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• Published: 07 April 2020

What is global health? Key concepts and clarification of misperceptions

Report of the 2019 GHRP editorial meeting

• Xinguang Chen 1 , 2 ,
• Hao Li 1 , 3 ,
• Don Eliseo Lucero-Prisno III 4 ,
• Abu S. Abdullah 5 , 6 ,
• Jiayan Huang 7 ,
• Charlotte Laurence 8 ,
• Xiaohui Liang 1 , 3 ,
• Zhenyu Ma 9 ,
• Zongfu Mao 1 , 3 ,
• Ran Ren 10 ,
• Shaolong Wu 11 ,
• Nan Wang 1 , 3 ,
• Peigang Wang 1 , 3 ,
• Tingting Wang 1 , 3 ,
• Hong Yan 3 &
• Yuliang Zou 3  

Global Health Research and Policy volume  5 , Article number:  14 ( 2020 ) Cite this article

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The call for “W orking Together to Build a Community of Shared Future for Mankind” requires us to improve people’s health across the globe, while global health development entails a satisfactory answer to a fundamental question: “What is global health?” To promote research, teaching, policymaking, and practice in global health, we summarize the main points on the definition of global health from the Editorial Board Meeting of Global Health Research and Policy, convened in July 2019 in Wuhan, China. The meeting functioned as a platform for free brainstorming, in-depth discussion, and post-meeting synthesizing. Through the meeting, we have reached a consensus that global health can be considered as a general guiding principle, an organizing framework for thinking and action, a new branch of sciences and specialized discipline in the large family of public health and medicine. The word “global” in global health can be subjective or objective, depending on the context and setting. In addition to dual-, multi-country and global, a project or a study conducted at a local area can be global if it (1) is framed with a global perspective, (2) intends to address an issue with global impact, and/or (3) seeks global solutions to an issue, such as frameworks, strategies, policies, laws, and regulations. In this regard, global health is eventually an extension of “international health” by borrowing related knowledge, theories, technologies and methodologies from public health and medicine. Although global health is a concept that will continue to evolve, our conceptualization through group effort provides, to date, a comprehensive understanding. This report helps to inform individuals in the global health community to advance global health science and practice, and recommend to take advantage of the Belt and Road Initiative proposed by China.

“Promoting Health For All” can be considered as the mission of global health for collective efforts to build “a Community of Shared Future for Mankind” first proposed by President Xi Jinping of China in 2013. The concept of global health continues to evolve along with the rapid development in global health research, education, policymaking, and practice. It has been promoted on various platforms for exchange, including conferences, workshops and academic journals. Within the Editorial Board of Global Health Research and Policy (GHRP), many members expressed their own points of view and often disagreed with each other with regard to the concept of global health. Substantial discrepancies in the definition of global health will not only affect the daily work of the Editorial Board of GHRP, but also impede the development of global health sciences.

To promote a better understanding of the term “ global health” , we convened a special session in the 2019 GHRP Editorial Board Meeting on the 7th of July at Wuhan University, China. The session started with a review of previous work on the concept of global health by researchers from different institutions across the globe, followed by free brainstorms, questions-answers and open discussion. Individual participants raised many questions and generously shared their thoughts and understanding of the term global health. The session was ended with a summary co-led by Dr. Xinguang Chen and Dr. Hao Li. Post-meeting efforts were thus organized to further synthesize the opinions and comments gathered during the meeting and post-meeting development through emails, telephone calls and in-person communications. With all these efforts together, concensus have been met on several key concepts and a number of confusions have been clarified regarding global health. In this editorial, we report the main results and conclusions.

A brief history

Our current understanding of the concept of global health is based on information in the literature in the past seven to eight decades. Global health as a scientific term first appeared in the literature in the 1940s [ 1 ]. It was subsequently used by the World Health Organization (WHO) as guidance and theoretical foundation [ 2 , 3 , 4 ]. Few scholars discussed the concept of global health until the 1990s, and the number of papers on this topic has risen rapidly in the subsequent decade [ 5 ] when global health was promoted under the Global Health Initiative - a global health plan signed by the U.S. President Barack Obama [ 6 ]. As a key part of the national strategy in economic globalization, security and international policies, global health in the United States has promoted collaborations across countries to deal with challenging medical and health issues through federal funding, development aids, capacity building, education, scientific research, policymaking and implementation.

Based on his experience working with Professor Zongfu Mao, the lead Editors-in-Chief, who established the Global Health Institute at Wuhan University in 2011 and launched the GHRP in 2016, Dr. Chen presented his own thoughts surrounding the definition of global health to the 2019 GHRP Editorial Board Meeting. Briefly, Dr. Chen defined global health with a three-dimensional perspective.

First, global health can be considered as a guiding principle, a branch of health sciences, and a specialized discipline within the broader arena of public health and medicine [ 5 ]. As many researchers posit, global health first serves as a guiding principle for people who would like to contribute to the health of all people across the globe [ 5 , 7 , 8 ].

Second, Dr. Chen’s conceptualization of global health is consistent with the opinions of many other scholars. Global health as a branch of sciences focuses primarily on the medical and health issues with global impact or can be effectively addressed through global solutions [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. Therefore, the goal of global health science is to understand global medical and health issues and develop global solutions and implications [ 7 , 9 , 15 , 17 , 18 , 19 ].

Third, according to Dr. Chen, to develop global health as a branch of science in the fields of public health and medicine, a specialized discipline must be established, including educational institutions, research entities, and academic societies. Only with such infrastructure, can the professionals and students in the global health field receive academic training, conduct global health research, exchange and disseminate research findings, and promote global health practices [ 5 , 15 , 20 , 21 , 22 , 23 ].

Developmentally and historically, we have learned and will continue to learn global health from the WHO [ 1 , 4 , 24 , 25 ]. WHO’s projects are often ambitious, involving multiple countries, or even global in scope. Through research and action projects, the WHO has established a solid knowledge base, relevant theories, models, methodologies, valuable data, and lots of experiences that can be directly used in developing global health [ 26 , 27 , 28 , 29 ]. Typical examples include WHO’s efforts for global HIV/AIDS control [ 13 , 30 , 31 , 32 ], and the Primary Healthcare Programs to promote Health For All [ 33 , 34 ].

The definition of Global Health

From published studies in the international literature and our experiences in research, training, teaching and practice, our meeting reached a consensus-global health is a newly established branch of health sciences, growing out from medicine, public health and international health, with much input from the WHO. What makes global health different from them is that (1) global health deals with only medical and health issues with global impact [ 35 , 5 , 36 , 10 , 14 , 2 ] the main task of global health is to seek for global solutions to the issues with global health impact [ 7 , 18 , 37 ]; and (3) the ultimate goal is to use the power of academic research and science to promote health for all, and to improve health equity and reduce health disparities [ 7 , 14 , 15 , 18 , 38 ]. Therefore, global health targets populations in all countries and involves all sectors beyond medical and health systems, although global health research and practice can be conducted locally [ 39 ].

As a branch of medical and health sciences, global health has three fundamental tasks: (1) to master the spatio-temporal patterns of a medical and/or health issue across the globe to gain a better understanding of the issue and to assess its global impact [ 40 , 41 , 42 , 43 ]; (2) to investigate the determinants and influential factors associated with medical and health issues that are known to have global impact [ 15 , 40 , 41 , 42 , 43 ]; and (3) to establish evidence-based global solutions, including strategies, frameworks, governances, policies, regulations and laws [ 14 , 15 , 28 , 38 , 44 , 45 , 46 , 47 ].

Like public health, medicine, and other branches of sciences, global health should have three basic functions : The first function is to generate new knowledge and theories about global health issues, influential factors, and develop global solutions. The second function is to distribute the knowledge through education, training, publication and other forms of knowledge sharing. The last function is to apply the global health knowledge, theories, and intervention strategies in practice to solve global health problems.

Understanding the word “global”

Confusion in understanding the term ‘global health’ has largely resulted from our understanding of the word “global”. There are few discrepancies when the word ‘global’ is used in other settings such as in geography. In there, the world global physically pertains to the Earth we live on, including all people and all countries in the world. However, discrepancies appear when the word “global” is combined with the word “health” to form the term “global health”. Following the word “global” literately, an institution, a research project, or an article can be considered as global only if it encompasses all people and all countries in the world. If we follow this understanding, few of the work we are doing now belong to global health; even the work by WHO are for member countries only, not for all people and all countries in the world. But most studies published in various global health journals, including those in our GHRP, are conducted at a local or international level. How could this global health happen?

The argument presented above leads to another conceptualization: Global health means health for a very large group of people in a very large geographic area such as the Western Pacific, Africa, Asia, Europe, and Latin America. Along with this line of understanding, an institution, a research project or an article involving multi-countries and places can be considered as global, including those conducted in countries involved in China’s Belt and Road Initiative (BRI) [ 26 , 48 , 49 , 50 , 51 ]. They are considered as global because they meet our definitions of global health which focus on medical and health issues with global impact or look for global solutions to a medical or health issue [ 5 , 7 , 22 ].

One step further, the word ‘global’ can be considered as a concept of goal-setting in global health. Typical examples of this understanding are the goals established for a global health institution, for faculty specialized in global health, and for students who major or minor in global health. Although few of the global health institutions, scholars and students have conducted or are going to conduct research studies with a global sample or delivered interventions to all people in all countries, all of them share a common goal: Preventing diseases and promoting health for all people in the world. For example, preventing HIV transmission within Wuhan would not necessarily be a global health project; but the same project can be considered as global if it is guided by a global perspective, analyzed with methods with global link such as phylogenetic analysis [ 52 , 53 ], and the goal is to contribute to global implications to end HIV/AIDS epidemic.

The concept of global impact

Global impact is a key concept for global health. Different from other public health and medical disciplines, global health can address any issue that has a global impact on the health of human kind, including health system problems that have already affected or will affect a large number of people or countries across the globe. Three illustrative examples are (1) the SARS epidemic that occurred in several areas in Hong Kong could spread globally in a short period [ 11 ] to cause many medical and public health challenges [ 54 , 55 ]; (2) the global epidemic of HIV/AIDS [ 13 ]; and the novel coronavirus epidemic first broke out in December 2019 in Wuhan and quickly spread to many countries in the world [ 56 ].

Along with rapid and unevenly paced globalization, economic growth, and technological development, more and more medical and health issues with global impact emerge. Typical examples include growing health disparities, migration-related medical and health issues, issues related to internet abuse, the spread of sedentary lifestyles and lack of physical activity, obesity, increasing rates of substance abuse, depression, suicide and many other emerging mental health issues, and so on [ 10 , 23 , 36 , 42 , 57 , 58 , 59 , 60 ]. GHRP is expecting to receive and publish more studies targeting these issues guided by a global health perspective and supports more researchers to look for global solutions to these issues.

The concept of global solution

Another concept parallel to global impact is global solution . What do we mean by global solutions? Different from the conventional understanding in public health and medicine, global health selectively targets issues with global impact. Such issues often can only be effectively solved at the macro level through cross-cultural, international, and/or even global collaboration and cooperation among different entities and stakeholders. Furthermore, as long as the problem is solved, it will benefit a large number of population. We term this type of interventions as a global solution. For example, the 90–90-90 strategy promoted by the WHO is a global solution to end the HIV/AIDS epidemic [ 61 , 62 ]; the measures used to end the SARS epidemic is a global solution [ 11 ]; and the ongoing measures to control influenza [ 63 , 64 ] and malaria [ 45 , 65 ], and the measures taken by China, WHO and many countries in the world to control the new coronaviral epidemic started in China are also great examples of global solutions [ 66 ].

Global solutions are also needed for many emerging health problems, including cardiovascular diseases, sedentary lifestyle, obesity, internet abuse, drug abuse, tobacco smoking, suicide, and other problems [ 29 , 44 ]. As described earlier, global solutions are not often a medical intervention or a procedure for individual patients but frameworks, policies, strategies, laws and regulations. Using social media to deliver interventions represents a promising approach in establishment of global solutions, given its power to penetrate physical barriers and can reach a large body of audience quickly.

Types of Global Health researches

One challenge to GHRP editors (and authors alike) is how to judge whether a research study is global? Based on the new definition of global health we proposed as described above, two types of studies are considered as global and will receive further reviews for publication consideration. Type I includes projects or studies that involve multiple countries with diverse backgrounds or cover a large diverse populations residing in a broad geographical area. Type II includes projects or studies guided by a global perspective, although they may use data from a local population or a local territory. Relative to Type I, we anticipate more Type II project and studies in the field of global health. Type I study is easy to assess, but caution is needed to assess if a project or a study is Type II. Therefore, we propose the following three points for consideration: (1) if the targeted issues are of global health impact, (2) if the research is attempted to understand an issue with a global perspective, and (3) if the research purpose is to seek for a global solution.

An illustrative example of Type I studies is the epidemic and control of SARS in Hong Kong [ 11 , 67 ]. Although started locally, SARS presents a global threat; while controlling the epidemic requires international and global collaboration, including measures to confine the infected and measures to block the transmission paths and measures to protect vulnerable populations, not simply the provisions of vaccines and medicines. HIV/AIDS presents another example of Type I project. The impact of HIV/AIDS is global. Any HIV/AIDS studies regardless of their scope will be global as long as it contributes to the global efforts to end the HIV/AIDS epidemic by 2030 [ 61 , 62 ]. Lastly, an investigation of cardiovascular diseases (CVD) in a country, in Nepal for example, can be considered as global if the study is framed from a global perspective [ 44 ].

The discussion presented above suggests that in addition to scope, the purpose of a project or study can determine if it is global. A pharmaceutical company can target all people in the world to develop a new drug. The research would be considered as global if the purpose is to improve the medical and health conditions of the global population. However, it would not be considered as global if the purpose is purely to pursue profit. A research study on a medical or health problem among rural-to-urban migrants in China [ 57 , 58 , 60 ] can be considered as global if the researchers frame the study with a global perspective and include an objective to inform other countries in the world to deal with the same or similar issues.

Think globally and act locally

The catchphrase “think globally and act locally” presents another guiding principle for global health and can be used to help determine whether a medical or public health research project or a study is global. First, thinking globally and acting locally means to learn from each other in understanding and solving local health problems with the broadest perspective possible. Taking traffic accidents as an example, traffic accidents increase rapidly in many countries undergoing rapid economic growth [ 68 , 69 ]. There are two approaches to the problem: (1) locally focused approach: conducting research studies locally to identify influential factors and to seek for solutions based on local research findings; or (2) a globally focused approach: conducting the same research with a global perspective by learning from other countries with successful solutions to issues related traffic accidents [ 70 ].

Second, thinking globally and acting locally means adopting solutions that haven been proven effective in other comparable settings. It may greatly increase the efficiency to solve many global health issues if we approach these issues with a globally focused perspective. For example, vector-borne diseases are very prevalent among people living in many countries in Africa and Latin America, such as malaria, dengue, and chikungunya [ 45 , 71 , 72 ]. We would be able to control these epidemics by directly adopting the successful strategy of massive use of bed nets that has been proven to be effective and cost-saving [ 73 ]. Unfortunately, this strategy is included only as “simple alternative measures” in the so-called global vector-borne disease control in these countries, while most resources are channeled towards more advanced technologies and vaccinations [ 16 , 19 , 74 ].

Third, thinking globally and acting locally means learning from each other at different levels. At the individual level, people in high income countries can learn from those in low- and mid-income countries (LMICs) to be physically more active, such as playing Taiji, Yoga, etc.; while people in LMICs can learn from those in high income countries to improve their hygiene, life styles, personal health management, etc. At the population level, communities, organizations, governments, and countries can learn from each other in understanding their own medical and health problems and healthcare systems, and to seek solutions for these problems. For example, China can learn from the United States to deal with health issues of rural to urban migrants [ 75 ]; and the United States can learn from China to build three-tier health care systems to deliver primary care and prevention measures to improve health equality.

Lastly, thinking globally and acting locally means opportunities to conduct global health research and to be able to exchange research findings and experiences across the globe; even without traveling to another country. For example, international immigrants and international students present a unique opportunity for global health research in a local city [ 5 , 76 ]. To be global, literature search and review remains the most important approach for us to learn from each other besides conducting collaborative work with the like-minded researchers across countries; rapid development in big data and machine learning provide another powerful approach for global health research. Institutions and programs for global health provides a formal venue for such learning and exchange opportunities.

Reframing a local research study as global

The purpose of this article is to promote global health through research and publication. Anyone who reads this paper up to this point might already be able to have a clear idea on how to reframe his/her own research project or article to be of global nature. There is no doubt that a research project is global if it involves multiple countries with investigators of diverse backgrounds from different countries. However, if a research project targets a local population with investigators from only one or two local institutions, can such project be considered as global?

Our answer to this question is “yes” even if a research study is conducted locally, if the researcher (1) can demonstrate that the issue to be studied or being studied has a global impact, or (2) eventually looks for a global solution although supported with local data. For example, the study of increased traffic accidents in a city in Pakistan can be considered as global if the researchers frame the problem from a global perspective and/or adopt global solutions by learning from other countries. On the other hand, a statistical report of traffic accidents or an epidemiological investigation of factors related to the traffic accidents at the local level will not be considered as global. Studies conducted in a local hospital on drug resistance to antibiotics and associated cost are global if expected findings can inform other countries to prevent abuse of antibiotics [ 77 ]. Lastly, studies supported by international health programs can be packaged as global simply by broadening the vision from international to global.

Is Global Health a new bottle with old wine?

Another challenge question many scholars often ask is: “What new things can global health bring to public health and medicine?” The essence of this question is whether global health is simply a collection of existing medical and health problems packaged with a new title? From our previous discussion, many readers may already have their own answer to this question that this is not true. However, we would like to emphasize a few points. First, global health is not equal to public health, medicine or both, but a newly emerged sub-discipline within the public health-medicine arena. Global health is not for all medical and health problems but for the problems with global impact and with the purpose of seeking global solutions. In other words, global health focuses primarily on mega medical and health problems that transcend geographical, cultural, and national boundaries and seeks broad solutions, including frameworks, partnerships and cooperation, policies, laws and regulations that can be implemented through governments, social media, communities, and other large and broad reaching mechanisms.

Second, global health needs many visions, methods, strategies, approaches, and frameworks that are not conventionally used in public health and medicine [ 5 , 18 , 22 , 34 ]. They will enable global health researchers to locate and investigate those medical and health issues with global impact, gain new knowledge about them, develop new strategies to solve them, and train health workers to deliver the developed strategies. Consequently, geography, history, culture, sociology, governance, and laws that are optional for medicine and public health are essential for global health. Lastly, it is fundamental to have a global perspective for anyone in global health, but this could be optional for other medical and health scientists [ 40 , 41 ].

Global Health, international health, and public health

As previously discussed, global health has been linked to several other related disciplines, particularly public health, international health, and medicine [ 3 , 5 , 7 , 18 , 22 ]. To our understanding, global health can be considered as an application of medical and public health sciences together with other disciplines (1) in tackling those issues with global impact and (2) in the effort to seek global solutions. Thus, global health treats public health sciences and medicine as their foundations, and will selectively use theories, knowledge, techniques, therapeutics and prevention measures from public health, medicine, and other disciplines to understand and solve global health problems.

There are also clear boundaries between global health, public health and medicine with regard to the target population. Medicine targets patient populations, public health targets health populations in general, while global health targets the global population. We have to admit that there are obvious overlaps between global health, public health and medicine, particularly between global health and international health. It is worth noting that global health can be considered as an extension of international health with regard to the scope and purposes. International health focuses on the health of participating countries with intention to affect non-participating countries, while global health directly states that its goal is to promote health and prevent and treat diseases for all people in all countries across the globe. Thus, global health can be considered as developed from, and eventually replace international health.

Challenges and opportunities for China to contribute to Global Health

To pursue A Community with a Shared Future for Mankind , China’s BRI , currently involving more than 150 countries across the globe, creates a great opportunity for Chinese scholars to contribute to global health. China has a lot to learn from other countries in advancing its medical and health technologies and to optimize its own healthcare system, and to reduce health disparities among the 56 ethnic groups of its people. China can also gain knowledge from other countries to construct healthy lifestyles and avoid unhealthy behaviors as Chinese people become more affluent. Adequate materials and money may be able to promote physical health in China; but it will be challenging for Chinese people to avoid mental health problems currently highly prevalent in many rich and developed countries.

To develop global health, we cannot ignore the opportunities along with the BRI for Chinese scholars to share China’s lessons and successful experience with other countries. China has made a lot of achievements in public health and medicine before and after the Open Door Policy [ 49 , 78 ]. Typical examples include the ups and downs of the 3-Tier Healthcare Systems, the Policy of Prevention First, and the Policy of Putting Rural Health as the Priority, the Massive Patriotic Hygiene Movement with emphasis on simple technology and broad community participation, the Free Healthcare System for urban and the Cooperative Healthcare System for rural residents. There are many aspects of these initiatives that other countries can emulate including the implementation of public health programs covering a huge population base unprecedented in many other countries.

There are challenges for Chinese scholars to share China’s experiences with others as encountered in practice. First of all, China is politically very stable while many other countries have to change their national leadership periodically. Changes in leadership may result in changes in the delivery of evidence- based intervention programs/projects, although the changes may not be evidence-based but politically oriented. For example, the 3-Tier Healthcare System that worked in China [ 79 , 80 ] may not work in other countries and places without modifications to suit for the settings where there is a lack of local organizational systems. Culturally, promotion of common values among the public is unique in China, thus interventions that are effective among Chinese population may not work in countries and places where individualism dominates. For example, vaccination program as a global solution against infectious diseases showed great success in China, but not in the United States as indicated by the 2019 measles outbreak [ 81 ].

China can also learn from countries and international agencies such as the United Kingdom, the United States, the World Health Organization, and the United Nations to successfully and effectively provide assistance to LMICs. As China develops, it will increasingly take on the role of a donor country. Therefore, it is important for Chinese scholars to learn from all countries in the world and to work together for a Community of Shared Future for Mankind during the great course to develop global health.

Promotion of global health is an essential part of the Working Together  to Build a Community of Shared Future for Mankind. In this editorial, we summarized our discussions in the 2019 GHRP Editorial Board Meeting regarding the concept of global health. The goal is to enhance consensus among the board members as well as researchers, practitioners, educators and students in the global health community. We welcome comments, suggestions and critiques that may help further our understanding of the concept. We would like to keep the concept of global health open and let it evolve along with our research, teaching, policy and practice in global health.

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Acknowledgements

We would like to thank those who had provided their comments for the improvement of the manuscript.

The work is funded by the journal development funds of Wuhan University.

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Xinguang Chen, Hao Li, Xiaohui Liang, Zongfu Mao, Nan Wang, Peigang Wang & Tingting Wang

Department of Epidemiology, University of Florida, Florida, USA

Xinguang Chen

School of Health Sciences, Wuhan University, Wuhan, China

Hao Li, Xiaohui Liang, Zongfu Mao, Nan Wang, Peigang Wang, Tingting Wang, Hong Yan & Yuliang Zou

Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

Don Eliseo Lucero-Prisno III

Global Health Research Center, Duke Kunshan University, Kunshan, China

Abu S. Abdullah

Duke Global Health Institute, Duke University, Durham, North Carolina, USA

School of Public Health, Fudan University, Shanghai, China

Jiayan Huang

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Charlotte Laurence

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Chen XG wrote the manuscript. LI H organized the meeting, collecting the comments and editing the manuscript. Lucero-Prisno DE integrated all the comments together. Abdullah AS, Huang JY, Laurence C, Liang XH, Ma ZY, Ren R, Wu SL, Wang N, Wang PG and Wang Tt all participated in the discussion and comments of this manuscript. Laurence C and Liang XH both provided language editing. The author(s) read and approved the final manuscript

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Chen, X., Li, H., Lucero-Prisno, D.E. et al. What is global health? Key concepts and clarification of misperceptions. glob health res policy 5 , 14 (2020). https://doi.org/10.1186/s41256-020-00142-7

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How has the COVID-19 Pandemic Impacted Global Health?

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Introduction

The emergence of the coronavirus disease 2019 (COVID-19), which is caused by infection from the previously unknown severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has devastated economies and caused unprecedented challenges to healthcare and food systems around the world. Globally, billions of people have been ordered to stay at home as a result of lockdowns, while almost three million people have died (as of the end of March 2021).

The Global Health Security (GHS) Index

At the end of the Ebola outbreak that occurred in 2014, the GHS Index was developed to determine the ability of a total of 195 countries to cope with a future infectious disease outbreak. In order to make this prediction, the GHS Index considers the biological risks of each country, which includes an analysis of the nation’s current geopolitics, health system and capacity to control infectious disease outbreaks.

To evaluate a given country’s GHS Index, they are rated on prevention, detection and reporting, rapid response, health system, compliance with international norms and risk environment.

Since the outbreak of COVID-19, public health officials have investigated whether the GHS Index could be used to assess the performance of countries during the current pandemic. In a research study looking to do just this, the GHS Index was found to have a positive correlation with COVID-19 associated morbidity and mortality rates in 178 different countries.

Despite this observation, these researchers actually found that this positive association had a limited value in determining a country’s ability to deal with a global pandemic.

The effect of COVID-19 on other health problems

The COVID-19 pandemic has overwhelmed healthcare systems around the world, having a knock-on effect on the diagnosis and treatment of other diseases.

Social distancing and lockdowns have reduced diagnosis rates of infectious diseases such as seasonal influenza, as would be expected with reduced social contact.

However, individuals have avoided seeking help for other health problems due to lockdowns and avoidance of medical settings, leading to reduced diagnosis and treatment despite the problem still being there. Meanwhile, even in diagnosed cases, treatment for diseases and conditions such as cancer had to be postponed in many cases due to the immediate threat of COVID-19 consuming health systems and their resources.

Scientific research around the world has also focused on COVID-19, potentially delaying research and breakthroughs on other diseases.

Furthermore, other infectious diseases such as malaria, HIV and tuberculosis were put on the sidelines, despite still being very real problems, particularly in more vulnerable populations. An assessment by the Bill & Melinda Gates foundations in September 2020 assessed data on vaccine coverage from the first portion of the pandemic and came to a conclusion that vaccine coverage in health systems had been pushed back around 25 years in 25 weeks.

Before the pandemic, around half of the world's population did not have access to essential healthcare, and this number has been increased by the pandemic. Healthcare systems across the globe need to become more accessible and need to be prepared for future pandemic-like events in a way that will reduce the impact on the management of other diseases.

Global mental health impact

The most common characteristics associated with the novel infectious COVID-19 include respiratory symptoms including cough, fever, respiratory problems, and, in certain cases, atypical pneumonia. Outside of the respiratory system, SARS-CoV-2 also appears to affect the cardiovascular, gastrointestinal, and urinary systems.

Psychological effects of COVID-19

In addition to these symptoms, various neurological manifestations have been observed following infection by SARS-CoV-2. Some examples of these manifestations include hyposmia, dysgeusia, encephalitis, meningitis, and acute cerebrovascular disease. It has been suggested that these neurological effects are due to direct infection of the brain, a virus-induced hyperinflammatory response, hypercoagulation, and post-infectious immune-mediated processes. As a result, these neurological effects can lead to a wide range of psychological issues ranging from depression, anxiety, fatigue, and post-traumatic stress disorder (PTSD).

Healthcare workers

In addition to having a direct impact on COVID-19 patients, the mental health of both health care providers and non-infected members of the general population has also been dramatically changed during the pandemic.

Health care providers, for example, are at a high risk of infection to the virus, as well as COVID-19 related traumatic events. Furthermore, healthcare workers who must quarantine have been shown to be at a greater risk of avoidance behaviors and more severe symptoms of PTSD as compared to the general public.  

General population

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Many will agree that the physical and social distancing measures that have been introduced throughout many parts of the world have significantly affected how the general population connects to and interacts with others. This loss of connection has been further impaired by the inability to meet with others at central areas of social interaction and support such as restaurants, libraries, sports facilities and both cultural and community centers.  

The closures of both schools and businesses have also increased the sense of isolation as unemployment numbers have risen and affected individuals experience significant financial distress. Taken together, these dramatic social changes have increased the mental health burden and subsequently worsened mental health outcomes. Furthermore, fear-related behaviors such as extreme avoidance of social contact have also risen, further exacerbating the risk of poor mental health issues.

Lessons learned

Overall, it is generally believed that no country was fully prepared to handle a pandemic, particularly one at the magnitude of the COVID-19 pandemic. SARS-CoV-2 has a unique ability to spread from asymptomatic people prior to the onset of symptoms which, combined with its long incubation time, makes it difficult for countries to prevent the spread of this disease.

Additional barriers to control the spread of COVID-19 include community resistance to outbreak mitigation efforts including travel restrictions, use of face masks in public, and social distancing, hospital transmission rates and a general lack of crucial funding and resources.

One of the most significant lessons that can be learned from the COVID-19 pandemic is the importance of political will in its role in protecting people from epidemics. The COVID-19 outbreak also awakened much of the global population to the broken and overextended health systems in many parts of the world.

In order to ensure that the world is better prepared for the next new infectious agent, public health systems must remain committed to developing adequate surveillance programs, prompt diagnostic techniques, and robust research initiatives that can detect and understand the basic biology and treatment, if necessary, of new organisms.

• Bill & Melinda Gates Foundation. COVID-19 A Global Perspective. Available from: https://www.gatesfoundation.org/goalkeepers/report/2020-report/#GlobalPerspective
• Hou, L., Mehta, S. D., Christian, E., et al. (2020). Impact of the COVID-19 pandemic on global health research training and education. Journal of Global Health 2 . doi:10.7189.jogh.10.020366.
• Impact of COVID-19 on people’s livelihoods, their health and our food systems [Online]. Available from: https://www.who.int/news/item/13-10-2020-impact-of-covid-19-on-people%27s-livelihoods-their-health-and-our-food-systems .
• Ji, Y., Shao, J., Tao, B., et al,. (2021). Are we ready to deal with a global COVID-19 pandemic? Rethinking countries’ capacity based on the Global Health Security Index. International Journal of Infectious Diseases. doi:10.1016/j.ijid.2021.03.089.
• Lange, K. W. (2021). Coronavirus disease 2019 (COVID-19) and global mental health. Global Health Journal. doi:10.1016/j.glohj.2021.02.004.

Further Reading

• All Coronavirus Disease COVID-19 Content
• The COVID-19 Pandemic: What have the experts learned?
• What Mutations of SARS-CoV-2 are Causing Concern?
• What Role has Social Media Played in COVID-19?
• Unlocking our clinical understanding of SARS-CoV-2 infection, Post-Acute COVID Syndrome (PACS), and systemic recovery

Last Updated: Jul 5, 2022

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After completing her Bachelor of Science in Toxicology with two minors in Spanish and Chemistry in 2016, Benedette continued her studies to complete her Master of Science in Toxicology in May of 2018. During graduate school, Benedette investigated the dermatotoxicity of mechlorethamine and bendamustine; two nitrogen mustard alkylating agents that are used in anticancer therapy.

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Why is advocacy important for global health?

January 22, 2014 by Rachel Wilson

It’s not enough to invent and implement solutions to global health problems. The global health community must also secure the support of global decision-makers.

Advocacy helps ensure solutions to challenges in global health reach the people who need them most. Photo: PATH/Gabe Bienczycki.

Believe it or not, advocacy is as much a part of your daily life as it is mine. Have you ever signed a petition to show your support for a cause or approached friends to speak up for change that you felt strongly about? Whether it’s working to place a stop sign on the corner of your street or campaigning to add newborn health protections to national health policy, advocacy is democracy in action.

In global health, we talk a lot about the importance and influence of advocacy. Rarely, though, do we break down what this really means.

A champion for better global health

To put it simply, it’s not enough to invent or implement solutions to global health problems. The global health community must secure the support of decision-makers, policymakers, and others who can commit the necessary resources and enact supportive policies to bring these solutions to scale. It takes advocacy as well as ingenuity to ensure that existing solutions, as well as those in development, can reach the people who need them most.

What does it take to ensure that these innovations result in sustainable improvement? Resources and political will—informed by the experts and communities who understand what is needed.

How we approach advocacy

At PATH, our advocates work to ensure that donors and developing countries make funding and policy decisions that will have the greatest health impact. At the heart of PATH’s work in advocacy is our distinctive approach to achieving public health goals through policy change. What makes our policy advocacy work unique is our diverse areas of expertise—as a research organization, as an implementer, and as an adviser on key global health platforms. We use this expertise to improve policies and leverage resources that will ultimately accelerate the delivery of global health services and innovations that save lives.

Staff at PATH work to influence government priorities and decisions by increasing awareness and engaging with policymakers, key constituencies, and other important individuals and groups. Each year, we determine the areas in which our advocacy work can have the greatest impact. Always among our priorities are child health, women’s and newborn health, infectious diseases, and research and development for global health technologies.

A powerful tool for change

Advocacy is one of the many powerful tools that PATH uses to drive transformative innovation to save lives. By influencing the priorities and actions of those in power, we work to create a policy environment that supports good health and equity around the world.

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10 global health issues to track in 2021

24 December 2020

2020 was a devastating year for global health. A previously unknown virus raced around the world, rapidly emerging as one of its top killers, laying bare the inadequacies of health systems. Today, health services in all regions are struggling to both tackle COVID-19, and provide people with vital care.

In another blow, the pandemic threatens to set back hard-won global health progress achieved over the past two decades - in fighting infectious diseases, for example, and improving maternal and child health.

So in 2021, countries around the world will need to continue battle COVID-19 (albeit with the knowledge that effective tools are evolving). They will need to move swiftly to repair and reinforce their health systems so they can deliver these tools, and to address the key societal and environmental issues that result in some sections of the population suffering so much more than others.  

WHO and its partners will be at their side. We will work to help countries strengthen preparedness for pandemics and other emergencies. We will remind them of the importance of bringing countries together and of involving the whole government, not just the health sector. And we will support them in building strong health systems and healthy populations   

Here are 10 ways we will do this:

Build global solidarity for worldwide health security

WHO will work with countries to improve their own preparedness for pandemics and health emergencies. But for this to be effective, we will ensure that countries work together. Above all, this pandemic has shown us over and again, that no one is safe until everyone is safe.

We will also help tackle health emergencies in humanitarian settings that have been intensified by COVID-19 . We will target support to better protect the most vulnerable communities against health emergency risks, including in urban settings, small island countries, conflict settings. 

We will leverage existing partnerships and create new ones to build a global health emergencies workforce to expand, train and standardize high-quality public health and medical assistance. We also plan to establish a Bio Bank – a globally agreed system for sharing pathogen materials and clinical samples to facilitate the rapid development of safe and effective vaccines and medicines. And we will sustain our focus on getting accurate information to people, building on our work with key partners to protect populations from infodemics .

Speed up access to COVID-19 tests, medicines and vaccines

A top priority in 2021 will be to continue our work across the four pillars of the ACT-Accelerator , to achieve equitable access to safe and effective vaccines, tests, and treatments and to ensure that health systems are strong enough to deliver them. Getting effective tools to everyone who needs them will be key to ending this first, acute phase of the pandemic, and to solve the health and economic crises it has caused.

At the end of 2020 there are a number of promising tools in the pipeline, thanks to an unprecedented speed of innovation. One immediate challenge is to source the remaining crucial funds needed to get these tools everywhere they are needed.  

Targets for the ACT-Accelerator in 2021 include: distributing 2 billion vaccines; 245 million treatments; establishing testing for 500 million people in low- and middle-income countries; and strengthening the health systems needed to support them.

Advance health for all

One of the clearest lessons the pandemic has taught us is the consequences of neglecting our health systems. In 2021 WHO will work across all three levels of the Organization and with partners worldwide to help countries strengthen systems so that they can respond to COVID-19 and deliver all the essential health services required to keep people of all ages healthy – close to home and without falling into poverty. 

Two important initiatives will underpin this work: the implementation and roll-out of WHO’s new primary health care programme in countries and the UHC compendium - a tool to help countries identify the essential health services they need -- for example to ensure that women can give birth safely, that children can get immunized, and that people can be tested and treated for diseases.

To further enhance this work, we will lead a global campaign to strengthen the global health workforce in 2021, the Year of the Health and Care Worker.

Tackling health inequities

The COVID-19 pandemic has drawn attention to the deep disparities that persist between and within countries, some of which are being exacerbated and risk widening even further.  

In 2021 we will draw on the latest WHO data and build on international commitments (and existing work) to advance universal health coverage and address the broader determinants of health. We will work with countries to monitor and address health inequities related to critical issues such as income, gender, ethnicity, living in remote rural areas or disadvantaged urban areas, education, occupation/employment conditions, and disability. 

We will focus on steps the health sector can take to ensure equitable access to quality health services across the continuum of care, as well as engage with other sectors to address social and environmental determinants of health.

As part of our year-long campaign, on World Health Day, 7 April 2021, WHO will call for global action to address health inequities.

Provide global leadership on science and data

WHO will monitor and evaluate the latest scientific developments around COVID-19 and beyond, identifying opportunities to harness those advances to improve global health. We will uphold and strengthen the excellence, relevance and efficacy of our own core technical functions, to provide the world with the best evidence-based recommendations for public health on issues ranging from Alzheimers to Zika.

And through efforts like our revamped SCORE Technical Package , we will support countries in strengthening the capacity of their health data and information systems to report on progress towards the health-related Sustainable Development Goals.

Revitalize efforts to tackle communicable diseases

In recent decades, WHO and partners have worked resolutely to end the scourge of polio, HIV, tuberculosis and malaria, and to avert epidemics of diseases like measles and yellow fever. COVID-19 set back much of this work in 2020. So in 2021 we will help countries get vaccines for polio and other diseases to the people who missed out during the pandemic. As part of this push, we will work to improve access to the HPV vaccine as part of the new global effort to  end cervical cancer  we launched in 2020.

We will work with partners to implement the new 10-year Roadmap for Neglected Tropical Diseases (NTDs) , with its global targets and milestones to prevent, control, eliminate and eradicate 20 NTDs. And we will intensify efforts to end AIDS, tuberculosis and malaria and to eliminate viral hepatitis by 2030 .

Combat drug resistance

Global efforts to end infectious diseases will only succeed if we have effective medicines to treat them. So it will be vital to build on the work we do with our One Health partners -- the Food and Agricultural Organization and World Organisation for Animal Health (OIE) -- and with stakeholders across all sectors to preserve antimicrobials. The new Global Leadership Group for Antimicrobial Resistance , which includes industry chiefs as well as political leaders, will meet for the first time in January to discuss ways to accelerate momentum on this critical issue. At the same time, WHO will further improve global monitoring and continue our support to national action plans, making sure that antimicrobial resistance is factored into health system strengthening and health emergencies preparedness plans.

Prevent and treat NCDs and mental health conditions

WHO’s latest Global Health Estimates revealed that noncommunicable diseases (NCDs) were responsible for 7 of the top 10 causes of death in 2019. In 2020 we saw how particularly vulnerable people with NCDs are to COVID-19, and how vital it is to ensure that screening and treatment programmes for diseases such as cancer, diabetes and heart disease are accessible to all who need them when they need them. This will be a major focus in 2021, along with a new Global Diabetes Compact , and a campaign to help 100 million people quit tobacco.

We also saw the devastating impact of the pandemic and the resulting lockdowns, economic security, and fear and uncertainty on people’s mental health the world over. In 2021 we will support efforts to expand services for community-based mental health care, and to people living in conflict- or disaster-affected areas.

Build back better

COVID-19 has been a pivotal moment in many ways, and offers a unique opportunity to build back a better, greener, healthier world. Our Manifesto for a Healthy Recovery from COVID-19 , with its goals of addressing climate change and health, reducing air pollution and improving air quality, can play a major role in making this happen.

A conference in June 2021 will focus on supporting health in Small Island Developing States. Meanwhile, we will take forward recommendations from the 2020 WHO/UNICEF/Lancet Commission to assure a healthier planet for our children, and continue our work to improve nutrition and food systems worldwide -- including through the global strategy on food safety and the United Nations Secretary-General’s Food Systems Summit in September.

Act in solidarity

One of the key principles WHO has emphasized throughout the fight against COVID-19 is the need to demonstrate greater solidarity – between nations, institutions, communities and individuals, closing the cracks in our defences on which the virus thrives.

In 2021 we will prioritize this – building national capacity through our work with Member States but also with new initiatives, for example working with youth groups, strengthening and expanding partnerships with civil society and the private sector, and partnering with the new WHO Foundation . Our institutional capacity will develop apace, including through new scientific collaborations and the WHO Academy .

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Committee on Global Health and the Future of the United States. Global Health and the Future Role of the United States. Washington (DC): National Academies Press (US); 2017 May 15.

Global Health and the Future Role of the United States.

• Hardcopy Version at National Academies Press

10 Summary of Conclusions and Recommendations

The global vision that has brought improved travel and trade and increased interdependency among countries also calls for a common vision of health around the world. All countries are vulnerable to the ever-present threats of infectious disease, outbreaks, and epidemics. At the same time, there are opportunities for shared innovation and universal purpose as many countries that suffer from similar disease burdens strive to develop best practices and strong health systems for their citizens.

Throughout this consensus study, the committee emphasized the need for a more holistic examination of problems and challenges in global health. Such an approach applies not only to issues of global health security but also to the external factors that influence health security, such as the building of general capacity in countries and the creation of strong societies that foster stability, healthy lifestyles, and accessible economic opportunities. Unless core capacities and strong health systems are developed around the world, the global risk of infectious disease will continue to threaten the health and security of the United States. Beyond the imperative of addressing infectious disease threats, it is necessary to understand the fundamental connection between health and economic prosperity. In addition to the economic costs of responding to infectious disease outbreaks, the increasing prevalence of chronic or noncommunicable diseases (NCDs) has negatively affected global economies—compromising societal gains in life expectancy, productivity, and overall quality of life ( WEF, 2017 ).

Many countries currently face the dual burden of a rapid increase in NCDs, such as cardiovascular disease (CVD) and cancer, and the continuing need to eliminate infectious diseases, such as malaria and tuberculosis (TB), in addition to the priority of reducing the burden of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Moreover, some countries are considered to bear a triple burden, as traumatic injury has been found to be the second leading cause of premature death in young men after HIV/AIDS ( Marquez and Farrington, 2013 ). Combined, these three disease burdens can stall the progress of a country's development and significantly affect its ability to become a strong trading partner or a business or travel destination. The cost of productivity losses associated with disability, unplanned absences, and increased accidents can be as much as 400 percent higher than the cost of treatment ( WEF, 2010 ). Research also shows that investors are less likely to enter markets where the labor force suffers a heavy disease burden ( Bloom et al., 2004 ). Human capital clearly contributes significantly to economic growth, and it follows that having a healthy population is critical for economic prosperity. This point has been demonstrated in recent years: between 2000 and 2011, 24 percent of income growth in low- and middle-income countries (LMICs) resulted from improvements in health ( Jamison et al., 2013 ).

The root causes of all three of these health burdens are often linked by such underlying social factors as poverty, education, and location ( Frenk and Gómez-Dantés, 2016 ; Marmot, 2005 ). This commonality suggests that methods for prevention are linked as well, and the tools used to prevent one burden can help to prevent the others, emphasizing the need for holistic examination of programs. Over the last few decades, the United States has demonstrated remarkable leadership in global health. Notable progress has been achieved by such initiatives as The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the President's Malaria Initiative (PMI), as well as the nation's commitment to such multilateral organizations as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); Gavi, the Vaccine Alliance; and, more recently, the Global Health Security Agenda (GHSA). Similarly, progress has been achieved by efforts to combat antimicrobial resistance (AMR) at the national and international levels. Against the backdrop of an influential legacy on the global health stage, the new U.S. administration faces the choice of whether or not to ensure that the gains won with billions of U.S. dollars, years of dedication, and strong programs are sustained and poised for further growth.

• CHANGING THE WAY THE UNITED STATES ENGAGES

The committee has focused this report where it believes the United States can have the most immediate and substantial effect despite the limited resources available. Throughout the report, the committee has highlighted four priority areas that demand continued attention from U.S. global health investment within a two-pronged approach of securing against global threats (areas 1 and 2), and promoting productivity and economic growth in other countries (areas 3 and 4):

achieving global health security (including addressing pandemics and AMR)

maintaining a sustained response to the continuous threats of communicable diseases such as HIV/AIDS, TB, and malaria

saving and improving the lives of women and children

promoting cardiovascular health and preventing cancer

In addition, the committee has underscored the imperative to change the way the United States does business in global health, highlighting an immediate need to focus on ensuring protection against global threats and enhancing productivity and economic growth in all countries. To these ends, a more systematic, proactive, and integrated approach is needed that includes long-range planning and vision; greater application of rigor and measurement in achieving return on investment; and cooperation with all global health partners to leverage the respective strengths of each, including the advancement of innovation through the private sector and political commitment to achieving global goals on the part of national governments and multilateral partners. This shift in approach places the focus on prevention and preparedness, with a vision of investing in cross-cutting infrastructure in three areas: catalyzing innovation in health systems through medical product development and digital health, enabling more flexible financing mechanisms to fund global health programs, and maintaining U.S. global health leadership internationally. The outcome of this approach will be resilient countries with positive health outcomes, resulting in turn in robust trade partners, safer travel destinations, and more active collaborators in preventing and controlling global health problems that affect citizens in every country, at every income level.

• SECURING AGAINST GLOBAL THREATS

Many laudable public health successes have been achieved at the global, regional, national, and community levels. However, the world continues to evolve, and public health measures must change accordingly. The global community is no safer from infectious disease today than it was 20 years ago when the Institute of Medicine report America's Vital Interest in Global Health ( IOM, 1997 ) was written. The U.S. Army recently estimated that if a severe infectious disease pandemic were to occur today, the number of U.S. fatalities could be almost double the total number of battlefield fatalities sustained in all of the nation's wars since the American Revolution ( GAO, 2017 ). Poverty and climate change have led to greater risk of mosquito-borne illness in the southern United States ( Hotez et al., 2014 ); AMR has been elevated to a global crisis by the United Nations (UN) ( UN, 2016 ); and the largest outbreak of influenza A (H7N9) to date is currently occurring in China ( Iuliano et al., 2017 ). The risk of transnational outbreaks may be greater today than ever before given recent dramatic increases in international trade and travel, urbanization, and population density, as well as critical biodiversity loss worldwide. Strong public health infrastructure is essential to combat these threats successfully wherever they may emerge. While the burden of infectious diseases rests predominantly with low-income countries, where limited resources and weak health care systems are unable to control and prevent them, these are global threats that can significantly affect any country, including the United States, and that need to be understood as a threat to U.S. national security.

As noted above, the costs of infectious diseases extend beyond human suffering and mortality through indirect impacts on economies. In just a few short months, for example, the 2003 outbreak of severe acute respiratory syndrome (SARS) cost the world between $30 and $54 billion ( Fan, 2003 ; World Bank, 2013 ). During the Ebola outbreak, which involved just four domestic cases, the United States spent $1.1 billion on domestic response ( Epstein et al., 2015 )—120 percent of the annual public health and health care preparedness budget for state and local health department and hospital capacity. 1 Between October 2014 and December 2015, $119 million was spent just on domestic migration and quarantine activities, such as airport screening and follow-up of potentially sick passengers, costing an average of more than $4,000 per passenger ( CDC, 2016 ). 2 And direct costs for just two Ebola patients treated at the specialty center in Nebraska were estimated at more than $1 million ( Gold, 2014 ).

Looking forward, a moderate influenza pandemic 3 is projected to cost the world $570 billion annually in terms of income loss and mortality ( Fan et al., 2016 ) with some estimates as high as $2 trillion ( Burns et al., 2008 ). Furthermore, the threat of AMR continues to grow because of poor stewardship, weak surveillance systems, and a lack of second-line therapeutics in the development pipeline. And in addition to naturally occurring threats is the potential for terrorist use of man-made biological weapons. Regardless of whether epidemics or biosecurity threats originate naturally or through human engineering, it is critical for the United States to recognize the severity of these threats and take proactive measures to build capacities and establish sustainable and cost-effective infrastructure to combat them.

Coordination of International Health Emergency Response

As experienced during the Ebola outbreak in 2014, the U.S. population's indifference to remote diseases can quickly turn to panic when even a single suspected case is reported within U.S. borders. The U.S. government implements extreme, government-wide responses to such occurrences—costing tremendous amounts of time and money—in a piecemeal, reactive fashion that can actually impede swift and efficient action, delaying response and discouraging private-sector involvement. While multiple agencies can bring unique expertise to a U.S. government–led response, it is difficult to execute a coordinated emergency plan in the midst of a crisis without a clear chain of command, a dedicated budget, and designated leadership. There is a need for a framework to guide international response to public health emergencies, similar to the domestic National Response Framework. While the Obama administration attempted this level of coordination on the fly with the creation of an Ebola czar, it would be more effective to consider the need for coordination in advance.

In addition to coordination, rapid access to funds during a response is of paramount importance to mobilizing assets and implementing needed interventions. After 7 months of disagreement and delay in fulfilling President Obama's request for $1.9 billion in Zika funding, Congress finally approved $1.1 billion with the passing of H.R. 5243 4 ( Wexler et al., 2016 ). Before this approval was secured, agencies were forced to shift funds from other accounts for Zika-related activities, including by borrowing money from the Ebola supplemental funding and from the U.S. Centers for Disease Control and Prevention's (CDC's) state-level emergency public health care preparedness account ( Epstein and Lister, 2016 ; Kodjak, 2016 ). While the appropriate focus is on prevention and preparedness, some level of response will always be necessary. To enable swift and rapid response when necessary, the committee supports the creation of a public health emergency response fund, to be used only in declared health emergencies.

Finally, the development of needed vaccines, therapeutic agents, and diagnostics is severely inadequate to enable the United States and the world to respond effectively to these global health threats. Currently, product development for response to pandemic and bioterror threats depends on the interagency Public Health Emergency Medical Countermeasures Enterprise, which is limited by annual appropriations and dependent on the goodwill of industry partners. Adequately protecting U.S. citizens requires long-term planning and vision that enables the development of strong and comprehensive capabilities to detect and diagnose pandemic threats wherever they occur, ensure the availability of needed medical products, reduce the risk of transmission, and properly treat and care for infected patients here in the United States. A critical medical product development fund supporting long-term, stable research and development through the engagement of industry, academia, and other partners would ensure the development of critical drugs, vaccines, and diagnostics.

Preparedness and Capacity Building for Global Health Security

Public health infrastructure in most countries, including the United States, is extremely underresourced or nonexistent, making levels of preparedness, even for everyday emergencies, decades behind where they should be and allowing for significant risks when a disaster does strike. Funding levels for U.S. health preparedness have been severely reduced since the Public Health Security and Bioterrorism Response Act was enacted in 2002. A dual focus on health preparedness at home and abroad is essential to reduce the risk of outbreaks and the transmission of infectious disease to U.S. citizens. To this end, it is necessary to build core preparedness capacities and public health infrastructure in the United States and in LMICs, supported by such partnerships as the GHSA.

While a portion of the Ebola supplemental funding was directed toward nonspecific capacity building over 5 years, the sustainability of funding thereafter is unclear. This sustainability is also vulnerable to new or reemerging diseases; Ebola funding was the first coffer proposed to be tapped upon the emergence of Zika ( Epstein and Lister, 2016 ). By contrast, a sustained level of investment in multidisciplinary One Health systems 5 can result in $15 billion in annual expected benefits from the prevention of mild pandemics and other major outbreaks ( World Bank, 2012 ). Assuming that improved systems could detect and control even half of incipient pandemics, the rates of return are well above those on nearly all other public spending and private capital markets ( World Bank, 2012 ), making this capacity building a smart investment. Enabling the right institutional capacity to reduce health risks, respond to emergencies, and innovate to improve the actions taken can dramatically improve the prevention and control of and response to health threats. At the same time, it is essential to remain engaged and coordinated with domestic and international stakeholders, including the World Health Organization (WHO), the UN Secretary-General's Committee on AMR, and the GHSA.

Recommendation 1: Improve International Emergency Response Coordination

The administration should create a coordinating body for international public health emergency response that is accountable for international and domestic actions and oversees preparedness for and responses to global health security threats. This body should have its own budget, experience with handling logistics, and the authority necessary to coordinate players across the government at the deputy secretary level. This coordinating body should do the following: Oversee the creation of an International Response Framework to guide the U.S. response to an international health emergency. Through this framework, this body would coordinate and direct activities involved in international response and preparedness, but would not duplicate functions already established in the Office of the Assistant Secretary for Preparedness and Response, the U.S. Centers for Disease Control and Prevention, the U.S. Agency for International Development, or the U.S. Department of Defense. Oversee three separate funding streams, dedicated to investments in preparedness, emergency response, and critical medical product development. The Office of Management and Budget should conduct an analysis to determine the appropriate levels for these three funding streams, commensurate with the associated risk, understanding that predictable and timely funds for these three purposes are critical. Align and coordinate efforts with effective multilateral organizations to reduce duplication and promote efficiency in building capacity and resilience in other countries.

Recommendation 2: Combat Antimicrobial Resistance

The U.S. Department of Health and Human Services, the U.S. Department of Defense, the U.S. Department of Agriculture, and the U.S. Agency for International Development (USAID) should continue to invest in national capabilities and accelerate the development of international capabilities to detect, monitor, report, and combat antibiotic resistance. Efforts to this end should include the following: Enhance surveillance systems to ensure that new resistant microbial strains are identified as soon as they emerge. Assist low-income countries in improving infection control and antimicrobial stewardship. USAID should leverage current supply chain partnerships with other countries to strengthen antibiotic supply chains, thus reducing the use of illegitimate antimicrobials and improving drug quality. Incentivize the development of therapeutics (including alternatives to antibiotics), vaccines, and diagnostics for use in humans and animals.

Recommendation 3: Build Public Health Capacity in Low- and Middle-Income Countries

The U.S. Centers for Disease Control and Prevention, the National Institutes of Health, the U.S. Department of Defense, and the U.S. Agency for International Development should expand training and information exchange efforts to increase the capacity of low- and middle-income countries to respond to both public health emergencies and acute mass casualty disasters. This training and information exchange should encompass core capacities such as surveillance, epidemiology, and disaster and injury care response, as well as enhanced capabilities to improve communication and information pathways for the dissemination of innovative findings.

Maintaining a Sustained Response to Continuous Threats: HIV/AIDS, Tuberculosis, and Malaria

Considerable successes have been achieved in slowing the advancement of HIV/AIDS, TB, and malaria worldwide, as evidenced by the millions of lives saved. However, these diseases are continuing health threats that can jeopardize global security and inflict a high cost on the economies of the countries in which they are prevalent. As of the end of 2015, there remained more than 36.7 million people living with HIV/AIDS globally ( UNAIDS, 2015b ), and there were more than 1.1 million deaths from AIDS ( UNAIDS, 2015a ). In 2015, 1.4 million people died from TB ( WHO, 2016b ), and 429,000 people died from malaria ( WHO, 2016d ). Complacency toward these diseases can lead to severe risk and harm for the entire global community, as all three are capable of developing strains resistant to currently available treatments. Should that occur, an even more lethal resurgence of these diseases would likely take place, threatening all progress made on these diseases in previous decades.

PEPFAR has played a key role in successfully slowing the HIV/AIDS epidemic globally since 2003, reducing new infections, and helping to save millions of lives around the world ( PEPFAR, 2017 ). In addition to this progress on its primary goal, studies have shown that the countries in which PEPFAR is active had better opinions of the United States ( Daschle and Frist, 2015 ) and also saw 13 percent increase in employment rates among men compared to non-PEPFAR countries ( Wagner et al., 2015 ).

As a truly bipartisan, collaborative program that has undergone transitions and shifts throughout the last 15 years, PEPFAR has adapted its focus to changes in the HIV/AIDS epidemic from that of a highly lethal, rapidly spreading emergency to one that requires sustaining care while targeting at-risk populations. Yet this work is far from finished, as 2 million new HIV infections still occur each year, and millions are without access to treatment ( PEPFAR, 2017 ). The next phase of PEPFAR will continue to require cross-sector and data-driven efforts to dramatically reduce the number of new HIV infections and AIDS-related deaths globally by 2030. However it will also rely on continued and expanded partnerships with the private sector and communities. A promising example is PEPFAR's multidisciplinary Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women (DREAMS) partnership, which focuses on lowering rates of HIV infection in young women by addressing multiple factors outside of the health sector that affect rates of infection (e.g., enabling and encouraging them to stay in school, addressing gender-based violence, and changing community norms). Given the substantial reduction in the costs of drugs used to treat HIV/AIDS, the increased involvement of private-sector partnerships, and the effect of treatment on preventing new infections, program ownership should continue shifting to host countries where possible. PEPFAR also should leverage its existing structures and platforms to address other priority health issues for its HIV-infected patient population, based on country needs.

Recommendation 4: Envision the Next Generation of PEPFAR

With its next reauthorization, Congress should fund The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) at current levels, and allow for more flexibility within the PEPFAR program by continuing to relax specific funding targets for all program areas. Continued accountability, efficiency, and measurement of results should be emphasized. In the future, moreover, PEPFAR should focus on the following key areas: Ensure that national governments assume greater ownership of national HIV/AIDS programs through joint planning and decision making, and that they increase domestic funding to help cover the costs of prevention and treatment. Adapt its delivery platform to become more of a cost-effective, chronic care system that is incorporated into each country's health system and priorities. Continue to support the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and rely on it for specific functions where it has the comparative advantage. Such functions could include the Global Fund's efficient procurement of products and multipartner efforts to encourage countries to transition to domestic sources of funding. Enhance emphasis on primary prevention through multisector efforts, including strong interventions against gender-based violence, given that many new HIV infections are occurring in adolescent girls.

Tuberculosis

Unfortunately, TB has not shown the same progress in treatment and prevention as HIV/AIDS and has been a historically underfunded disease. In 2015, there were 10.4 million new cases of TB and 1.4 million attributable deaths ( WHO, 2016b ). Further complicating efforts to combat this disease is the rapid rise of multidrug-resistant strains of TB (MDR-TB). The current available drug regimens for TB, MDR-TB, and a more severe extensively drug-resistant TB (XDR-TB) are lengthy and complex and frequently have low success rates ( WHO, 2016b ). Furthermore, treatment for MDR-TB and XDR-TB can cost 100 times as much as treatment for nonresistant TB ( Laurence et al., 2015 ; Nieburg et al., 2015 ; Pooran et al., 2013 ). With few drugs available to treat MDR-TB and XDR-TB and little progress on new treatment options, TB and its drug-resistant strains pose a growing threat to the health and health security of all countries, including the United States. TB has been a priority for the United States since passage of the Foreign Service Act of 1961, and in 2010 the U.S. Agency for International Development (USAID) laid out a sweeping strategy 6 for combating global TB. Of the $4 billion authorized over 5 years to implement this strategy, however, only 40 percent was ever appropriated. The U.S. government's underprioritization of TB undercuts its capability to reduce the global burden of disease. Accordingly, the U.S. government should reevaluate its investment in and strategies for combating TB.

Recommendation 5: Confront the Threat of Tuberculosis

The U.S. Centers for Disease Control and Prevention, the National Institute of Allergy and Infectious Diseases, and the U.S. Agency for International Development should conduct a thorough global threat assessment of rising tuberculosis (TB) levels, including multidrug-resistant TB and extensively drug-resistant TB. They should then execute a plan of action, including governance structure and priority activities, for developing and investing in new diagnostics, drugs, vaccines, and delivery systems.

Commensurate with the dedicated investment in combating malaria by the global community are tremendous successes in preventing and controlling the disease, with an estimated 41 percent reduction in incidence since 2000 and a 62 percent reduction in mortality rates globally ( WHO, 2016d ). This progress has been possible in large part because of increases in programmatic and financial support—from $100 million in 2000 ( WHO, 2013 ) to $2.9 billion in 2015 ( WHO, 2016d ;). Through PMI and the Global Fund, which accounted for an estimated 35 percent of global funding for malaria efforts in 2015, the United States has, both directly and indirectly, been a major contributor to this success ( WHO, 2016d ). While the investment in malaria may appear costly, a cost–benefit analysis modeling the effect of global reduction and elimination of the disease found that the net gains in economic output would be worth $208.6 billion ( Purdy et al., 2013 ).

As a result of these investments, elimination of malaria has become a realistic goal for many countries. Some countries can now declare themselves malaria-free, a welcome status for not only healthier communities but also healthier economies. Additionally, since 2006, all 15 PMI countries have seen up to 50 percent reductions in child mortality due to malaria infection ( USAID, 2014 ). However, malaria still imposes a major burden of disease, with 212 million cases occurring in 2015 ( WHO, 2016d ), further imposing a financial burden on families and country economies. Malaria can cost families 25 percent of their income through lost days of work and prevention and treatment costs, and since 2000, average annual costs to sub-Saharan Africa totaled nearly $300 million simply for case management ( UNICEF, 2004 ; WHO, 2015a ). Given these high costs to individuals and countries and the threat of drug-resistant strains, a sustained, dedicated focus on malaria should continue.

Recommendation 6: Sustain Progress toward Malaria Elimination

Relevant agencies of the U.S. government should continue their commitment to the fight against malaria through the President's Malaria Initiative and collaborative work with all partners toward elimination of the disease.

• ENHANCING PRODUCTIVITY AND ECONOMIC GROWTH

The general health and well-being of other countries, including their burden of NCDs such as CVD and cancer, may at first glance not appear to be the top priority of donor countries such as the United States. However, investing in countries' prosperity and stability can result in greater order and predictability in the world, as well as promote U.S. health and prosperity and create more reliable and durable global partners. Premature death and disability stemming from NCDs coalesce to contribute to decreased productivity, decreased gross domestic product, and overall higher costs of health care because existing health systems are not designed to care for chronic disease in an integrated and holistic fashion ( OECD, 2011 ).

As prevention is always less costly than treatment, efforts to prevent premature death and disability from NCDs ideally begin at birth and continue across an individual's life course. Cost-effective investments made during a child's early years can mitigate deleterious effects of poverty and social inequality, often resulting in long-lasting gains through adulthood. Healthy behaviors formed during childhood also can have long-term effects. Interventions carried out during the very early years can even translate into lifelong benefits in terms of labor market participation, earnings, and economic growth, generating returns of up to 25 percent ( Gertler et al., 2014 ). Furthermore, the private sector has a clear interest in preventing NCDs as globalization continues to encourage international travel and trade. Multinational companies have workforces in many regions of the world and have interests in a productive and capable employee base, which also results in societies that are attractive places to locate their businesses.

Saving and Improving the Lives of Women and Children

Remarkable strides have been made in reducing mortality among women and children worldwide. Through the launch of the Ending Preventable Maternal and Child Death initiative, USAID has saved the lives of 46 million children and 200,000 women since 2008 ( USAID, 2017 ). Yet global mortality rates for both mothers and children under 5 are still unacceptably high, with maternal mortality at 216 deaths per 100,000 births and child mortality at 41 deaths per 1,000 live births. As a result, each year 5.9 million children die before their fifth birthday ( WHO, 2016a ), and an estimated 303,000 women die from causes related to pregnancy and childbirth ( WHO, 2016c ). The majority of these deaths are preventable through interventions whose effectiveness is supported by extremely strong evidence, but challenges remain around how to scale up these interventions. Accelerating investments in cost-effective, evidence-based interventions is critical to sustain the progress made thus far and further avoid preventable deaths of infants, children, adolescents, and pregnant and lactating women.

Recommendation 7: Improve Survival in Women and Children

Congress should increase funding for the U.S. Agency for International Development to augment the agency's investments in ending preventable maternal and child mortality, defined as global maternal mortality rates of fewer than 70 deaths per 100,000 live births by 2020 and fewer than 25 child deaths per 1,000 live births by 2030. Investments should focus on the most effective interventions and be supported by rigorous monitoring and evaluation. These priority interventions include immunizations; integrated management of child illness; nutrition (pregnant women, newborns, infants, children); prenatal care and safe delivery, including early identification of at-risk pregnancies, safe delivery, and access to emergency obstetrical care; and access to contraceptives and family planning.

The committee found that while continued investment in the survival agenda is critical, it is only part of the challenge. Without proper progress in development in the first 1,000 days of life, many adverse consequences resulting from disease and malnutrition can follow a child through life. Strong neurological evidence demonstrates long-term mental and physical effects of such early risk factors as poor nutrition, lack of nurturing care, and lack of immunizations ( Sudfeld et al., 2015 ). In LMICs, extreme poverty and stunting causes 250 million children (43 percent) younger than 5 fail to reach their developmental potential ( Black et al., 2017 ). Building empowering, nurturing, and cognitively enriching environments (which include responsive and emotionally supportive parenting, opportunities for play and learning, and support for early education) for vulnerable children under 5 and their mothers requires an agenda that incorporates the health, education, and social services sectors. Thus, a thrive agenda is an important focal point for investment in addition to the existing survival agenda.

Recommendation 8: Ensure Healthy and Productive Lives for Women and Children

The U.S. Agency for International Development, The U.S. President's Emergency Plan for AIDS Relief, their implementing partners, and other funders should support and incorporate proven, cost-effective interventions into their existing programs for ensuring that all children reach their developmental potential and become healthy, productive adults. This integration should embrace principles of country ownership, domestic financing, and community engagement. These interventions should include the following: Provide adequate nutrition for optimal infant and child cognitive development. Reduce childhood exposure to domestic and other violence. Detect and manage postpartum depression and other maternal mental health issues. Support and promote early education and cognitive stimulation in young children.

Promoting Cardiovascular Health and Preventing Cancer

NCDs such as CVD, chronic obstructive pulmonary disease, and lung cancer kill 40 million people globally each year, almost three-quarters of whom are in LMICs ( WHO, 2015b ). Of these deaths, 17 million are considered “premature.” The annual global cost of CVD alone is estimated to rise to more than $1 trillion in 2030 ( Reddy et al., 2016 ). Additionally, more people are dying from cancer in LMICs than from AIDS, TB, and malaria combined, with the total annual cost in 2010 approximated at $1.16 trillion 7 —more than 2 percent of total global gross domestic product ( Stewart and Wild, 2014 ). Between 30 and 50 percent of cancer deaths are preventable through prevention, early detection, and treatment. This means that more than 2.4 million annual deaths are avoidable, with an approximate $100–$200 billion in global economic savings to be achieved ( Stewart and Wild, 2014 ). Yet many health care systems in these countries are not designed to manage NCDs, and they have difficulty integrating various platforms across disease types. The lack of a properly trained workforce and of the effective population-level policies described in Chapter 6 is also a challenge for LMICs, and indeed for countries at all income levels. With conditions across the NCD spectrum also affecting populations in the United States, this is a clear area for shared innovation to tackle common problems. Greater awareness of successful interventions and best practices for combating CVD, cancer, and other NCDs can reduce duplication and allow for more rapid information exchange, leading more quickly to solutions.

Unfortunately, many efforts to combat NCDs are incorporated into other programs as an afterthought, and there is no overall coordination mechanism or strategy for a global focus on these diseases. However, U.S. programs have established strong networks and knowledge bases in many countries through decades of global health efforts by various agencies, through such program areas as PEPFAR and maternal and child health efforts. These existing platforms can serve as opportunities in which to integrate prevention and treatment efforts for NCDs. Additionally, as noted earlier, recent years have seen strong interest from the private sector in addressing the global burden of these diseases because of their clear effects on workforce productivity; however, there is no synergy among private-sector efforts across countries or health systems. The knowledge base acquired by U.S. agencies and programs should be leveraged and paired with private-sector interest and community-level commitment to mobilize and coordinate high-impact, evidence-based interventions that can be applied in all countries. Absent such concerted efforts, these diseases will continue to result in high rates of premature death and lost productivity, reversing the recent gains in and trends toward improved economic growth and stability in many countries.

Recommendation 9: Promote Cardiovascular Health and Prevent Cancer

The U.S. Agency for International Development, the U.S. Department of State, and the U.S. Centers for Disease Control and Prevention, through their country offices, should provide seed funding to facilitate the mobilization and involvement of the private sector in addressing cardiovascular disease and cancer at the country level. These efforts should be closely aligned and coordinated with the efforts of national governments and should strive to integrate services at the community level. The priority strategies to ensure highest impact are Target and manage risk factors (e.g., smoking, alcohol use, obesity) for the major noncommunicable diseases, particularly through the adoption of fiscal policies and regulations that facilitate tobacco control and healthy diets; Detect and treat hypertension early; Detect and treat early cervical cancer; and Immunize for vaccine-preventable cancers (specifically human papilloma virus and hepatitis B vaccines).

• MAXIMIZING RETURNS ON INVESTMENTS

The committee identified opportunities for changing the way the United States operates in the arena of global health and finances relevant programs to maximize the returns on U.S. investments through improved health outcomes and cost-effectiveness. If the United States can transition from its traditional siloed and reactive approach to global health to a more proactive, systematic, and sustainable approach, the committee believes U.S. investments will have an even more significant positive impact on the four priority areas outlined in this report—achieving global health security, maintaining a sustained response to the continuous threats of communicable diseases, saving and improving the lives of women and children, and promoting cardiovascular health and preventing cancer. To maximize the returns on investments in these four areas and achieve better health outcomes and more effective use of funding, the United States will need to

• catalyze innovation through the accelerated development of both medical products and integrated digital health infrastructure;
• employ more nimble and flexible financing mechanisms to leverage new partners and funders in global health; and
• maintain U.S. status and influence as a world leader in global health while adhering to evidence-based science and economics, measurement, and accountability.

Catalyze Innovation

Achieving the improvements in global health called for by numerous previous reports will require changing the way global health business is conducted to better enable innovation. Given the multisectoral nature of health, simply addressing individual challenges in a singular, siloed manner will never solve the overall problem. Challenges in the development process for vaccines and drugs to prevent and treat infectious and neglected diseases have plagued researchers and developers since before HIV/AIDS captured the world's attention in the 1980s. Additionally, health systems in LMICs are typically underresourced and lack basic infrastructure, making it difficult to provide all types of care and public health protections, such as surveillance or access to specialty care. Unless researchers, regulators, health providers, and private-sector partners are encouraged to think more creatively to solve these complex problems and enable changes in current processes, new and innovative models will be difficult to achieve. The committee believes that the creation of an environment that enables innovation can accelerate the development of critical medical products and make it possible to augment public health services through technology such that they can be provided in a more sustainable manner.

Development of Medical Products

Global health priorities will be difficult to achieve without safe and effective drugs, vaccines, diagnostics, and devices. The private sector is an essential player, together with academia, civil society, and government, in ensuring that required products are developed and manufactured. However, the markets for many global health products are uncertain or risky, making it difficult for private-sector development and manufacturing partners to justify their shareholders' investments. For example, industry considers investments in innovations to address unpredictable and fast-moving pandemics high-risk, especially given the experience of several firms with investing millions of dollars in the development of vaccines against SARS and Ebola only to find that the government was no longer interested in these products ( Ebola Vaccine Team B, 2016 ; Osterholm and Olshaker, 2017 ). Through regulatory or market incentives, the U.S. government can reduce or share the burden of development costs and risks with industry, effectively “pushing” a product through the pipeline. Similarly, the U.S. government can reduce market risk (creating market “pull”) by increasing the certainty, speed, or volume of the purchase of products. In the absence of these push and pull interventions, the United States and other governments risk spending far more than is necessary to prevent, detect, respond to, and treat disease outbreaks by using suboptimal tools.

In addition to market forces, human and institutional capacity for research and development (R&D) underpins the ability of the private sector, academia, civil society, and governments to develop priority technologies. This R&D capacity is needed in countries where outbreaks begin and disease burdens are high. Helping to build the capacity for LMICs to conduct clinical trials using their own workforces and facilities is both more efficient and more cost-effective than trying to export foreign human capacity and technical infrastructure for every disease outbreak. The necessary capacity includes laboratory capacity, the ability to collect baseline data on disease burden, and an appropriately trained research-competent workforce. Building this capacity also enables sustainability and encourages innovation by creating environments in which local researchers can solve local problems. The U.S. government has an opportunity to streamline processes, reduce costs, and create more appropriate incentives that will enable industry, academia, and others to contribute to the development of priority innovations for global health.

Recommendation 10: Accelerate the Development of Medical Products

U.S. government agencies should invest in a targeted effort to reduce the costs and risks of developing, licensing, and introducing vaccines, therapeutics, diagnostics, and devices needed to address global health priorities by enabling innovative approaches for trial design, streamlining regulation, ensuring production capacity, creating market incentives, and building international capacity for research and development. This effort should include the following: Enabling innovative approaches for trial design: The U.S. Food and Drug Administration (FDA), the Biomedical Advanced Research and Development Authority (BARDA), the U.S. Department of Defense (DoD), and the National Institutes of Health (NIH) should actively encourage public- and private-sector product development efforts using innovative product development approaches, including platform studies, adaptive trial designs, pragmatic trials, and improved biomarker development. BARDA should assess expanding its list of priority products for codevelopment with industry, taking into account global health priorities. Streamlining regulation: FDA should receive adequate resources to improve the tropical disease priority review voucher program and should assess the application of the provisions outlined in the Generating Antibiotic Incentives Now Act to neglected tropical diseases beyond those on the qualified pathogen list. Ensuring production capacity: BARDA should increase its efforts to promote adequate global manufacturing capacity for priority technologies (e.g., Centers for Innovation in Advanced Development and Manufacturing). Creating market incentives: The U.S. government should invest in generating and disseminating accurate and transparent market estimates and should use the purchasing power of U.S. government agencies and global partnerships such as Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as such creative financing mechanisms as volume guarantees, to reduce market uncertainty for priority health products. Building international capacity for research and development: The U.S. Centers for Disease Control and Prevention, NIH, and DoD should increase the number of people and institutions in partner countries capable of conducting clinical trials for global health priorities (e.g., through funding partnerships with academic institutions). This effort should encompass providing support for sustainable core capacities such as drug, vaccine, and diagnostic research capabilities and building the skills of principal investigators.

Development of Integrated Digital Health Infrastructure

Digital health efforts have shown promise in reducing costs and promoting health across the United States and the globe. However, many such investments have been siloed and shortsighted in their approach, often focusing on single diseases or sectors and missing opportunities to develop a sustainable, integrated platform. Growing mobile and internet connectivity worldwide, along with positive disruptive advances in the information and communications technology sector, provide a timely opportunity for the United States to reexamine its investment and development approaches to digital health efforts in other countries. A renewed focus should include goals of reducing fragmentation, improving integration of programs, and maximizing reusability to improve returns on investments. An emphasis on health systems innovation through technical assistance and public–private partnerships in digital health can lead to better care and more effective care delivery at lower cost.

Given the proliferation of digital health applications and platforms in countries across the world, created by public- and private-sector players alike, there is a need for a common digital health framework that can be applied to different country contexts, allowing for easier replication of best practices and information sharing. At the country level, cross-cutting digital health platforms should be interoperable and yet adaptable to local requirements and sovereignty. Such platforms should address each country's health care priorities during steady-state times, thereby incentivizing country coinvestment and ownership, while at the same time serving as a resilient system to facilitate controlled sharing of data across countries, thereby enhancing surveillance, coordinated responses, and delivery of services during an emergency. The U.S. government has the opportunity to leverage government content expertise and private-sector talent to build on recent and ongoing efforts, including legislation 8 aimed at improving and integrating efforts to incorporate internet access into education, development, and economic growth programs. Digital health efforts can be woven into each of those sectors with a holistic and cross-cutting perspective. New and existing U.S. investments should be buttressed by cross-cutting platforms and should assist in making these technological advances available to interested countries to improve their own health systems in a manner that is interoperable and scalable for future-minded solutions.

Recommendation 11: Improve Digital Health Infrastructure

Relevant agencies of the U.S. government should convene an international group of public and private stakeholders to create a common digital health framework that addresses country-level needs ranging from integrated care to research and development. The U.S. Agency for International Development (USAID) and the U.S. Department of State should incentivize and support countries in building interoperable digital health platforms that can efficiently collect and use health data and analytic insights to enable the delivery of integrated services within a country. USAID's Global Development Laboratory should provide technical assistance to countries in the development and implementation of interoperable digital health platforms co-funded by the country and adaptable to local requirements. U.S. agencies should expand on the “build-once” principle of the Digital Global Access Policy Act and align U.S. funding in digital health by multiple agencies to reduce fragmentation and duplication, as well as maximize the effectiveness of investments. The provision of this funding should employ methods that reflect smart financing strategies to leverage private industry and country cofinancing (see Recommendation 13).

Employ More Nimble and Flexible Financing Mechanisms

In the changing landscape of globalization and growth in middle-income countries, traditional aid models are also changing. As a global health leader, the United States should adapt its spending accordingly. Current U.S. global health financing is focused largely on immediate disease-specific priorities. This financial support is seen as development and humanitarian assistance for strategic partner countries. Instead, programs should focus on long-term goals of building global health systems and platforms that are disease-agnostic and can respond rapidly and flexibly to emerging threats that potentially impact the entire world, including the United States. There are innovative mechanisms for making present funds more effective, and opportunities exist for creative partnerships with new players and investors to develop better programs and goals. Existing platforms such as PEPFAR can be augmented through public–private partnerships to improve health outcomes in countries, such as efforts made in the last decade on generic drugs and strengthening of supply chains ( Waning et al., 2010 ). There is also potential in incentivizing the private sector to invest in global health, both for social benefit and for positive long-term business outcomes. Governments can crowd-in additional funding sources by increasing the demand for goods through public funds, and sharing risk in various ways, which then catalyzes private investment that would not have otherwise taken place ( Powers and Butterfield, 2014 ). Overall, by conducting more strategic and systematic assessments, the U.S. government can make long-term investments in global health that contribute to global public goods rather than short-term expenditures. These long-term investments should maintain a focus on global health security; disease prevention and control; cross-cutting health systems innovation; and R&D for essential vaccines, drugs, diagnostics, and devices.

In addition to pursuing more systematic spending, the United States needs to consider that many countries continue to grow economically, and their needs will change from direct support for the procurement of drugs, diagnostics, and other commodities to technical support and sustainable financing from multiple sources. Thinking more strategically about how to help growing middle-income countries transition out of bilateral aid programs and optimize their use of domestic resources in a sustainable way will be an important future role of the United States. Assisting interested countries in structuring debt ratios and tax initiatives, along with implementing other innovative mechanisms, can build stronger and more holistic health systems and provide multiple returns on investments. The U.S. government should review the wide variety of mechanisms that have been implemented by partners around the world as it explores options for expanding and diversifying U.S. global health funding to increase its effectiveness.

Recommendation 12: Transition Investments Toward Global Public Goods

The U.S. Agency for International Development, the U.S. Department of State, and the U.S. Department of Health and Human Services should, together, systematically assess their approach to global health funding with an eye toward making long-term investments in high-impact, country-level programs. The focus should be on programs that both build national health systems and provide the greatest value in terms of global health security (to prevent pandemics), as well as respond to humanitarian emergencies and provide opportunities for joint research and development for essential drugs, diagnostics, and vaccines that will benefit many countries, including the United States.

Recommendation 13: Optimize Resources Through Smart Financing

Relevant agencies of the U.S. government should expand efforts to complement direct bilateral support for health with financing mechanisms that include results-based financing; risk sharing; and attracting funding from private investment, recipient governments, and other donors. The U.S. Agency for International Development (USAID) and The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) should structure their financing to promote greater country ownership and domestic financing. Assistance should be provided in developing innovative financing products/modalities and in working with the finance sector to push the envelope on innovative sources of financing, crowding in private-sector capital. USAID and PEPFAR should engage with ministries on system design and financing to assist in plan design, model refinement and expansion, return-on-investment analysis, and financial plan execution. USAID should expand the use and flexibility of such mechanisms as the Development Credit Authority, and the U.S. Department of the Treasury, the U.S. Department of State, and USAID should motivate the World Bank; the International Monetary Fund; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Gavi, the Vaccine Alliance, respectively, to promote transitioning to domestic financing, assist countries in creating fiscal space for health, leverage fiscal policies to improve health, and attract alternative financing sources.

Maintain U.S. Global Health Leadership

Finally, given the extremely interconnected nature of the world today, it is critical for the United States to continue to be a leader in global health. Adequately protecting U.S. citizens at home and abroad requires not only investment in U.S. infrastructure, but also continued awareness of global issues and active engagement in the international global health arena. There have been continuing calls for management and operational reforms of WHO, and while the committee agrees on the need for reform, it also recognizes that WHO performs many essential functions—for example, setting such standards as International Health Regulations. In addition, many other UN agencies and international organizations and partnerships formed in the last few decades are crucial in providing support to countries around the world. The success of all of these multilateral entities, such as the Global Fund, will help the U.S. government accomplish its global health goals and maximize its returns on investments.

Many of the events and elements of the changing global health landscape described throughout this report have created an environment for a centralized and comprehensive strategy for U.S. global health diplomacy. The United States has an opportunity to solidify its leadership and take a more deliberate foreign policy approach, including the creation of a system to support a more sustainable global health workforce in the United States. The limited number of noncareer health appointments currently available abroad are ad hoc and do not facilitate institutional knowledge or a promising career track for health professionals. Also needed is better bidirectional communication between health and diplomacy professionals and increased cross-disciplinary training. Greater flexibility for U.S. health professionals to work abroad, with emphasis on country and cultural competence and understanding, can allow for better sharing of information and more coordinated response during an outbreak or other emergency. It also could enable long-term partnerships focused on developing cures for such diseases as HIV/AIDS and cancer. Strengthening relations with countries through a strong, centralized office of global health diplomacy can create a coordinating health role for U.S. embassies while also improving situational awareness and networking with other sectors connected to health, such as finance and energy.

Recommendation 14: Commit to Continued Global Health Leadership

To protect itself from global threats, benefit from successes achieved in global health programs, and maintain a strong research and development pipeline, the United States should commit to maintaining its leadership in global health and actively participating in global health governance, coordination, and collaboration. To this end, the U.S. Department of State and the U.S. Department of Health and Human Services (HHS) should do the following: Use their influence to improve the performance of key United Nations agencies and other international organizations important to global health, particularly the World Health Organization (WHO). WHO is in need of greater resources to address the health challenges of the 21st century, and many of its priorities align with those of the U.S. government. However, U.S. government financial contributions to WHO should come with a requirement that the organization adopt and implement the much-needed management and operational reforms identified in recent reports. Remain involved in and firmly committed to innovative global partnerships that further U.S. global health goals, such as the highly successful Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as promising new entities such as the Global Health Security Agenda and the Global Financing Facility. Implement a more strategic approach to achieving global health goals. This new approach should include the commitment of the U.S. Department of State to creating a global health career track and congressional action to enable the establishment of a cadre of global health experts within HHS through an amendment to the Foreign Service Act. This would create the environment necessary to expand the health attaché program, particularly in middle-income countries.

• A BLUEPRINT FOR ACTION

The committee's 14 recommendations are directed toward a wide range of U.S. government entities. In Table 10-1 , the recommendations pertinent to each entity are summarized to form a blueprint for action to achieve global health security and enhance productivity and economic growth worldwide.

Report Recommendations Outlined by Entity.

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This percentage was calculated by using fiscal year 2016 Public Health Emergency Preparedness program funding ($660 million) and Hospital Preparedness Program funding ($255 million) as the preparedness amounts. See Chapter 3 for more details.

During this timeframe, 29,000 people were monitored following screening at five major U.S. international airports. The monitoring included follow-up for 21 days, and a check and report Ebola kit including a thermometer, a prepaid cell phone, and educational materials.

A “moderate” influenza pandemic is defined as one in which global output is reduced by more than 2 percent.

Zika Response Appropriations Act, H.R. 5243. 2016.

Defined as the funding needed to bring major zoonotic disease prevention and control systems in developing countries up to World Organisation for Animal Health and World Health Organization standards. The World Bank report estimates that the required investments range from $1.9 billion to $3.4 billion per year.

See Lantos-Hyde United States Government Tuberculosis Strategy.

This figure is the sum of the costs of prevention and treatment, plus the annual economic value of disability-adjusted life years (DALYs) lost as a result of cancer. This value fails to estimate longer-term costs to families and the costs that patients and families attribute to human suffering.

Digital Global Access Policy Act of 2017, H.R. 600, 115th Congress.

• Cite this Page National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Committee on Global Health and the Future of the United States. Global Health and the Future Role of the United States. Washington (DC): National Academies Press (US); 2017 May 15. 10, Summary of Conclusions and Recommendations.
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