Tiaji Salaam-Blyther wrote this CRS Report (9 February 2024):'Global Health Security - Background and Issues for Congress'.
Download CRS_InFocus_Rpt_Global_Health_Security_Background_Issues_Congress_9Feb2024_IF12590
Background
Congressional interest in the capacity of health systems, especially in low- and middle-income countries (LMIC), to detect, control, and respond to infectious disease threats is growing. Programs to build such capacity are integral to U.S. “global health security” (GHS) policy. Key areas of focus of such programs include strengthening national laboratory and surveillance systems and improving risk communication. GHS appropriations have been growing, particularly since the emergence of COVID-19 in early 2020. Related issues for Congress include deliberation of funding levels for GHS programs, oversight of reorganization within the Department of State (DOS) to establish the new Bureau for Global Health Security and Diplomacy (GHSD), and consideration of how the reorganization might affect the administration of global HIV/AIDS programs.GHS Appropriations
Appropriations for GHS efforts administered by the U.S. Agency for International Development (USAID)—the primary funder of U.S. bilateral GHS programs—more than quadrupled between FY2021 and FY2023 (Table 1). Since FY2022, the Biden Administration has also requested multilateral GHS funding in the DOS budget. These amounts are in addition to funds provided for COVID-19 control through emergency appropriations.
GHS Mandatory Funding Request
The increased frequency and severity of infectious disease outbreaks has intensified debates about the effectiveness of appropriating funds annually for GHS. In March 2022, the Biden Administration released its FY2023 State, Foreign Operations (SFOPS) Congressional Budget Justification (CBJ), which included a $6.5 billion request for mandatory multiyear funding authority for GHS programs (global health funding is typically discretionary). The funds were requested in addition to the discretionary appropriations detailed in Table 1, and included
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$4.5 billion “in seed funding” from DOS for the World Bank Pandemic Fund;
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$1.0 billion, including $250.0 million for DOS and $750.0 million for USAID bilateral GHS programs;
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$500.0 million to USAID for a contribution to the Coalition for Epidemic Preparedness Innovations (CEPI) to support vaccine research, development, and delivery, and to develop and deploy innovative tools to build resilience for future pandemics; and
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$500.0 million to replenish the Emergency Reserve Fund, which USAID uses to respond rapidly to infectious disease outbreaks.
Congress did not enact the mandatory spending proposal, but it authorized $5.0 billion for GHS activities for the same five-year period through the Global Health Security and International Pandemic Prevention, Preparedness and Response Act of 2022 (“Global Health Security Act,” Title LV of P.L. 117-263, FY2023 National Defense Authorization Act), discussed below.
Global Health Security Act
Congress enacted the Global Health Security Act in December 2022. Among other things, the act addressed many of the items in the Biden Administration’s multiyear budget request for GHS and included provisions to enable congressional oversight of authorized activities, such as the following:
Support for World Bank Pandemic Fund. Authorized U.S. contributions to (up to 33% of contributions from all sources) and participation in a Financial Intermediary Fund for Pandemic Prevention, Preparedness, and Response (later referred to as the Pandemic Fund) at the World Bank.
Coordination of bilateral GHS activities. Required the President to identify the relevant departments and agencies leading U.S. responses to global infectious disease outbreaks, and to notify the appropriate congressional committees of the aforementioned roles and responsibilities no later than 120 days after enactment of the act, and regularly thereafter.
Allocate USAID staff for GHS activities. Authorized USAID to cover the cost of detailing its employees to address global health emergencies and natural or human- induced disasters, and required the USAID Administrator to notify the appropriate congressional committees at least 15 days before making funds available for such purposes.
GHS strategy. Required the President to develop and maintain a strategy for improving GHSD for pandemic prevention, preparedness, and response. The strategy was to be submitted to the appropriate committees within 180 days of enactment, followed by annual progress reports. As of February 8, 2024, the Administration has not published a GHS Strategy, per se, though it released a National Biodefense Strategy and Implementation Plan in October 2022, which outlined goals for building “capacity across at least five technical areas in at least 50 countries.”
U.S. Coordinator for Global Health Security. Instructed the President to designate an appropriate senior official to be the U.S. Coordinator for Global Health Security, who shall be responsible for the coordination of the Global Health Security Agenda Interagency Review Council. (See“GHSD Bureau” section for more information.)
Ambassador-at-Large for Global Health Security and Diplomacy. Established the position of Ambassador-at- Large for GHSD at DOS to ensure oversight, coordination, and management of GHS funds used by DOS; lead, in collaboration with the U.S. Department of Health and Human Services (HHS) Secretary and USAID Administrator, diplomatic GHS activities; and promote investments for building GHS worldwide. (See “GHSD Bureau” section for more information.)
Coordinating global health and GHS. Directed the USAID Administrator to collaborate and coordinate with the Global Malaria Coordinator, Global AIDS Coordinator, the Ambassador-at-Large for GHSD, and the HHS Secretary, where possible, on U.S. global health programs.
GHSD Bureau
On December 13, 2022, DOS submitted a congressional notification (CN) to Congress describing its intent to create a new GHSD Bureau whose mission is to lead U.S. diplomatic engagement and improve the efficiency of U.S. GHS programs; leverage and help coordinate bilateral foreign aid; promote international coordination for improving GHS and convene global stakeholders to establish norms and policies to mitigate global health threats; and elevate and integrate GHS as a U.S. national security and foreign policy priority.
In August 2023, Secretary of State Antony Blinken announced the launch of GHSD, which houses several operating units across DOS, including the Office of International Health and Biodefense, the Office of Global Health Diplomacy, and the Office of the Global AIDS Coordinator (OGAC), along with the functions of the Coordinator for Global COVID-19 Response and Health Security. In September 2023, President Biden formally nominated the current U.S. Global AIDS Coordinator, Ambassador Dr. John Nkengasong, to serve as Ambassador-at-Large and Senior Bureau Official for Global Health Security and Diplomacy. The Biden Administration intends for the Ambassador to concurrently lead GHSD and OGAC. The Senate is considering the nomination.
The DOS FY2024 CBJ included the first budgetary request for the administration of GHSD ($10.3 million). According to the CBJ, the funds are to be used to pay the salaries of 35 staff through the Diplomatic Programs account. An additional 102 positions are to be funded through OGAC.
Issues for Congress
Funding. Congress has increased GHS appropriations while also raising questions about the capacity of programs to expand. The House Appropriations Committee noted in H.Rept. 118-146, “a substantial amount of unobligated balances despite critical needs.” Questions from some Members about the pace of GHS spending through bilateral programs reflect long-standing debates about the appropriate balance of funding for bilateral and multilateral programs. The bulk of the Administration’s FY2023 multiyear request and FY2024 GHS request was for the multilateral Pandemic Fund, not bilateral programs.
Oversight. The Senate Appropriations Committee has questioned how bilateral GHS funds are being used, calling for greater oversight of the funds. In S.Rept. 118-71, for example, the committee instructed the USAID Administrator to report to the Appropriations Committees on how it intended to use GHS funds per country and project within 90 days of enactment and every 90 days until such funds are expended. Other oversight interests might include the status of a GHSD strategy, as required by the Global Health Security Act, and clarification with regard to which agency is to receive funds authorized by the Global Health Security Act and for which activities.
Reorganization. Congress may also consider whether, and to what extent, it seeks to oversee ongoing reorganization at DOS for the establishment of the GHSD Bureau. According to the FY2024 CBJ, roughly 74% of GHSD positions are to be held by OGAC staff. In 2022, the Government Accountability Office issued a report describing workload and retention issues at OGAC. Congress may choose to ask the Administration how DOS will effectively administrate additional GHSD duties while simultaneously addressing staffing challenges at OGAC. Congress might also debate whether one person can effectively oversee two major global health programs (President’s Emergency Plan for AIDS Relief [PEPFAR] and GHSD).
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“Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” - WHO
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