performance that was able to keep the numbers of deaths and infections low. Accordingly, the value and the form of the knowledge produced by existing preparedness monitoring measures has come into question, not just from the perspective of critical voices commenting on the programs and means of global health security but also from voices from within the governance efforts, which appreciate preparedness monitoring as an important instrument to improve global health. Nevertheless, in the moment of it being discussed most critically, preparedness monitoring was not abandoned. Rather, it was reinstated through the introduction of yet another procedure, the Universal Health and Preparedness Review, which is going to be positioned even more prominently within the shifting legal-administrative governance arrangements of global health security.

A number of questions have been raised in the context of this – for many, paradoxical and disappointing – development: Why have so many people been infected and have died in high-income and highly prepared countries too, oftentimes in higher numbers than in supposedly less prepared countries? What exactly is being monitored in preparedness monitoring, and which expectations can reasonably be attached to the knowledge produced in preparedness monitoring? Does preparedness monitoring predict the pandemic response performance and resilience of countries? Does it actually help to close preparedness gaps? If not, what is the value and the function of preparedness monitoring, for individual countries and within the governance architecture of global health security?

By answering some of these questions, this study argues, based on document analysis, ethnographical observations, and interview material, that global pandemic preparedness is a paradoxical effort of infrastructural development. Preparedness monitoring operates by means of an infrastructural problematization: it urges to build up infrastructures for preparedness data, transparency, and accountability, and aims to foster and develop health systems infrastructures. This book traces the ways preparedness monitoring builds on the (modernist) promise of infrastructure and development, and discusses how and why this promise fails.

Approaching global health security and preparedness governance as an infrastructural governance effort is not new; rather, it builds on existing literature along these lines and picks up long-standing tropes of (critical) global health: that there is an unmet need for more ‘structural solutions’ and for stronger investment in health systems infrastructures. This critique is most visibly reiterated in the context of epidemic and pandemic events, and the focus of this investigation rests on the developments in the time between the Ebola virus epidemic in West Africa in 2014-16 and approximately mid-2022. As this research has been conducted from 2018 to mid-2022, it has witnessed turbulent times for the field of global health: the SARS-CoV-2 pandemic appeared to be the ultimate “stress test” for the health security governance architecture, which had consolidated since the revised International Health Regulations entered into force in 2007. While I was finishing this manuscript in 2023 and 2024, the developments toward amending the existing legal apparatus and implementing a new international preparedness review were still ongoing.

Overall, my following analysis is carried by an interest in power dynamics and in the conditions of inequity which characterize global health and global health security. To the relevant sociological and anthropological literature this study adds a twofold description of the peculiar infrastructuralism that characterizes preparedness governance: Part I lays out an event-based genealogy of the successive establishment of preparedness monitoring. It traces the development of the practice in relation to those health crises and outbreak events which cyclically have catalyzed changes in the global health security governance architecture and have introduced new preparedness and preparedness monitoring efforts. Such an event-absed genealogy highlights how power relations and the reach of certain and not other actors shape the implementation of preparedness monitoring and its technologies. Part II complements this account with an ethnographic case study and scrutinizes one of the most important preparedness monitoring measures, the Joint External Evaluations (JEE). Here, thick ethnographical descriptions give an account of the logics and the tensions that characterize the infrastructural promise of preparedness and preparedness monitoring. Based on my ethnographical observations, I argue that the process is characterized by the technocratic and modernist assumption about the universality and the effectiveness of administrative paperwork and media infrastructures. This allows me to pick up and nuance one of the core critiques of preparedness monitoring: that this transparency practice monitors the capacity to produce evidence for preparedness capacities, i.e. paperwork, rather than the actual preparedness capacities.

Preparedness Monitoring as Infrastructural Inversion

The following research is anchored in two related and interdisciplinary fields of scholarship. These are, on the one hand, social science investigations, which have discussed the rise of formats of transparency and monitoring in (global) governance, the so-called “audit culture” or “evaluation society” (e.g. Power 1996; Dahler-Larsen 2011). And on the other, studies on infrastructure. Building on this scholarship, I anchor the analysis in the premise that, firstly, preparedness monitoring is an accountability practice, situated in the inherently unequal power relations that characterize global health, and secondly that it is an infrastructural inversion, a “turning” of attention to those underlying structures enabling public provision and a reliable state,...