Last week, the US launched its Global Health Security Strategy (GHSS). This strategy outlined a framework for how the US government will work to improve health security capabilities, both domestically and abroad. The report is built around 3 main goals, with the remainder of the report outlining future priorities, expanding upon current activities, and delineating roles and responsibilities for various government agencies and programs.

The GHSS is designed to work in concert with the US National Security Strategy and Biodefense Strategy to address a broad scope of global health and health security threats and promote sustainable global health security capacity. The GHSS recognizes the health and economic threats of emerging infectious diseases and cites an increase in naturally occurring outbreaks as a driving force behind the strategy. In addition, the GHSS  highlights the need for establishing preparedness and response capabilities that extend beyond a single country’s borders as well as the importance of incorporating a One Health approach when addressing existing and emerging biosecurity threats.

Due to the integral role that this strategy will developing national and global infectious disease preparedness and response capacity, this week’s Outbreak Thursday will take a quick look at the GHSS as a whole to provide some insight into the evolving US perception of and engagement in global health and health security. We will also provide a high-level, preliminary assessment of the strategy in the context of a series of recommendations generated by relevant subject matter experts and other stakeholders.

The US Global Health Security Strategy

The GHSS is organized around 3 main goals that outline the US approach to global health security:

  1. Strengthened Partner Country Global Health Security Capacity

  2. Increased International Support for Global Health Security

  3. A Homeland Prepared for and Resilient against Global Health Security Threats

The first two goals aim to improve health security capabilities internationally, but through different approaches and objectives. The main difference in these goals is the source of investment. The first goal focuses on improving global health security through direct US government investment into specific partner countries and programs, while the second aims to build a global culture that can support and sustain health security programs around the world “beyond the lifespan of US government investments.” Both of these goals will leverage existing partnerships and mechanisms with a focus on the network of countries that have committed to building and maintaining health security capacity, including those that have signed on to the Global Health Security Agenda (GHSA). For example, the US will utilize results from Joint External Evaluations (JEEs) to identify priority areas for intervention in partner countries with the goal of helping them achieve time-based GHSA objectives. Together, these goals express the US government’s hope of addressing immediate global health security concerns while simultaneously building more sustainable systems.

The third goal addresses domestic health security needs. In 2016, the US completed its own JEE, and following this evaluation, the US government published its “Health Security National Action Plan,” which provides a roadmap of specific steps that the US needs to take to improve on existing capabilities and remediate identified gaps. This third goal of the GHSS reiterates this ongoing effort and commits the US will continuing to document its progress on these goals, with the aim of evaluating the progress in a follow-up JEE in 2020.

The remainder of the GHSS features 3 sections that provide details on the approach, capabilities, and responsibilities that will help the US achieve the overarching goals discussed above. The first section aligns directly with the first goal of the GHSS and outlines the technical and geographic priorities for catalyzing health security efforts abroad. The second section categorizes the US government's’ multisectoral and international efforts into 4 major bins: response to international outbreaks, infectious disease response in humanitarian emergencies, research, and strengthening international biosafety and biosecurity. These bins span all 3 of the main GHSS goals and consolidate the wide range of US activities into something a little more digestible. The final section adds a layer of specificity regarding which parts of the US government would be responsible for leading different aspects of the GHSS. The responsibilities were divided amongst fifteen government agencies, including a bulleted list of roles and responsibilities moving forward, providing a brief but informative picture of how everything falls into place. In total, these closing sections add the context needed to piece together the puzzle of how the US government intends to transition the strategy’s three main goals from concept to reality.

How does the GHSS stack up against expert recommendations?

In July 2018, the Johns Hopkins Center for Health Security convened a large group of experts and stakeholders from across a variety of fields relevant to global health and health security to solicit input for the anticipated GHSS. These stakeholders generated a series of recommendations for topics that the GHSS should address as well as priorities for US government involvement in global health security. This list of recommendations is far from the only example, but the collective expertise of these stakeholders and their recommendations provide a lens through which we can conduct an initial evaluation of the GHSS. Below, we provide a high-level overview of how the GHSS addressed these issues.

Recommendation #1: The GHSS Should Acknowledge that US Global Health Security Investments Provide Direct Value to US National Security and Economy

This topic was addressed early and often in the first 2 sections of the GHSS. It was clear that health security was tied to national security, and the report went as far as indicating that this strategy will be used to help guide 2 of the National Security Strategy’s priority actions: Detecting and Containing Biothreats at their Source and Improving Emergency Response. The GHSS did not address the US economy quite as explicitly, but it did frame infectious disease outbreaks as major disruptors to local, national, and global economies in the broader sense.

Recommendation #2: The US Definition of Global Health Security Should be Flexible, but Retain Focus on Health Security

The concerns guiding this recommendation are twofold: First, that the US definition of global health security would would be limited to specific terms, such as “dangerous pathogens,” rather than encompass the wide array of relevant infectious disease threats. Second, that other related national security issues, such as nuclear and chemical threats, would shift the focus of the strategy beyond health security, potentially reducing its effectiveness. The GHSS defines global health security as “the capacity to prevent, detect, and respond to infectious disease threats that can quickly spread across borders,” which appears to align with the stakeholders recommendation. This definition does not limit global health security to any particular subset of infectious disease threats, and it does not appear to be substantially influenced by nuclear, chemical, or other national security priorities. This definition allows the strategy to be flexible in the threats it addresses while remaining firmly rooted in the field of health security. The strategy lists 16 technical priorities ranging from AMR to zoonotic diseases, covering a diverse swath of the capabilities and threats that fall under the umbrella of health security. The GHSS does mention nuclear and chemical threats, but these are limited to the context of UN Security Council Resolution 1540 (UNSCR 1540) and nonproliferation efforts.

Recommendation #3: The GHSS Should Call for Meaningful Integration of the Non-Governmental Sector into Global Health Security Efforts

The stakeholders stressed that previous efforts to increase global health security capacity were tied too exclusively to collaboration with national governments, and they called for strategies to expand this focus to include broader participation from civil society. While “meaningful” is, by definition, a subjective term, the GHSS includes specific considerations for engaging civil society, including the importance of engaging directly with nongovernmental organizations. Additionally, the section on the 2nd main goal explicitly lists 3 actions for the US to take to improve civil society engagement:

  • Expanding existing relationships and partnerships with the GHSA Consortium, Private Sector Roundtable, and Next Generation Global Health Security Network (NextGen) to achieve goals laid out in this strategy

  • Expanding existing and develop new partnerships with nongovernmental sector that addresses identified gaps in strengthening global health security

  • Encourage and facilitate concrete relationships and partnerships between other countries and the nongovernmental sector to close identified health security gaps

In total, this dedicated section and numerous other references to nongovernmental engagement dispersed throughout the GHSS provide an encouraging sign for the prospects of meaningful integration between the US government and civil society on global health security issues.

Recommendation #4: The GHSS Should Recognize that Continued US Investment is Necessary to Sustain Global Health Security and to Promote US Interests

The GHSS makes it clear that the US recognizes the importance of continued investment in establishing sustainable global health security capacity. The strategy does not include detailed reports of potential financing beyond the President’s 2020 budget request. This request, which runs through FY 2020, includes at least $250 million for CDC and other HHS global health security programs. It remains to be seen how this strategy translates into tangible investments, but it is encouraging to see that the strategy recognizes the importance of continued US investment in global health security and explicitly highlights the long-term budgetary planning for government-sponsored global health security investments.

Recommendation #5: The US GHSS Should Establish Clear Targets by Which to Measure Progress

The strategy’s “Approaches to Accelerate the Capabilities of Targeted Countries” lays out plans for monitoring and evaluating the value and success for program investments. This section is paired with a 3-step plan that will track:

  • The outputs of US-funded activities

  • The effect of US investments on JEE-relevant capacities

  • The impact of new capacities on detection and response

This approach provides multiple perspectives on the value of US global health security efforts. First, it documents directly the established capacities and capabilities through these programs. It also tracks the impact of these capabilities on the established JEE metrics that are used to evaluate and track health security capacity around the world. And finally, it attempts to assess the operational impact of these capabilities in the context of identifying and responding to biological events.

The GHSS also lays out plans to establish a working group dedicated to monitoring and evaluating US efforts internationally. The language in the GHSS suggests that the program will build upon existing metrics in the JEE and the IHR Monitoring and Evaluation Framework to harmonize monitoring efforts at the international level, but not much further detail is provided. Although the strategy includes mention of proposed monitoring efforts, it does not appear to provide specific priority indicators or an indication of how the working group will go about evaluating them. The GHSS acknowledges that monitoring and evaluation are key to determining the effects and value of US global health security efforts and investments, but additional detail on the metrics and monitoring programs and their implementation would be beneficial.

Recommendation #6: The GHSS Should Address Gaps Under Existing Global Health Security Efforts

The final recommendation from the stakeholder meeting stems from the sentiment that, while current global health security efforts, such as the GHSA and JEE, have had a considerable positive impact, their methods still have gaps. Take for example this quote from the report:

“The JEE and other national assessments tend to assume that public health laboratories are supported by function health systems… However, many resource-constrained countries lack robust health systems, and efforts aimed at ‘health-systems strengthening’ are not well integrated into efforts to promote health security.”

The stakeholders provided several other examples as well of areas in which ongoing global health security efforts could be improved. The hope was that the GHSS would include critical analysis of these broader global health security activities and lay the groundwork to address some of these gaps. The GHSS did not explicitly state any gaps in ongoing global health security efforts and, rather, expressed commitment to widely adopted global health security methods as the framework for the proposed US government efforts. The strategy’s commitment to existing global health security efforts reflects the value of widespread international collaboration, but the lack of critical reflection may allow certain gaps to persist into the future.

Conclusion

The US Global Health Security Strategy outlines the continued evolution of the US governments’ involvement in the broader effort to establish and maintain global health security capacity to protect populations from an array of infectious disease and other health threats. While this document does not explicitly outline programs or allocate funding to global health or health security priorities, it will undoubtedly have an impact on global and domestic preparedness, detection, and response capabilities.

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