Health Security Volume 13, Number 1, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/hs.2014.0047

Implementing the Global Health Security Agenda: Lessons from Global Health and Security Programs Suman M. Paranjape and David R. Franz

The Global Health Security Agenda (GHSA) describes a vision for a world that is safe and secure from infectious disease threats; it underscores the importance of developing the international capacity to prevent, detect, and respond to pandemic agents. In February 2014, the United States committed to support the GHSA by expanding and intensifying ongoing efforts across the US government. Implementing these goals will require interagency coordination and harmonization of diverse health security elements. Lessons learned from the Global Health Initiative (GHI), the President’s Emergency Program for AIDS Relief (PEPFAR), and the Cooperative Threat Reduction (CTR) program underscore that centralized political, technical, and fiscal authority will be key to developing robust, sustainable, and integrated global health security efforts across the US government. In this article, we review the strengths and challenges of GHI, PEPFAR, and CTR and develop recommendations for implementing a unified US global health security program.

I

n conjunction with the formal launch of the Global Health Security Agenda (GHSA) in February 2014, the United States formalized its commitment to work with partners to ensure a ‘‘world safe and secure from global health threats posed by infectious diseases.’’1 To achieve this, the US outlined an ambitious goal of partnering with 30 countries, with a combined population of at least 4 billion, over the next 5 years to improve the capability to prevent, detect, and respond to infectious disease outbreaks.2 The Department of Health and Human Services (HHS) and its Centers for Disease Control and Prevention (CDC), the United States Agency for International Development (USAID), the US Department of Agriculture

(USDA), the Department of State (DoS), and the Department of Defense (DoD), among others, will contribute to the efforts through existing agency-run programs.3 The World Health Organization (WHO) defines global health security as ‘‘the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries.’’4 The success of the United States in implementing the GHSA requires that issues of governance, management, and accountability be addressed to ensure coordination of political, technical, and fiscal inputs and outputs. In the absence of a defined operational plan,

Suman M. Paranjape, PhD, MPH, is a former Regional Program Lead for the US Department of Defense, Defense Threat Reduction Agency, Cooperative Biological Engagement Program (DOD/DTRA/CBEP); a former American Association for the Advancement of Sciences Diplomacy, Security, and Development Fellow at the US Department of State; co-leader of a collaboration to draft the USWHO Memorandum of Understanding for Health Security; and is currently a consultant with SW Consulting in Washington, DC, and co-founder of the Maya Health Network. David R. Franz, DVM, PhD, is a former commander of the US Army Medical Research Institute of Infectious Diseases (USAMRIID); former Chief Inspector on 3 United Nations Special Commission (UNSCOM) missions to understand the Iraqi biological warfare program; co-chair of the National Academies’ 2009 report, Global Security Engagement: A New Model for Cooperative Threat Reduction (CTR 2.0); and currently chair of the Biological Subgroup of NAS’s Committee for International Security and Arms Control. 9

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significant questions remain about how government agencies will harmonize programs and avoid redundant activities. In the current austere fiscal climate, it is especially important to enable synergistic outcomes in global health security across agency programs and with external stakeholders and international partners. In all of these respects, important lessons can be learned from other US government global health programs. Here we review some of the strengths and challenges of the Global Health Initiative (GHI), the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Nunn-Lugar Cooperative Threat Reduction (CTR) program’s Cooperative Biological Engagement Program (CBEP) and make recommendations based on lessons learned.

Global Health Security Agenda Efforts by the United States to enhance global health security require the expertise to address threats precipitated naturally, accidentally, or intentionally and to underscore the important role of diverse US interagency stakeholders, nongovernmental organizations (NGOs), and academic institutions in attaining sustainable global health security goals. Pandemic threats of SARS, H1N1, MERS-CoV, and Ebola; reports of terrorist interest in acquiring or manufacturing biological materials; and our own concerns after the events of 2001 have intensified attention to global health security. The GHSA recognizes that, regardless of the origin of an outbreak or pandemic, prevention, detection, and response are key to protecting citizens of all nations.1 Currently, the US commitment to the GHSA includes plans to expand and intensify ongoing efforts across the government but does not specify how disparate activities will be coordinated. In the absence of funding specified for the coordination and oversight of the program, departments and agencies including HHS, USAID, USDA, DoS, and DoD will continue to pursue overlapping programs that align or intersect with global health security objectives. As we illustrate with examples of other global health programs, centralized governance of GHSA is critical to its success.

Global Health Initiative The GHI provides a precedent, and perhaps a cautionary tale, about the challenges that may lie ahead for the GHSA. President Obama and Secretary of State Clinton established the GHI in early 2009 to unify and streamline the United States’ investments and outcomes in global health and to develop a whole-of-government approach to the massive challenge. The GHI was initially led by the White House through the National Security Staff (NSS) and the Office of Management and Budget (OMB), in coordination with DoS.5 In 2011, approximately 18 months after the in10

ception of the GHI, an executive director was appointed to the GHI office located in the office of the Secretary of State and was assigned to coordinate and strengthen global health programs in 42 countries.6 Although the GHI executive director had clear political authority, with a small staff and limited technical and financial oversight, the GHI faced governance and accountability challenges from the beginning. Although $63 billion was promised over 6 years for the GHI, these funds were neither new money nor allocated directly to the GHI; instead, the funds were allocated for existing programs such as PEPFAR. Moreover, because of the deep fiscal crisis, global health budgets declined, decreasing expected GHI dollars and inciting interagency competition for resources and technical leadership. In 2012, the Obama administration discontinued the program and appointed the PEPFAR ambassador to oversee key aspects of the GHI, including development of global health systems, in a newly formed office of Global Health Diplomacy (GHD) at DoS. Following a change in leadership at PEPFAR, an ambassador was appointed solely to head the GHD office, with a mission focused on the important tasks of strengthening sustainable health systems and supporting health diplomacy.7 Despite backing from the White House, the lack of financial and technical authority undermined the ability of the GHI to leverage and coordinate the US agency stakeholders working in the global health space and led to failure of the initiative.

President’s Emergency Plan for AIDS Relief While the GHI faced challenges in its efforts to integrate and coordinate global health programs worldwide, the PEPFAR program exemplifies a model of integrated, whole-of-government implementation of a complex global health mission aimed primarily at controlling the spread of HIV/AIDS. Like the GHSA and GHI, PEPFAR was authorized not to pursue wholly new programs but to integrate, expand, align, and harmonize funding and global projects administered by several agencies, including HHS/ CDC, USAID, and DoD entities. At the request of President George W. Bush, Congress enacted legislation called the U.S. Leadership Against AIDS, Tuberculosis, and Malaria Act of 2003 (Leadership Act),8 providing authorization for the program that came to be known as PEPFAR with up to $15 billion over 5 years for the treatment, care, and prevention of HIV/AIDS. The Leadership Act mandated a policy framework, organizational and management requirements, and technical and fiscal targets for the program and directed the executive branch to develop ‘‘. a comprehensive, integrated, fiveyear strategy to combat global HIV/AIDS.’’8(p8) The legislation specified establishment of a single oversight body, the Office of Global AIDS Coordinator (OGAC), in the Health Security

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DoS in the Office of the Secretary and created the position of an HIV/AIDS Response Coordinator with the rank of ambassador, appointed by the President and confirmed by the Senate. The global AIDS coordinator was granted ‘‘primary responsibility for the oversight and coordination of all resources and international activities of the United States Government to combat the HIV/AIDS pandemic, including all programs, projects, and activities of the United States Government relating to the HIV/AIDS pandemic under the United States Leadership Against HIV/ AIDS, Tuberculosis, and Malaria Act of 2003 or any amendment made by that Act.’’8(p12) In addition to establishing fiscal and political management and oversight, the legislation specified technical targets and required the development of comprehensive metrics and knowledge management processes. The Leadership Act acknowledges the challenges of interagency coordination and mandated the establishment of an oversight entity with appropriate diplomatic, fiscal, political, and technical purview to effectively oversee coordination of US government agencies, harmonization of existing programs, and alignment of outcomes. The Leadership Act and subsequent reauthorizing legislation—the Lantos-Hyde Act9 and the PEPFAR Stewardship and Oversight Act of 201310—have established the largest US government global health commitment to date. PEPFAR currently oversees bilateral programs in 31 countries and has 3 regional commitments and projects in other countries. Activities are conducted by agencies and departments including USAID, DoD, HHS, and HHS/ CDC. As directed by Congress, DoS/OGAC oversees nearly all budget requests for PEPFAR, although some funds are distributed directly to partner agencies. The global AIDS coordinator and the OGAC staff oversee fiscal, technical, diplomatic, and political aspects of the program, both domestically and internationally. To ensure harmonization of interagency efforts, PEPFAR’s organizational structure has evolved to include a Deputy Principals Group11,12 composed of program directors from stakeholder agencies, which advises agency political appointees as well as the global AIDS coordinator. In partner countries, the ambassador or the deputy chief of mission has primary authority for PEPFAR activities and serves as the diplomatic face of the program. In most cases, an appointed PEPFAR country manager oversees program operations and the PEPFAR interagency mission team. As the Office of the Inspector General notes, ‘‘[T]hose embassies that hired effective PEPFAR coordinators had relatively successful programs. There was less interagency strife, better communication with S/GAC, less strain on embassy resources, and better integration of the program with U.S. interests in the host countries.’’13(p13) Recognizing that strong leadership is essential for orchestrating and coordinating programs of PEPFAR’s scale, OGAC has recently instituted a training program that prepares incoming PEPFAR country coordinators for the position.13 Volume 13, Number 1, 2015

Since its inception in 2003, PEPFAR has developed strategies to improve interagency coordination and consensus and ensure successful program development. As mandated in the Leadership Act and reauthorizing legislation, PEPFAR headquarters is required to develop subsequent 5-year strategic plans detailing overarching vision, goals, and annual targets for the program. The initial plan became the namesake of the program and laid the foundation for the program. Interagency stakeholders, through interagency committees, are responsible for developing the annual headquarters operational plan. This plan outlines all PEPFAR funding commitments and activities and ‘‘articulate[s] how these primary functions will be supported across a diverse set of agencies, each of which offers a comparative advantage to global engagement in HIV/ AIDS.’’14 As directed by the Lantos-Hyde reauthorization act of 2008, PEPFAR has developed a mechanism for negotiating framework documents with partner countries that ensures that activities are designed to meet the needs and realities of partner countries. This mechanism, called the Partnership Framework, focuses on 7 areas that promote the bilateral development of strategies that align with the priorities and capabilities of the country and enable the development of PEPFAR-funded programs that are country-led and sustainable. Country-level US interagency committees are also responsible for developing annual country operational plans and regional operational plans that outline strategies for bilateral resource allocation as well as primary implementing functions of interagency stakeholders. At both the headquarters level and the country level, PEPFAR uses a mechanism of collaborative governance to ensure that stakeholders share priorities and work together efficiently to achieve goals. To ensure evidence-based policy and decision making, technical working groups develop recommendations on subjects including technical strategies and program information that are conveyed to the Deputy Principles Group and the OGAC coordinator. An important aspect of PEPFAR’s coordination is a rigorous system for managing knowledge, including shared metrics and evaluations. PEPFAR leverages technical working groups and metrics to ensure that funded programs are conducted in alignment with rigorous technical and scientific knowledge. In general, technical working groups take their lead from normative organizations such as WHO and are composed of experts and stakeholders from all agencies, including members from headquarters and country teams. The technical working groups ensure that country teams receive consolidated and coordinated technical support on key programmatic areas that can be applied worldwide. Additionally, PEPFAR recognizes the critical importance of collecting comprehensive program data, tracking program targets, and assessing program impact. These efforts are coordinated by a dedicated team that is tasked to coordinate inputs from all stakeholders, including country 11

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partners, and develop an annual report. PEPFAR’s approaches ensure that data on program implementation are consistently reported, that evaluations are conducted periodically to ensure that targets are being met, and that scientific information is updated to ensure strong evidencebased programs. Periodic reviews of PEPFAR by the National Academy of Sciences Institute of Medicine (IOM), the OIG, the Government Accountability Office (GAO), and others have evaluated strengths and weaknesses of the program over time. Overall, PEPFAR is seen as a very successful program, exceeding key goals and evolving to take on new challenges. Since 2003, PEPFAR has provided support and care to more than 17 million people and antiretroviral therapy to 6.7 million people in developing countries, exceeding the goal of 6 million and quadrupling the number of people treated since 2008. In 2014, the budget for PEPFAR was 3 times the 2003 budget. In addition, PEPFAR has implemented robust programs for prevention and detection, successfully implementing HIV testing and counseling, reducing mother-child transmission of HIV, and providing voluntary male medical circumcision.15 Nonetheless, issues including interagency tension, competition, program redundancy, and country accountability continue to create challenges. Opportunities for collaborative program development and implementation appear to be important for interagency harmony; for example, interviewees indicated that collaborative development of a country operational plan afforded the opportunity to better understand related missions and to identify overlapping investments.12 To ensure country accountability, it is equally important to establish mechanisms that facilitate deeper involvement and investment of partner countries in the development and execution of operational plans. Transparency and clarity in program management and strong leadership have promoted interagency collaborations and trust and enabled harmonized program delivery. To minimize competition and create a more cohesive culture, the OIG recommends that PEPFAR programs not be branded by specific implementing agencies.13 Although strong leadership and defined coordination mechanisms have vastly improved implementation, development of a cohesive PEPFAR culture remains a challenge. As PEPFAR moves to a sustainability phase focused on strengthening health systems in partner countries, the application of metrics based on outcomes rather than implementation outputs will create opportunities for country teams, in coordination with country partners and stakeholders, to collaborate on developing more tailored strategies and implementation plans.12 The development of strategies, technical norms, and country accountability mechanisms will be paramount to the sustainability and success of PEPFAR. In its early years, PEPFAR, like other programs, faced significant challenges caused by unaligned interagency business processes and requirements and funding delays. 12

However, over time, PEPFAR administrators and interagency partners have learned how to apply individual agency strengths, overcome bureaucratic obstacles, and, ultimately, find ways to leverage agency capabilities to enable greater overall team flexibility. With strong centralized governance and fiscal, technical, and political authority, PEPFAR has successfully addressed the challenges of global HIV/AIDS, malaria, and tuberculosis and leads efforts to strengthen global health systems.

DoD CTR-CBEP While PEPFAR’s success stems in part from centralized governance and operations, DoD’s Cooperative Biological Engagement Program underscores the challenges faced by a program with extensive financial resources when it undergoes shifts that reduce technical and political authority. CBEP is one of several Cooperative Threat Reduction programs authorized by the Soviet Nuclear Threat Reduction Act of 1991, commonly referred to as the NunnLugar Act,16 to help the states of the former Soviet Union safeguard and dismantle enormous stockpiles of nuclear, chemical, and biological weapons, related materials, and delivery systems and to prevent hostile nations and terrorist organizations from gaining access to these weapons or the knowledge and materials required to manufacture and use them. Under the CTR program, CBEP, as well as the Biosecurity Engagement Program (BEP) of the DoS and the Department of Energy (DoE), were tasked to implement programs to destroy biological weapons and related infrastructure, redirect former biological weapons scientists, and establish science and technology centers to facilitate collaboration on new public health and bio-industry goals. Although Congress expressed concern about coordination across the agency programs,17 external assessments concluded that CBEP, BEP, and DoE were very successful in implementing projects that reduced biological threats in Russia and the former Soviet Union (FSU).18 The end of Cold War offensive programs in the FSU and increased concern about security in the Middle East, North Africa, and Asia necessitated a shift in goals and prompted expansion of CBEP and BEP to ‘‘new countries.’’ In 2008, under the National Defense Authorization Act,19 Congress authorized DoD CTR, including CBEP, to expand to regions including the Middle East and Asia. In subsequent years, CBEP was granted authority to conduct work in India and countries in Africa and Southeast Asia. The Next Generation Cooperative Threat Reduction Strategy Act of 201320 reauthorized the CTR program and mandated assessment of CTR programs in the Middle East and North Africa as well as development of a long-term strategy and coordination mechanisms for CTR programs in the those regions. Nonproliferation aims that had focused on weapons dismantlement and redirection of scientists were recalibrated to encompass what we now Health Security

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consider global health security goals aimed at preventing and detecting biological threats through enhancement of global capabilities for biological risk management, biosurveillance, and cooperative biological research.18 In accordance, CBEP has implemented numerous collaborations to assist WHO and Member States in developing systems and capacities to meet obligations under the WHO International Health Regulations (IHR) (2005) and has established itself as a key player in the global health security arena. Although CBEP has significant funding to support a shift to ‘‘softer’’ threat reduction and health security goals, the National Academy of Sciences (NAS) anticipated that a shift would necessitate improved mechanisms for interagency coordination18 and communication to ensure technical and political alignment and to reduce longstanding friction and differences in agency cultures. In a 2009 report that was mandated by Congress to assess and provide recommendations for DoD CTR expansion, the NAS provided several specific recommendations for reformulating and managing DoD CTR funds and programs in the new phase of the program, which they dubbed CTR 2.0.18 Noting the tangible results achieved in the FSU and the importance of ensuring sustainability of legacy programs, the NAS determined that ‘‘future efforts to enhance global security must be part of a broader, integrated set of programs. To meet the magnitude of new security challenges, particularly at the nexus of weapons of mass destruction and terrorism, a new model is needed that will draw on a broader range of partners and require more flexibility than the current programs have.’’18(p1) The NAS advocated for ‘‘softer’’ threat reduction tactics and the involvement of a broad range of domestic and international partners, including experts from US government agencies, to enable CTR programs to leverage the technical expertise and political credibility of other agencies and ultimately to allow CBEP to present a ‘‘softer’’ face and enhance international acceptance and program implementation. Reflecting the NAS’s conclusions, the Next Generation CTR Strategy Act of 2013,20 the Cooperative Threat Reduction Modernization Act of 2013-14,21 and the FY2014 National Defense Authorization Act22 directed CTR to develop ‘‘a comprehensive and effective, whole-of-government approach to global cooperative threat reduction and nonproliferation assistance programs’’20(p13) and set forth requirements for developing strategic and integrated nonproliferation programs in the Middle East and North Africa. To facilitate coordination and effectiveness of the CTR programs, including CBEP and BEP, President Obama designated a director of his National Security Council (NSC) staff to oversee weapons of mass destruction efforts, with a deputy director to oversee threat reduction activities.17 However, without fiscal control or broad technical expertise, the NSC deputy director lacks the ability to govern agency expenditures and coordinate program goals for implementation.17 Volume 13, Number 1, 2015

While the CTR programs at DoD and DoS had authority to implement similar biological nonproliferation programs in the Former Soviet Union and Russia, the pivot of CBEP and BEP to ‘‘new countries’’ and alignment with ‘‘softer’’ global health security objectives further necessitated that CBEP and BEP coordinate with global health programs of agencies such as USAID and CDC. As shown in Figure 1, although CBEP, the CDC Global Health Security Branch (GHSB), and the USAID Emerging Pandemic Threats (EPT) program have different missions and define program pillars differently, goals are very similar. Mapping program activities for CBEP and GHSB to the activities of EPT generates a grayscale color map (Figure 2). CBEP’s and GHSB’s program goals intersect completely with USAID’s goals of ‘‘predict,’’ ‘‘identify,’’ and ‘‘respond.’’ While there is only partial overlap with ‘‘prevent,’’ where USAID is focused on understanding behavioral activities that lead to zoonotic disease transmission, CBEP and GHSB perform related research on host-pathogen interaction and epidemiology of pandemic diseases. CBEP’s mission spans nonproliferation, GHSB focuses on drug and food safety, and EPT focuses on controlling emerging pandemic threats, but the programs clearly have more commonalities than distinctions. Overlap becomes even more difficult to manage when nongovernment stakeholders and implementers are tasked by different agencies to execute similar projects. With no structure for collaborative governance or knowledge management, redundancy creates significant challenges for alignment and technical and fiscal coordination of global health security projects among CBEP, BEP, CDC, and USAID. Interagency tensions have been exacerbated by interagency competition for financial allocations. As shown in Table 1, CBEP receives the largest allocation for programs related directly to global health security. A Kaiser Family Foundation study released in 2012 determined that CBEP, with FY2012 funding of $259.5 million, had the largest budget of all DoD programs involved in global health—4 times larger than any other program.32 The distinction in funding among CBEP, BEP, GHSB, and USAID is significant and has created competition and division between the agencies. For DoD/CBEP, improved interagency coordination is clearly necessary to improve technical and political governance. While CBEP was well suited for the early task of redirecting scientists from legacy biological warfare programs in the former Soviet Union, the transition to the NAS vision of CTR 2.0—from security to health security—appears to have been made more difficult by a dual chain of authority and responsibility in the DoD and the necessity to continue to demonstrate to Congress that CBEP is ‘‘doing security work.’’ Although CBEP has significant financial resources, flexible funding mechanisms could better facilitate coordinated program development with interagency partners. In addition, technical input and knowledge management 13

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Figure 1. Missions and Program Pillars of Major Global Health Security Agenda Partners, USAID Emerging Pandemic Threats Program, CDC Global Health Security Branch, DOD/Defense Threat Reduction Agency CBEP

PARANJAPE AND FRANZ Figure 2. Overlap in USAID, CDC, and DoD GHS Missions. Program activities of CDC Global Health Security Branch and DoD’s Cooperative Biological Engagement Program were reorganized to align with USAID’s Emerging Pandemic Threats (EPT) pillars to assess program overlap.

a

Field epidemiology training program Laboratory capacity c Biological risk management b

tools are important to ensure that programs are built on a strong technical foundation and operate efficiently. With the added challenge of answering to NSC, CBEP will face increased challenges in developing adaptable, nimble, and sustainable biological nonproliferation programs. While improved interagency coordination mechanisms and coordinated funding mechanisms will help streamline implementation of a multidisciplinary program that spans public health and security, the development of mechanisms for collaborative governance is also essential. Collaborative governance will help to ensure that the personal relationships that currently underpin interagency coordination17 are enhanced through the establishment of operational structures that promote programmatic integrity, continuity, and expertise.

US Global Health Security Agenda The US commitment to the GHSA represents the culmination of many policy directives formulated during the Obama administration and recognizes that successful imVolume 13, Number 1, 2015

plementation of global health security requires strong political oversight and integration of interagency technical expertise as well as fiscal resources for security and global health. Since 2009, the Obama White House has led the interagency development of key policy documents for global health security, including the National Strategy for Countering Biological Threats,33 the National Strategy for Biosurveillance,34 and the US-WHO Memorandum of Understanding Regarding Cooperation on Global Health Security Initiatives.35 Led by the White House NSC, the US GHSA knits together existing interagency investments in global health security. However, while the NSC has political responsibility for the agenda, fiscal and technical expertise and authority reside across many agencies, and no procedures have been proposed for governance mechanisms to ensure harmonization and coordination. As we learned from experiences with GHI and CBEP, political authority without technical and fiscal oversight impedes governance and harmonized, sustainable program implementation. As budgetary allocations to multiple US agencies and departments for global health security increase, misalignment and disharmony will likely be amplified. The 15

IMPLEMENTING THE GLOBAL HEALTH SECURITY AGENDA Table 1. US Funding (in $millions) for Global Health and Health Security Programs

Department of Defense Defense Threat Reduction Agency CBEP27 Department of State USAID EPT28 ISN/CTR/BEP29,30 Centers for Disease Control and Prevention Global Health25 Global Public Health Protection (GHSA) Global Disease Detection and Emergency Response TOTAL CDC TOTAL US Global Health Security PEPFAR31 Department of State (including USAID) Total Global Health Programs29,30

FY2013 (actual)

FY2014 (estimated)

FY2015 (requested)

211.3

260.0

256.8

54.9 35.0a

72.1 32.0a

50.0 32.5a

54.3

62.8

100.3

54.3

62.8

55.3

108.6 409.8

125.6 489.7

155.6 494.9

6,527.0

6,756.0

6,403.0

8,065.9

8,439.5

8,050.0

a

Estimate. Because budgets for different programs in Dos/ISN/CTR were not available, we estimated that 50% of funding went to BEP. CBEP = Cooperative Biologic Engagement Program; EPT = Emerging Pandemic Threat Program; ISN/CTR/BEP = International Security and Nonproliferation/Cooperative Threat Reduction/Biosecurity Engagement Program; PEPFAR = President’s Emergency Program for AIDS Relief.

President’s 2015 budget requests more than $407,015,000 for GHSA programs, including CBEP, CDC GHSB, and USAID EPT—an increase of $87,480,000 from 2013 (Table 1).27-32 A similar effect will occur among US interagency stakeholders and nongovernment project implementers. Prior to PEPFAR, agencies struggled to coordinate global HIV/AIDS projects and, in the 5 years prior to PEPFAR authorization, received only about $3.1 million for global HIV/AIDs and related programs.41 When PEPFAR was launched in 2003, $2.3 billion was allocated for programs— nearly 800 times the amount allocated during the preceding 5 years. Since 2003, Congress has continued to recognize the efficacy of the program and has tripled the budget to the 2014 level of approximately $6.8 billion.31 Although GHSA program leads from different agencies have made good faith attempts to coordinate and align programs, including installation of liaisons to assist with country and regional coordination, projects remain fragmented and inconsistent. As it stands, because programs are covered by different authorizations, funded through different department appropriations, and implemented by different organizations, there is no requirement—and often no time or incentive—to harmonize or coordinate project implementation and align strategies for partner country accountability. The development of centralized collaborative governance mechanisms will enable improved interagency collaboration, streamlined and nonredundant funding, development of technical consensus, and coordination with country partners. To justify increased budget allocations for 16

US GHSA, it will be essential to establish strong governance structures that ensure accountability, harmonization of strategic goals, and coordination and alignment of fiscal and technical goals. In the wake of the Ebola crisis, the need for centralized coordination of US global health security activities has intensified. As this article goes to press, the 2015 omnibus budget approved by Congress included $5.4 billion for agency-wide programs ‘‘to prevent, prepare for, and respond to Ebola domestically and internationally.’’37 With $1.8 billion going to CDC and $2.5 billion to USAID, the emergency funding dramatically changes the US health security playing field and makes coordination and harmonization of agency programming even more critical. Global health security lies at the nexus of security, health, and diplomacy, with several different agencies required to achieve success (Figure 3). Achieving the goals of GHSA will require a complex integration of technical expertise, establishment of knowledge management systems, and integration of diplomatic, development, and defense expertise. Like all important endeavors, success will depend to a great extent on finding and empowering the best leaders at home and building trusted relationships with excellent partners abroad. White House support for the program is important, but, as we learned from the failures of GHI, political governance will be insufficient in the absence of fiscal and technical authority for implementation. Drawing on the successful example of PEPFAR, we recommend that Congress establish mechanisms for central collaborative governance of US GHSA. Through the Health Security

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Figure 3. Global Health Security (GHS) lies at the Nexus of Global Health, Security, and Diplomacy. Primary areas of responsibility are depicted for US interagency partners. (Color graphics available at www.liebertonline.com/hs)

Figure 4. Summary of Lessons Learned from Implementation of Large US Global Health Programs

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establishment of a Global Health Security Coordinator and a Deputy Principals Group, designated officials would be responsible for blending diverse agency cultures, establishing priorities, leveraging the technical and operational strengths of different departments and agencies, and aligning fiscal commitments. To ensure effective program implementation in partner countries, it will be equally important to establish ambassador-led country-level efforts that are administered by global health security directors committed to transcending traditional interagency barriers. At all levels, centralized collaborative governance will facilitate interagency harmony and empower stakeholders. A seamless, whole-of-government solution will require strong, democratic, coordinated leadership dedicated to transparency, accountability, and harmonization of diverse agencies and motivated to develop unified programs, a culture of cohesion, transparent knowledge management systems, and instructive metrics. With a central team empowered to oversee and govern global health security programs, overarching strategies and operational plans will establish a framework for coordination and harmonization. Implementation should draw from collective experiences of global health and security programs, and in-country programs should be developed and implemented bilaterally to ensure sustainability and alignment with the health systems of partner countries. As exemplified by PEPFAR, periodic external review, robust monitoring mechanisms, and development of strategies to align agencies and develop a whole-of-government program are critical elements for success. A GHSA strategy and organizational framework should be closely coordinated and aligned with PEPFAR and other global health programs, because, as we are learning from the 2014 Ebola outbreak, the success and sustainability of US GHSA projects, like all global health efforts, will be determined by the resilience of a partner country’s health system. As partner country accountability requires that partners establish strong governance and leadership on political, technical, and fiscal issues, strong US interagency country teams can also provide an important model for country partners to ensure sustainability. GHSA’s challenge will be to build capabilities for prevention, detection, and response to dangerous infectious diseases in a balanced manner that enhances the strengthening of health systems. Drawing on the lessons learned from GHI, CTR, and PEPFAR (summarized in Figure 4), the President and Congress now have the opportunity to establish a US GHSA that is politically unified, able to integrate and align funding and knowledge management resources and to achieve an agenda that is critical to global health, international diplomacy, and national security. The White House has developed innovative guidance documents on global health security and has led the GHSA launch. Drawing from experiences with PEPFAR, GHI, and CBEP, it will be important to develop a centralized and collaborative governance structure that can integrate political, fiscal, and technical 18

inputs. With strong bipartisan support for both global health and security issues,38 the Administration and Congress have an opportunity to enact legislation that can profoundly enhance health security both at home and around the world.

Acknowledgments The authors are grateful to D. M. Edgil and L. W. Chapman for insightful technical and editorial input.

References 1. Global Health Security Agenda: Toward A World Safe & Secure From Infectious Disease Threats. 2014. http://www. globalhealth.gov/global-health-topics/global-health-security/ GHS%20Agenda.pdf. Accessed December 22, 2014. 2. Global Health Security—Vision and Overarching Target. 2014. http://www.globalhealth.gov/global-health-topics/globalhealth-security/Overarching%20Target.pdf. Accessed December 22, 2014. 3. U.S. Commitment to the Global Health Security Agenda. 2014. http://www.cdc.gov/globalhealth/security/pdf/ghs_us_ commitment.pdf. Accessed December 22, 2014. 4. World Health Organization (WHO). The World Health Report 2007—A Safer Future: Global Public Health Security in the 21st Century. 2007. http://www.who.int/whr/2007/en/. Accessed December 22, 2014. 5. Kaiser Family Foundation. Policy Brief: The U.S. Global Health Initiative: Key Issues. April 2010. http:// kaiserfamilyfoundation.files.wordpress.com/2013/01/8063.pdf. Accessed December 22, 2014. 6. Morrison SJ. Global Health Policy in the Second Obama Term. Washington, DC: Center for Strategic and International Studies; 2013. http://csis.org/program/global-healthpolicy-second-obama-term. Accessed December 22, 2014. 7. About the Office of Global Health Diplomacy. U.S. Department of State website. http://www.state.gov/s/ghd/about/ index.htm. Accessed December 22, 2014. 8. United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003. H.R. 1298. http://www.state.gov/ documents/organization/30368.pdf. Accessed December 22, 2014. 9. Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. P.L. 110-293. http://www.gpo. gov/fdsys/pkg/PLAW-110publ293/html/PLAW-110publ293. htm. Accessed December 22, 2014. 10. PEPFAR Stewardship and Oversight Act of 2013. S.1545. http://www.gpo.gov/fdsys/pkg/BILLS-113s1545enr/pdf/BILLS113s1545enr.pdf. Accessed December 22, 2014. 11. Sepulveda J, Carpenter C, Curran J, et al, eds; Committee for the Evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR) Implementation; Board on Global Health; Board on Children, Youth and Families; Institute of Medicine. PEPFAR Implementation: Progress and Promise. Washington, DC: National Academies Press; 2007. 12. Committee on the Outcome and Impact Evaluation of Global HIV/AIDS Programs Implemented Under the Lantos-Hyde Health Security

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13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

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Act of 2008; Board on Global Health; Board on Children, Youth, and Families; Institute of Medicine. Evaluation of PEPFAR. Washington, DC: National Academies Press; 2013. US Department of State and the Broadcasting Board of Governors; Office of Inspector General. Review of the President’s Emergency Plan for AIDS Relief (PEPFAR) at Select Embassies Overseas. Report Number ISP-I-11-07. 2010. http://oig.state.gov/system/files/154967.pdf. Accessed December 22, 2014. PEPFAR New Initiatives. The United States President’s Emergency Plan for AIDS Relief website. http://www.pepfar. gov/about/122416.htm. Accessed December 22, 2014. Funding and Results. The United States President’s Emergency Plan for AIDS Relief website. http://www.pepfar.gov/ funding/index.htm. Accessed December 22, 2014. Soviet Nuclear Threat Reduction Act of 1991. H.R. 3807. https://www.govtrack.us/congress/bills/102/hr3807. Accessed December 22, 2014. Nikitin MBD, Woolf AF. 2013. The Evolution of Cooperative Threat Reduction: Issues for Congress. Washington, DC: Congressional Research Service; 2013. https://www.hsdl.org/ ?view&did = 743292. Accessed December 22, 2014. Committee on Strengthening and Expanding the Department of Defense Cooperative Threat Program. Global Security Engagement: A New Model for Cooperative Threat Reduction. Washington, DC: National Academies Press; 2009. National Defense Authorization Act for Fiscal Year 2008. Conference Report. H.R. 1585. http://www.gpo.gov/fdsys/ pkg/CRPT-110hrpt477/pdf/CRPT-110hrpt477.pdf. Accessed December 22, 2014. Next Generation Cooperative Threat Reduction Strategy Act of 2013. S. 1021. http://www.gpo.gov/fdsys/pkg/BILLS113s1021is/pdf/BILLS-113s1021is.pdf. Accessed December 22, 2014. Cooperative Threat Reduction Modernization Act (2013/ 2014). H.R. 2314. https://www.congress.gov/bill/113thcongress/house-bill/2314/text. Accessed December 22, 2014. National Defense Authorization Act for Fiscal Year 2014. H.R. 3304. P.L. 113-66. http://www.gpo.gov/fdsys/pkg/ CPRT-113HPRT86280/pdf/CPRT-113HPRT86280.pdf. Accessed December 22, 2014. Pandemic influenza and other emerging threats. USAID Factsheet. April 2013. http://www.usaid.gov/sites/default/ files/documents/1864/PIOETFact%20SheetApril2013.pdf. Accessed January 7, 2015. Global health – health protection. Centers for Disease Control and Prevention website. Update February 13, 2014. http://www.cdc.gov/globalhealth/healthprotection/ghsb/index. htm. Accessed January 7, 2015. US Centers for Disease Control and Prevention. Budget Request Summary FY15. US Centers for Disease Control and Prevention; 2014. http://www.cdc.gov/fmo/topic/Budget% 20Information/appropriations_budget_form_pdf/FY2015_ Budget_Request_Summary.pdf. Accessed December 22, 2014. Fiscal Year 2015 Budget Estimates: Cooperative Threat Reduction Program, March 2014. https://www.yumpu.com/ en/document/view/26016445/ymiva/9. Accessed January 7, 2015. Defense Threat Reduction Agency. Fiscal Year 2015 Budget Estimates. Ft. Belvoir, VA: Department of Defense; 2014.

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29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

http://comptroller.defense.gov/Portals/45/Documents/ defbudget/fy2015/budget_justification/pdfs/01_Operation_ and_Maintenance/O_M_VOL_1_PART_1/DTRA_PB15. pdf. Accessed December 22, 2014. US Department of State. Congressional Budget Justification (Foreign Operations) FY15. Washington, DC: US Department of State; 2014. http://www.state.gov/documents/ organization/222898.pdf. Accessed December 22, 2014. US Department of State. The Budget for Fiscal Year 2014. Department of State and Other International Programs. 2014. http://www.whitehouse.gov/sites/default/files/omb/ budget/fy2014/assets/sta.pdf. Accessed December 22, 2014. US Department of State. Congressional Budget Justification FY15. Washington, DC: US Department of State; 2014. http://www.state.gov/documents/organization/223495.pdf. Accessed December 22, 2014. US Department of State. Shared Responsibility-Strengthening Results for an AIDS-Free Generation: Latest PEPFAR Funding. 2014. http://www.pepfar.gov/documents/organization/ 189671.pdf. Accessed December 22, 2014. Michaud J, Moss K, Kates J. U.S. Global Health Policy: The U.S. Department of Defense and Global Health. Washington, DC: Kaiser Family Foundation; September 2012. http:// kaiserfamilyfoundation.files.wordpress.com/2013/01/8358.pdf. Accessed December 22, 2014. The White House. National Strategy for Countering Biological Threats. July 2012. http://www.whitehouse.gov/sites/default/ files/National_Strategy_for_Countering_BioThreats.pdf. Accessed December 22, 2014. The White House. National Strategy for Biosurveillance. July 2012. http://www.whitehouse.gov/sites/default/files/National_ Strategy_for_Biosurveillance_July_2012.pdf. Accessed December 22, 2014. Memorandum of understanding between the government of the United States of America and the World Health Organization regarding cooperation on global health security initiatives. 2009. http://www.globalhealth.gov/pdfs/mouwho-usg-health-security.pdf. Accessed December 22, 2014. Salaam-Blyther T. Global health: appropriations to USAID programs from FY2001 through FY2008. CRS Report for Congress. Washington, DC: Congressional Research Service; July 8, 2008. http://fpc.state.gov/documents/organization/ 107209.pdf. Accessed December 22, 2014. Consolidated and Further Continuing Appropriations Act, 2015. H.R. 83. https://www.congress.gov/113bills/hr83/ BILLS-113hr83enr.pdf. Accessed January 22, 2014. Morrison JS, Cullison T, Daniel JC, Hiebert M. A Greater Mekong Health Security Partnership. Washington, DC: Center for Strategic and International Studies; July 2013. http:// csis.org/files/publication/130719_Morrison_GreaterMekong Health_WEB.pdf. Accessed December 22, 2014.

Manuscript received May 20, 2014; accepted for publication October 21, 2014. Address correspondence to: Suman M. Paranjape, PhD, MPH 1355 Independence Ct., SE Washington, DC 20003 E-mail: [email protected]

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