Even as the world is struggling to address COVID-19, we must plan and prepare for future pandemics. In fact, a recent estimate shows that the probability of a future zoonotic spillover event resulting in a pandemic of COVID-19 magnitude or larger is high: a 22-28% chance within the next ten years. 

With this risk in mind, the leadership of the US Senate Foreign Relations Committee has been building a fresh approach to global health security. Their internal negotiations, and dialogue with civil society, culminated in a vote last week on a landmark piece of bipartisan legislation—the International Pandemic Preparedness and COVID-19 Response Act.

Going well beyond previous bills on this topic, this measure includes important provisions on the health workforce and health systems. That’s important for many reasons, but one is that many countries are finding weak health systems to be an impediment to rapid scale-up of COVID-19 vaccination. There is a risk that later this year vaccine supplies could far exceed country capacity to administer them.

Senators Risch (R-ID), the Committee’s ranking member, and Menendez (D-NJ), the Committee chair, are the principal authors of the bill, and Senators Portman (R-OH) and Murphy (D-CT) joined as initial cosponsors. During the markup last week (recording now online) Senator Risch said, "Something of this magnitude has to be a bipartisan bill. At some point in history, this bill may be the most important thing that everyone on this committee has done.”

The bill has been the subject of intensive advocacy efforts by a range of organizations and advocacy groups, including the Frontline Health Workers Coalition. We suggested many additions and changes to the bill, to make it more inclusive and to reflect the needs of the health workforce in low- and middle-income countries, many of which were included in the final version that the Committee approved.

Chances are good this bill will become law. The House has already passed a similar bill, HR 391, that is much narrower in scope, and the two bodies may merge the two bills or simply pass the Senate version. It is unclear how larger political and legislation considerations will affect movement of this bill toward becoming law, but the possibility of President Biden signing it by the end of the year is real. It will require concerted advocacy across all constituencies and interested stakeholders to ensure that this momentum continues.

What does the bill contain?

The primary purpose of the bill is to improve the coordination of US global health diplomacy and assistance efforts, establish effective international early warning systems for disease outbreaks, and create an international incentive fund for pandemic prevention and preparedness.

The bill authorizes $5 billion for these purposes over a five-year period (note: “authorize” in this case does not mean the bill itself provides funding; rather, this funding provision serves as a recommendation to the Appropriations Committee.)

However, unlike H.R 391, the “companion” bill in the House, the bill also establishes a health systems strengthening pilot program for the US Agency for International Development (USAID) to launch in at least five countries where the US has significantly invested in global health. 

How will the health systems pilot program work?

For each of the pilot countries, USAID is to “develop an integrated approach toward health systems strengthening that takes advantage of all sources of funding for global health in such country.” The bill states that the aim is to establish “an enduring model for coordinating health systems strengthening activities in additional countries in the future.”

USAID Missions in each country, in consultation with USAID’s Office of Health Systems, must assess the health system and the resource landscape, consult with a wide variety of stakeholders, and then develop and implement a five-year strategy to strengthen the health system.

The country strategies must have “clear goals, benchmarks, outputs, desired outcomes, a means of measuring progress, and a cost analysis.” Among the many strategy elements listed are supporting proper distribution and high-quality job performance of health workers, formalization of the community health workforce, and ensuring women and frontline health workers are included in decision-making.

What about funding for health systems strengthening?

Congress provides no dedicated budget line for health systems strengthening in its annual funding bills, nor have successive Administrations requested it in the past. In fact, USAID recently stated that it is unable to provide centralized strategic direction or incentives to Missions to support health systems strengthening.

Will USAID have the resources to carry out this pilot program? This bill alone will not determine yes or no. The bill does not authorize or mandate a specific funding amount for this purpose, nor does it place a cap on funding; rather it requires the USAID Administrator to ensure that the Agency has sufficient capacity to carry out the program. Focus will now turn to the appropriations process in Congress to determine priorities for this coming fiscal year beginning on October 1. 

To press for and track progress, the bill contains some important reporting provisions:

• Each agency—including the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative, and USAID—must report on their participation and contribution in each pilot country, including in the PEPFAR Annual Report to Congress.
• Within 180 days of enactment, USAID and the Office of the Global AIDS Coordinator and Health Diplomacy (OGAC) must provide a joint report that outlines progress in implementing the program, including for cross-cutting efforts to strengthen local health workforces.
• The bill requires USAID and OGAC to provide detailed information on funding for health systems strengthening in the Administration’s Fiscal Year 2023 budget justification, including on what resources are needed to carry out the pilot program and any areas of joint funding.

It is also worth noting that the House has approved a funding bill for Fiscal Year 2022 that requires that not less than 10% of each global health program be spent on cross-cutting health systems capacity. If approved by the full Congress, this provision would provide significant, immediate funding to carry out the pilot program.

A new “Global Fund” – this time for pandemic preparedness and response

A centerpiece of the bill is Title III, which says the US should begin international negotiations to set up a Fund for Global Health Security and Pandemic Prevention and Preparedness. It lays out a series of recommendations for how the Fund should be structured and what it should prioritize.

Various versions of such a fund have been proposed, for instance by the G20 HLIP. In addition, $250 million is included in the Biden Fiscal Year 2022 budget proposal for such a multilateral, catalytic fund, and 120 House members signed a letter calling for the US to contribute $2 billion to the Fund.

Among the objectives of this new Fund are to “strengthen and sustain resilient health systems and supply chains with the resources, capacity, and personnel required to prevent, detect, mitigate, and respond to infectious disease threats, including zoonotic spillover, before they become pandemics.”

The bill suggests a governance structure for this Fund that includes representatives from low- and middle-income countries as well as independent civil society representatives—including frontline health workers—to make funding and other decisions. 

The bill also says the Fund should finance a list of activities, some of which go beyond what is usually considered “global health security,” including these, to name just a few:

• “Strengthen the health workforce, including hiring, training, and deploying experts and other essential staff, including community health workers…including capacity to surge and manage additional staff during emergencies,”
• “Improve the quality of community health worker programs as the foundation of pandemic preparedness and response through application of appropriate assessment tools,” and
• “Improve infection prevention and control, the protection of healthcare workers, including community health workers, and access to water and sanitation within health care settings.”

The bill also has a number of provisions directly related to the current crisis. For instance, it sets a target of vaccinating 60% of people in all countries worldwide by mid-2022, as well as “supporting global COVID vaccine distribution strategies that strengthen underlying health systems.” During the markup, Senator Merkley (D-OR) also made a strong plea for bolder US action to stop the global crisis of COVID-19.

Next steps

Thanks to all who worked to advance this bill, and the Senators who weighed in to strengthen its provisions on the health workforce and health systems, notably Senators Coons (D-DE) and Markey (D-MA).

Now global health workforce advocates need to make sure the provisions we feel are important—like the ones I highlighted above—make it through any negotiation with the House and influence the Appropriations Committee, which decides the funding levels. We also need to urge the Biden Administration to incorporate the ideas we favor into its own approach to global health security, including in its Fiscal Year 2023 budget proposal and how USAID targets a proposed three-fold increase in global health security funding in Fiscal Year 2022.

The health workforce, which has suffered tremendously during the COVID-19 pandemic, is counting on us to learn lessons from this crisis and act on them.

This post was originally published on the Frontline Health Workers Coalition blog on August 5, 2021. You can read it here.