The Global Health Security Agenda and International Health Regulations

December 19, 2014 The Global Health Security Agenda and International Health Regulations Introduction In recent years, a succession of new and reemerging infectious diseases have caused outbreaks and pandemics that have affected thousands of people worldwide: Severe Acute Respiratory Syndrome (SARS, 2003), Avian Influenza H5N1 (2005), Pandemic Influenza H1N1 (2009), Middle East Respiratory Syndrome coronavirus (MERS-CoV, 2013), and the ongoing Ebola outbreak in West Africa. In 2005, the World Health Assembly (WHA), the governing body of the World Health Organization (WHO), amended the International Health Regulations (IHR) to • expand the scope of the IHR from the original three diseases (cholera, plague, and yellow fever) to include new, emergent, and re-emergent diseases, as well as other non-infectious disease agents; • define core public health preparedness and response capacities necessary for ensuring global capacity to detect, assess, report, and respond to public health threats; and • designate national points of contacts to ensure adherence to the regulations. The Department of Health and Human Services (HHS) is the U.S. point of contact. The regulations, referred to as IHR (2005) to reflect the date in which they were amended, describe measures to be taken to strengthen global capacity to respond to public health events with potential international impact. The IHR (2005) includes provisions that call for all WHO Member States to • notify WHO of any event that may constitute a Public Health Emergency of International Concern (PHEIC) and respond to requests for verification of information regarding such events; • follow WHO recommendations concerning appropriate public health responses to the relevant PHEIC; • build and maintain core public health capacities for disease surveillance and response; and • collaborate with other Member States to provide or facilitate the delivery of technical assistance in support of developing and maintaining core public health capacities among all Member States. Global commitment to the regulations have been questioned, as IHR (2005) implementation has been sluggish. As of June 2014, approximately 20% of countries worldwide had fully implemented the regulations. The majority of countries worldwide, especially resource-poor states, do not have the capacity to implement the IHR (2005) without additional assistance, as evidenced by the inability of Guinea, Sierra Leone, and Liberia to contain the ongoing Ebola outbreak in West Africa. The lack of significant improvements in the core public health capacities since the adoption of IHR (2005), slow response by the international community when presented with an identified PHEIC, and inconsistent public health actions in light of recommendations issued through IHR (2005) technical advisory mechanisms has called into question the global commitment to IHR (2005). Slow responses by the international community to the Ebola outbreak and lackluster progress in implementing IHR (2005) have deepened support for the Global Health Security Agenda (GHSA), a global effort to accelerate IHR implementation. Overview Announced in February 2014 by former HHS Secretary Kathleen Sebelius and WHO Director-General Margaret Chan, the GHSA is aimed at accelerating IHR (2005) implementation, particularly in resource-poor countries that lack the capacity to comply with the regulations. The agenda is led by governments, private partners, and nongovernmental (NGO) groups who have committed to lead or contribute to advancing the GHSA. Eleven Action Packages outline a specific set of actions to be taken to achieve GHSA targets and objectives within five years. Each Action Package focuses on a particular element of infectious disease control. These include 1. antimicrobial resistance; 2. zoonotic diseases; 3. biosafety and biosecurity; 4. immunizations; 5. national laboratory systems; 6. surveillance systems; 7. disease reporting; 8. workforce development; 9. emergency operations centers; 10. linking public health with law and conducting multi-sectoral rapid responses; and 11. medical countermeasures and personnel deployment. The United States has committed to lead the Action Package on national laboratory systems and to contribute toward five others (indicated by italics). By the end of September, more than 40 countries had committed to the GHSA and others are expected to join. www.crs.gov | 7-5700 The Global Health Security Agenda and International Health Regulations Though there is no specific budget for the GHSA, the strategy offers a coordinated mechanism through which donors can target technical and financial aid for various Action Packages. At the same time, the GHSA provides a structure through which countries can seek assistance in developing core public health capacities, as described in IHR (2005). Resources for supporting GHSA implementation are provided directly by donors to participating countries seeking aid. U.S. Policy The United States has played a leading role in the development and implementation of the GHSA. President Barack Obama has prioritized the GHSA and has ensured high-level support for the initiative. In September, the United States hosted the fourth meeting on the GHSA, which was attended by the President, members of his Cabinet, and top White House Officials. During the meeting, countries committed to take concrete steps toward implementing the GHSA and Administration officials announced that the United States would help at least 30 countries achieve the GHSA objectives over the next five years. U.S. Funding for GHSA Relevant Activities In the absence of a specific budget for the GHSA, it is not possible to determine how much the United States has spent or will spend on advancing the effort. For FY2015, the Administration has requested funds for the GHSA as part of the regular budget request as well as in an emergency funding request for Ebola. The FY2015 Congressional Budget Justification (CBJ) for the Centers for Disease Control and Prevention (CDC) included $100 million for “global public health protection,” $45 million of which would be for establishing a Global Health Security (GHS) program to • improve the capacity of 10 countries to manage emerging threats, detect disease outbreaks, and respond to global epidemics and other health emergencies; • build capacities for testing new pathogens globally; and • accelerate the development of new diagnostics tests. According to the CBJ, the GHS program “will be part of” U.S. implementation of the Global Health Security Agenda. Key objectives of the GHS program include • prevention of avoidable catastrophes—improving global food and drug safety, addressing antimicrobial drug resistance, strengthening biosafety and biosecurity, improving immunization capacity, and enhancing border safety and security; • early threat detection—establishing a global laboratory network, improving disease surveillance and monitoring systems, training and deploying epidemiologists and laboratory scientists, creating a bioinformatics system, and developing and disseminating novel diagnostic tools; and • effective outbreak responses—creating an interconnected global network of Emergency Operations Centers, establishing rapid response teams worldwide, operating a global reagent resource, and developing response communications and crisis planning and management tools. total program costs (in-kind or financial) during the first year, and contributions are expected to average half of all spending in-country by 2025. Middle-income recipient countries will reportedly contribute at least 10% in 2015, and contribution levels are planned to reach 90% by 2025. The FY2015 Consolidated Appropriations Act did not specify funding for the GHS program but included $1.2 billion to HHS for international Ebola activities, including $597 million for CDC to establish and strengthen National Public Health Institutes (NPHIs) and global health security. Budgetary requests for ongoing USAID pandemic preparedness programs could also be used to advance the GHSA. In FY2015, USAID requested $50 million for pandemic preparedness efforts, roughly 31% less than the FY2014 level. The FY2015 Consolidated Appropriations Act provided $72.5 million for related efforts. Issues for Congressional Consideration Congressional support for strengthening weak health systems around the world has grown in recent months, prompted in large part by the West African Ebola outbreak. It remains to be seen whether this support will be extended to the GHSA. The Administration has requested that Congress fund GHSA activities through both regular appropriations and the emergency Ebola request. Experts agree that the global spread of the Ebola outbreak has demonstrated the threat weak health systems in foreign nations pose to the international community. There is some debate, however, about whether the emergency Ebola request is the appropriate mechanism for funding health system strengthening efforts like the GHSA. At issue is whether addressing a long-term problem (weak health systems) should be funded through a short-term mechanism (emergency appropriations). Approaches for supporting the GHSA raise other questions as well: • coordination and oversight—U.S. Government (USG) implementation of the GHSA is carried out by several U.S. agencies and departments. The White House regularly convenes interagency meetings, though there is no formal mechanism for doing so. What agency, if any, should coordinate these efforts over the five-year period to avoid duplication of efforts and ensure efficient and effective use of U.S. resources? How will the Administration integrate and report on each agency’s contribution to the GHSA? • measurement—USG implementation of the GHSA is carried out by several agencies through a number of existing programs. The Administration would also like to develop a new program at CDC specifically for the GHSA. What relationship, if any, will the new Global Health Security program have with ongoing USG global health programs? How will the United States distinguish progress made in achieving GHSA Action Packages from other related bilateral efforts? What mechanisms, if any, have been established to measure agency-specific contributions to the GHSA? Tiaji Salaam-Blyther, tsalaam@crs.loc.gov, 7-7677 In an effort to build sustainability, CDC has incorporated costsharing mechanisms into the GHS program. Low-income recipient countries will reportedly contribute at least 10% of www.crs.gov | 7-5700 IF10022