What's in the US Senate's pandemic preparedness bill?

U.S. lawmakers are looking closely at how the country should tackle pandemic preparedness and prevention moving forward. While a new bipartisan Senate bill represents a promise of action, it also highlights some key debates around how to respond, according to global health experts.

The International Pandemic Preparedness and COVID-19 Response Act of 2021 was introduced last month and is co-sponsored by Sen. James Risch, the top Republican from Idaho on the Senate Foreign Relations Committee, and the committee chairman, Sen. Robert Menendez, a Democrat from New Jersey who had introduced competing legislation on the issue last year.

“It’s welcome because it’s bipartisan and the kind of signaling that's needed right now to the [President Joe] Biden White House that there is a nucleus of bipartisan consensus on the need to do more at a bigger scale quickly to deal with the expansive threats,” said J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies and director of its Global Health Policy Center.

While the Biden administration has taken some positive action, a longer-term vision that is scaled and a better structure for coordination “beyond the fragmented effort of talented people at different agencies” are both needed, he said. The congressional support — the Senate bill, a number of House bills addressing the issue, and a budget bill passed by the House that boosts global health security funding, including for a new global fund — should motivate the White House to do more, Morrison said.

The Senate Foreign Relations Committee appears to be prioritizing the legislation and would like to move quickly, said Carolyn Reynolds, co-founder of the Pandemic Action Network, who spoke with committee staff Monday. What is less clear though, is whether Senate leadership will prioritize the legislation amid a busy and contentious schedule.

A variety of congressional efforts, reports, and administrative actions are coalescing, and while the details on language and terms may differ “this is the time to go big on this agenda,” Reynolds said.

“There are some things we would like to see strengthened and improved but it is important for Congress to pass a robust piece of legislation this year that prioritizes the threat of pandemics as a national security priority, authorizes significant funding, and strengthens U.S. leadership,” she said.

There is some debate about the specifics in the Senate bill, but there does seem to be one place where many members of the global health community agree: It does not include enough funding.

The recent G-20 High Level Independent Panel financing report said that $15 billion in global funding was needed annually, including $10 billion a year to a new global fund addressing pandemic preparedness and response. The current numbers in the bill — about $3 billion over five years — are less than what the U.S. should contribute and also is below what the administration has requested for the fiscal year 2022 budget.

The U.S. share of a $10 billion global fund should be at least a $2 billion a year investment, Reynolds said — numbers that might be hard to reach in a difficult funding environment for foreign aid dollars.

An interesting proposal in a CSIS white paper released this week could offer a solution. It suggests creating a new mechanism, called a Health Defense Operations budget designation, modeled after the Overseas Contingency Operations designation, that would allow health security funding to be exempt from congressional spending caps.

What’s in the bill?

The Senate bill offers a broad set of guidelines for how the U.S. should respond to the COVID-19 pandemic and how the U.S. should engage in and lead global pandemic preparedness and response efforts.

The bill states that the U.S. should “lead and implement a comprehensive and coordinated response to end the COVID-19 pandemic.”

It outlines a number of steps the U.S. should take to do so, including supporting a United Nations Security Council resolution that declares pandemics a threat to national peace and security; advancing efforts to reform the World Health Organization; and working to meet global vaccination goals of at least 60% of the population of all countries vaccinated by the first half of 2022.

It also tackles two big issues — how the U.S. government is structured to address pandemic preparedness and the establishment of a new global fund to address pandemic preparedness and global health security.

On the first issue, the bill spells out the role of a variety of agencies including the State Department, the U.S. Agency for International Development, and the Centers for Disease Control and Prevention, and suggests new leadership at the National Security Council and at the State Department.

It said the NSC should establish a committee on Global Health Security and Pandemic and Biological threats to be led by a special adviser for global health security and composed of the members of the Cabinet and representatives of a number of other relevant agencies. The committee would provide strategic guidance and develop a policy framework for global health security including pandemic preparedness and response, and ensuing policy coordination between agencies.

It would also establish a new position at the State Department — a special representative for U.S. international activities to advance global health security and diplomacy overseas — a Senate-confirmed position that would have the ability to transfer and allocate funding to relevant departments and agencies.

The legislation also supports the idea of a new “multilateral, catalytic financing mechanism for global health security and pandemic prevention and preparedness, which may be known as the Fund for Global Health Security and Pandemic Prevention and Preparedness” with the goal of closing critical gaps in global health security and building capacity in partner countries in areas of global health security, infectious disease control, and pandemic preparedness and response.

A new global fund

Experts agree that new, dedicated, sustainable funding is needed to address pandemic preparedness and response. Several said it’s critical that a new global fund does not take funding away from existing global health priorities and the U.S. should be careful not to rob one part of the budget to increase funding here.

Some propose the new fund should be housed at the World Bank, while others believe that the creation of a whole new fund isn’t necessary and existing implementers should be used.

“We definitely need new and additional pandemic preparedness resources,” said Chris Collins, the president, and CEO at Friends of the Global Fight Against AIDS, Tuberculosis and Malaria. “It’s creating a whole new financing mechanism that presents some concerns.”

In the past, new funding mechanisms have taken years to get up and running so creating a new fund could delay implementation and lead to a slower disbursement of the much-needed resources, he said.

Collins proposes further investing in existing implementing agencies including the Global Fund to Fight AIDS, Tuberculosis and Malaria; Gavi, the Vaccine Alliance; the Coalition for Epidemic Preparedness Innovations; and others, and broadening the pandemic response work that they do.

The Global Fund is particularly well suited to the task, he said, because it is already actively supporting multiple critical areas of pandemic preparedness and response, and investing through the Global Fund incentivizes other donors to share the burden and country governments to increase their own investment.

While some critics have said that the Global Fund might lose sight of its focus on HIV, TB, and malaria, Collins said that shouldn’t be a concern if this is new funding for pandemic preparedness and response.

Even at the World Bank, a new mechanism could be structured in a number of different ways.

The Global Fund technically operates under the auspices of the World Bank, which serves a treasury function for the organization but is otherwise hands-off. A similar structure could work with this new fund, or it could have closer ties to the World Bank, which is the case with some other global funds and facilities, said Reynolds.

A facility similar to the Global Environment Facility at the World Bank, focused on pandemic preparedness and response would work well, said Amanda Glassman, executive vice president at the Center for Global Development.

The Senate bill doesn’t need to answer that question though, Reynolds said. The important thing is for the bill to signal that a new fund is important, authorize the funds for the U.S. contribution and signal some parameters around what it should invest in and how it should work, she said.

The legislation should not be overly prescriptive because it is designed to be a multilateral fund so the administration will need flexibility to set the terms with other partners, Reynolds said.

“A sticking point that may make some global health advocates hesitant to support the bill is that it lacks an inclusive and equitable governance structure,” said Keifer Buckingham, advocacy director for the Open Society Foundations.

While it does mention civil society and other groups being part of the board of the institution, they would be selected by the donors. The most successful governance structures of similar organizations include recipient governments, NGO participation, and community representation, with members independently chosen by their peers, Buckingham said.

“If we come up with some sort of fund with a model that doesn't reflect what we know already to be best practice with stakeholder communities then we fail,” she said. “If we create a board that is exclusionary, that doesn't do anything to address some major inequities, we have globally a huge missed opportunity.”

Global health advocates are pushing for the legislation to be tweaked to address that concern.

US structure

The Senate legislation also tackles the issue of how to best structure the U.S. government’s response to pandemic preparedness and response and how leadership should be designed.

The new mechanisms it suggests are a combination of previous efforts and seem to seek to address concerns over proposals from Risch and former President Donald Trump’s administration last year that drew criticism from development advocates that consolidating power and budget control at the State Department would undercut USAID.

The question of the best way to structure management continues to be debated in the global health community, with the NSC and the State Department playing the lead role as the top contenders.

A bipartisan CSIS commission on strengthening U.S. health security released a white paper with recommendations this week, proposing two potential ways the administration could improve pandemic preparedness staffing within the U.S. government.

The first option it proposes is a dedicated NSC deputy slot focused on pandemic preparedness and response or global health security that would have multiple directors. The second is to have a new position and new office at the State Department — likely structured similarly to the U.S. President's Emergency Plan for AIDS Relief — that would be responsible for the issues.

Morrison thinks leadership on these issues should be centered at the State Department because the White House is not as good at operational issues, and the effort is going to be an “overwhelmingly international diplomatic effort” so it is important that the State Department has bought in and is well equipped.

The Pandemic Action Network also supports the leadership being based at the State Department, Reynolds said. Leadership needs to be “hardwired into the national security and foreign policy apparatus” and the best place for that is at the State Department, she said.