WASHINGTON – U.S. Senator Benjamin L. Cardin (D-MD), member of the Senate Foreign Relations Committee and Chair of the Subcommittee on State Department and U.S. Agency for International Development (USAID) Management, International Operations, and Bilateral International Development, is requesting feedback from global health implementers, local partners, experts, and others on actions Congress should take to improve the way the U.S. strengthens the overall performance of health systems globally through local partnerships.

“Supporting local organizations and governments in low and middle-income countries to strengthen their health systems is a cornerstone of American efforts to combat HIV/AIDS, prepare for future pandemics and integrate disease response and prevention programs into sustainable and locally owned health systems,” wrote Senator Cardin. “Localized HSS saves lives, promotes country ownership, and sustains America’s historic achievements in global health—at no additional cost to specific disease programs.”

Since 2020, Congress has directed the USAID to apportion 10% of its global health funds towards health systems strengthening (HSS). Together with investments in combatting specific diseases such as HIV/AIDS and COVID-19, these expenditures have contributed to overall health system improvements, such as higher local budgets for health in selected countries, and greater utilization of health facilities and health insurance. To capitalize on these investments, Congress should consider articulating an overall vision, authorities, and set of targets for HSS, including how much of our HSS investment should be carried out by local partners and what that investment should achieve.

Read the full letter here or below:

To Whom It May Concern:

Supporting local organizations and governments in low and middle-income countries to strengthen their health systems is a cornerstone of American efforts to combat HIV/AIDS, prepare for future pandemics, and integrate disease response and prevention programs into sustainable and locally owned health systems. Ongoing efforts to improve the efficiency and effectiveness of healthcare delivery in partner countries can lead to cost-savings over time that safeguard U.S. taxpayer dollars.

Over the years, the international global health and development agenda has gradually made targeted investments in health systems strengthening (HSS) and expanded the focus on localization of foreign aid. These efforts have further grown in importance as COVID-19 both overwhelmed and severely disrupted the provision of essential services by national and local health systems. In many countries, the pandemic slowed, and in some cases reversed, gains made in reducing illnesses and deaths related to malaria, tuberculosis, and other health challenges.

In December 2020, the U.S. House of Representatives issued an explanatory report accompanying the FY2021 State, Foreign Operations appropriations directing the U.S. Agency for International Development (USAID) to apportion 10% of its global health funds towards HSS. Despite the directive to spend 10% of all global health programs on HSS, and despite commitments by USAID and PEPFAR (through the State Department) to spend 25% and 75% of their resources respectively on local organizations, HSS remains what the USAID Office of the Inspector General described in a 2019 report as a “second-order priority” in U.S. global health programs, relative to specific disease goals.

The FY23 National Defense Authorization Act helped to elevate the importance of HSS, stating that it is U.S. policy “to contribute to the strengthening of health systems for global health security and pandemic prevention, preparedness, and response” in countries where bilateral global health assistance programs are carried out. The NDAA also empowered the USAID Administrator to coordinate across agencies in furtherance of this policy. This lays the foundation for Congress to further articulate a vision, authorities, and set of targets for HSS, including how much of our HSS investment should be carried out by local partners and what that investment should achieve.

As we seek to build on the success of disease-specific programs and strengthen global health security, Congress should consider specific legislation on supporting local entities to strengthen the overall performance of health systems (hereafter “localized HSS”). Localized HSS saves lives, promotes country ownership, and sustains America’s historic achievements in global health—at no additional cost to specific disease programs. I am soliciting feedback for a more comprehensive approach that gives localized HSS its rightful place in our shared development agenda.

BACKGROUND

Although the United States and other countries have been supporting local organizations and governments to strengthen their health systems for decades, it was not until 2013 that a Lancet Commission on Investing in Health concluded that that “structured investments in health systems strengthening must accompany all spending on discrete disease interventions to lead to sustained impact.” A year later, the worst Ebola outbreak in history occurred in Western Africa, demonstrating how the integrity of a health system undergirds the capacity of a country to react to large-scale health emergencies. In the ensuing years, U.S. agencies have redoubled their attention to HSS within the authorities set out by Congress:

• Starting in 2015, USAID issued a vision for HSS and established procedures to better enable missions to budget and program for HSS activities. As their HSS activities grew, USAID issued a guide for monitoring its HSS activities, emphasizing the importance of strengthening systems as a whole rather than developing discrete activities for each of the health system “building blocks” (financing, governance, information, human resources, service delivery and medical products, vaccines and technologies). USAID released a new vision for HSS in 2019, which encouraged cross-cutting HSS activities (i.e. those that further multiple health goals) and emphasized a systems approach for carrying out health programs and measuring impact. In 2022, USAID launched Primary Impact, a partnership to develop primary health care action plans with the governments of Cote d’Ivoire, Ghana, Indonesia, Kenya, Malawi, Nigeria, and the Philippines.

• In 2019, on the eve of the COVID-19 pandemic, the White House released its Global Health Security Strategy, stating that HSS “complements and contributes to the core elements of global health security” by improving information systems needed for monitoring and reporting, fostering more effective health financing, and bolstering the capability of local healthcare workers to respond to infectious disease outbreaks. USAID was tasked with leading a wide range of capacity-building efforts relevant to global health security. The same year, the U.S. Centers for Disease Control and Prevention (CDC) adopted a Global Health Strategy which included an objective to “strengthen the capacity to build resilient public health systems to protect and secure essential healthcare services.”

• In 2022, the U.S. State Department’s Office of the Global Health Coordinator and Health Diplomacy further elevated the importance of localized HSS within its 5-year strategy and Country Operational Plan Guidance for the President’s Emergency Plan for AIDS Relief. The latest PEPFAR Strategy emphasizes the need to integrate PEPFAR HIV programmatic efforts into country-led programs and systems. PEPFAR’s investments in HSS, which include strengthening laboratory surveillance, health facilities, and the health workforce, have proven essential to the response to COVID-19 and to the broader Global Health Security Agenda.

It is now beyond dispute that strengthening the overall performance of health systems helps to advance rather than detract from efforts to combat specific diseases and health conditions, such as HIV/AIDS, maternal and infant mortality, malaria, and polio. It is therefore logical to ask whether the U.S. is doing enough to maximize its investments in HSS. In 2019, the USAID Office of the Inspector General concluded in its investigative reporting that HSS was a “second order priority” for the Agency compared to specific disease goals, and that because the United States relies in part on strong health systems abroad for control of global pandemics, this compromised the United States’s own health security.

A related concern is whether U.S. investments in HSS are as efficient and sustainable as they could be. A large proportion of U.S. investments in HSS still fund international intermediaries rather than local organizations and governments. In response to this, at a recent hearing of the Senate Foreign Relations Committee’s Subcommittee on State Department and USAID Management, International Operations, and Bilateral International Development, Members of Congress and witnesses highlighted the inefficiencies and sustainability challenges created by relying on intermediaries to advance local health objectives. The hearing illustrated the relative success of PEPFAR (which is a program administered by the State Department in partnership with multiple agencies, including USAID) in investing in local health-systems capacity compared to USAID as an agency. Witnesses cited the bureaucratic, cultural, and philosophical norms standing in the way of USAID mission staff using their broad procurement authority to reach the Agency’s target of 25% funding going to local groups.

APPROPRIATIONS

Since FY2021, the House Appropriations Committee has included report language specifying that at least 10% of all funds provided through the Global Health Programs account be used for health system strengthening activities. According to the USAID’s reports to Congress in 2020 and 2021, these activities have contributed to higher local budgets for health in selected countries, increased government ownership of health information systems, improved financial management skills among government officials, enhanced adaptability of health services during the COVID-19 pandemic, boosted utilization of health facilities, and encouraged greater uptake of health insurance.

In 2022, the FY23 National Defense Authorization Act authorized an additional US$5 billion to be appropriated over the next 5 years for U.S. participation and investment in global health security and pandemic preparedness activities. The NDAA clarifies that strengthening health systems for the purpose of global health security is U.S. policy. It directs the USAID Administrator to work with all agencies implementing bilateral global health programs to ensure that such activities contribute to the goal of HSS for global health security. It also directs the President to issue a Global Health Security Strategy that ensures partner country ownership.

SEIZING THE OPPORTUNITY

The experience of a pandemic has highlighted a need and opportunity to make localized HSS a first-order priority in order to advance disease goals, promote local ownership and sustainability, and prepare for future pandemics. Consequently, I am requesting input from government agencies, implementers and beneficiaries of HSS programs, advocacy organizations, health systems researchers, and others on the current state of localized HSS and what more Congress can do.

Specifically, I seek your feedback on actions Congress could take to establish and clarify the vision, targets, and authorities for localized HSS, in the way it has for specific health outcomes. Responses could address (but are not limited to):

1. The most significant contributions of the United States government to localized HSS in the past decade, and what we should strive for in the coming decade;
2. How Congress can ensure U.S. bilateral global health assistance is adequately responding to HSS needs of local populations and effectively coordinating with local partners and governments to meet these needs;
3. How Congress can support more effective integration of HSS activities and reduction of health system fragmentation across the full spectrum of global health programming, including disease specific programming, regional efforts, and humanitarian response;
4. The contribution that U.S.-funded HSS activities can make to reducing health disparities, such as between urban and rural populations or various vulnerable groups;
5. The cost savings of supporting localized HSS, both in terms of greater efficiencies in local health systems and money saved by funding HSS activities directly rather than through international intermediaries;
6. The flexibility and authority to expedite the localization of funds for HSS, particularly in the case of USAID; and
7. How greater incorporation of primary health care activities into U.S. global health policy can strengthen HSS and enhance global health security.

I am committed to working toward a more targeted, localized, and effective approach to HSS that reflects the importance of this global health goal. I appreciate your time and attention to this important matter. Please direct any feedback to HSSRFI@cardin.senate.gov no later than September 8, 2023.

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