USAID and CDC Funding, Activities, and Assessments of Countries' Capacities to Address Infectious Disease Threats before COVID-19 Onset (GAO-21-359)
Summary
A GAO report to congressional committees, GAO-21-359, dated April 2021, on global health security (GHS). It reports that as of March 31, 2020 the U.S. Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC) had obligated a combined total of more than $1.2 billion and disbursed about $1 billion for GHS activities, using funds appropriated in fiscal years 2015 through 2019. It describes activities USAID and CDC supported to help build countries' capacities to address infectious disease threats, and assessments of those capacities, before the onset of COVID-19.
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United States Government Accountability Office
Report to Congressional Committees
GLOBAL HEALTH
April 2021
SECURITY
USAID and CDC
Funding, Activities, and
Assessments of
Countries’ Capacities to
Address Infectious
Disease Threats before
COVID-19 Onset
GAO-21-359
April 2021
GLOBAL HEALTH SECURITY
USAID and CDC Funding, Activities, and
Assessments of Countries’ Capacities to Address
Highlights of GAO-21-359, a report to Infectious Disease Threats before COVID-19 Onset
congressional committees
Why GAO Did This Study What GAO Found
The outbreak of Coronavirus Disease As of March 31, 2020, the U.S. Agency for International Development (USAID)
2019 (COVID-19) in December 2019 and the Centers for Disease Control and Prevention (CDC) had obligated a
demonstrated that infectious diseases combined total of more than $1.2 billion and disbursed about $1 billion for global
can lead to catastrophic loss of life and health security (GHS) activities, using funds appropriated in fiscal years 2015
sustained damage to the global through 2019. USAID and CDC supported activities to help build countries’
economy. USAID and CDC have led capacities in 11 technical areas related to addressing infectious disease threats.
U.S. efforts to strengthen GHS—that The obligated funding supported GHS activities in at least 34 countries, including
is, global capacity to prepare for, 25 identified as Global Health Security Agenda (GHSA) partner countries.
detect, and respond to infectious
disease threats and to reduce or
prevent their spread across borders. U.S.-Supported Activities in Ethiopia to Strengthen Global Health Security
These efforts include work related to
the multilateral GHSA initiative, which
aims to accelerate progress toward
compliance with international health
regulations and other agreements.
House Report 114-693 contained a
provision for GAO to review the use of
GHS funds. In this report, GAO
examines, for the 5 fiscal years before
the onset of the COVID-19 pandemic,
(1) the status of USAID’s and CDC’s
GHS funding and activities and (2)
U.S. agencies’ assessments, at the
end of fiscal year 2019, of GHSA
partner countries’ capacities to address
infectious disease threats and of
challenges these countries faced in
building capacity. U.S. officials’ assessments of 17 GHSA partner countries’ capacities to address
infectious disease threats showed that at the end of fiscal year 2019, most
GAO analyzed agency, interagency,
countries had some capacity in each of the 11 technical areas but faced various
and international organization
documents. GAO also interviewed challenges. U.S. interagency country teams produce biannual capacity
agency officials in Washington, D.C., assessments that USAID and CDC headquarters officials use to track the
and Atlanta, Georgia, and in Ethiopia, countries’ progress. According to fiscal year 2019 assessment reports, 14
Indonesia, Senegal, and Vietnam. countries had developed or demonstrated capacity in most technical areas. In
GAO selected these four countries on addition, the reports showed the majority of capacities in each country had
the basis of factors such as the remained stable or increased since 2016 and 2017. The technical area
presence of staff from multiple U.S. antimicrobial resistance showed the largest numbers of capacity increases—for
agencies. In addition, GAO analyzed example, in the development of surveillance systems. GAO’s analysis of the
interagency assessments of countries’ progress reports found the most common challenges to developing GHS capacity
capacities to address infectious were weaknesses in government institutions, constrained resources, and
disease threats in fiscal year 2019 and insufficient human capital. According to agency officials, some challenges can be
compared them with baseline overcome with additional U.S. government funding, technical support, or
assessments from 2016 and 2017. diplomatic efforts, but many other challenges remain outside the U.S.
government’s control.
View GAO-21-359. For more information, This is a public version of a sensitive report that GAO issued in February 2021.
contact David Gootnick at (202) 512-3149 Information that USAID and CDC deemed sensitive has been omitted.
or gootnickd@gao.gov.
United States Government Accountability Office
Contents
Letter 1
Background 5
USAID and CDC Obligated Over $1.2 Billion and Disbursed About
$1 Billion to Build GHS Capacity in at Least 34 Countries from
Fiscal Years 2015–2019 Appropriations 13
U.S. Assessments Showed Some GHS Capacity in Most Phase I
Countries, but Countries Faced Several Challenges 26
Agency Comments 45
Appendix I Objectives, Scope, and Methodology 47
Appendix II Implementing Partners That Received Largest Amounts of
Obligated Funds for GHS 51
Appendix III Comments from the U.S. Agency for International Development 53
Appendix IV GAO Contact and Staff Acknowledgments 57
Tables
Table 1: Global Health Security Agenda Technical Areas and
Examples of Objectives in Joint External Evaluation Tool 10
Table 2: Global Health Security Capacity Indicators Assessed in
Joint External Evaluations (JEE) of GHSA Technical
Areas in 2016 and 2017 27
Table 3: Capacity Levels for GHSA Indicators Identified in Joint
External Evaluation (JEE) Tool 29
Table 4: Numbers of Indicator Scores at Each Capacity Level for
All Phase I Countries, by GHSA Technical Area, at the
End of Fiscal Year 2019 32
Table 5: Numbers of Indicator Scores for Phase I Countries That
Remained Stable, Increased, or Decreased, by GHSA
Technical Area, from 2016/2017 to 2019 35
Table 6: Examples of Challenges Identified in 16 GHSA Progress
Reports for Fiscal Year 2019 44
Page i GAO-21-359 Global Health Security
Table 7: USAID and CDC Implementing Partners That Received
Largest Amounts of Obligated Funds for Global Health
Security from Fiscal Years 2015-2019 Appropriations, by
Total Amount Obligated as of March 31, 2020 52
Figures
Figure 1: Timeline of Recent Key Global Events and U.S. Efforts
Related to Global Health Security 6
Figure 2: U.S. Government–Supported GHSA Partner Countries,
Fiscal Years 2015–2019 8
Figure 3: Technical Areas of Global Health Security Capacity 9
Figure 4: USAID’s and CDC’s Combined Total Obligations and
Disbursements for Global Health Security Activities from
Fiscal Years 2015–2019 Appropriations, as of March 31,
2020 14
Figure 5: Examples of Facilities in Ethiopia and Senegal Where
USAID and CDC Supported GHS Activities 16
Figure 6: USAID Obligations and Disbursements for Global Health
Security Activities from Fiscal Years 2015–2019
Appropriations, as of March 31, 2020 17
Figure 7: USAID Obligations in Fiscal Years 2015-2019 for
Countries Where the Agency Supported GHS Activities
with Fiscal Year 2015 Ebola Appropriation for USAID, as
of March 31, 2020 18
Figure 8: Countries Where USAID Supported Global Health
Security Activities with Fiscal Years 2015-2019
Appropriations, as of March 31, 2020 21
Figure 9: CDC Obligations in Fiscal Years 2015-2019 for
Countries Where the Agency Supported GHS Activities
from Fiscal Year 2015 Appropriation to HHS, as of March
31, 2020 25
Figure 10: Equipment Used in Senegal’s Institute for Health
Research Epidemiology Surveillance Training 31
Figure 11: Examples of USAID’s and CDC’s Activities to Support
Ethiopia’s and Senegal’s National Laboratory Systems 38
Figure 12: Specimen Samples in Laboratory at Ethiopian Public
Health Institute 40
Figure 13: Types of Challenges Identified in GHSA Progress
Reports and Number of Reports Identifying Each Type,
Fiscal Year 2019 42
Page ii GAO-21-359 Global Health Security
Figure 14: Damaged Exterior Door and Exposed Wiring at Bahir
Dar Veterinary Lab in Ethiopia 43
Abbreviations
AMR antimicrobial resistance
CDC Centers for Disease Control and Prevention
COVID-19 Coronavirus Disease 2019
Ebola Ebola Virus Disease
EOC emergency operation center
FAO Food and Agriculture Organization
GHS global health security
GHSA Global Health Security Agenda
HHS Department of Health and Human Services
IHR International Health Regulations
JEE Joint External Evaluation
OIE World Organization for Animal Health
State Department of State
U.S. GHS Strategy United States Government Global Health
Security Strategy
USAID U.S. Agency for International Development
WHO World Health Organization
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Page iii GAO-21-359 Global Health Security
Letter
441 G St. N.W.
Washington, DC 20548
April 14, 2021
The Honorable Chris Coons
Chairman
The Honorable Lindsey Graham
Ranking Member
Subcommittee on State, Foreign Operations, and Related Programs
Committee on Appropriations
United States Senate
The Honorable Barbara Lee
Chairwoman
The Honorable Hal Rogers
Ranking Member
Subcommittee on State, Foreign Operations, and Related Programs
Committee on Appropriations
House of Representatives
The first reported outbreak of Coronavirus Disease 2019 (COVID-19), in
December 2019, heightened concerns about global health security
(GHS)—that is, global capacity to prepare for, detect, and respond to
infectious disease threats and to reduce or prevent their spread across
borders. Other new or reemerging diseases, such as Ebola Virus Disease
(Ebola) and Zika virus, have also posed threats over the past 15 years.
Outbreaks can spread rapidly across the globe, jeopardizing health and
security and overwhelming health systems. As the world has experienced
since the onset of the COVID-19 pandemic, such outbreaks can lead to
catastrophic loss of life as well as sustained damage to the economy,
societal stability, and global security. 1
The U.S. government has expressed its commitment to GHS. In 2014,
after the outbreak of Ebola in West Africa, President Obama announced a
U.S. government strategy to address Ebola that included, as one of its
four pillars, strengthening GHS. Also in 2014, the United States and other
nations launched the Global Health Security Agenda (GHSA), a
multilateral initiative to accelerate progress toward a world safe and
secure from infectious disease threats. In May 2019, the U.S. government
published the United States Government Global Health Security Strategy
1The World Health Organization declared COVID-19 a global pandemic on March 11,
2020.
Page 1 GAO-21-359 Global Health Security
(U.S. GHS Strategy), which further emphasized the U.S. commitment to
the GHSA. This strategy identifies the U.S. Agency for International
Development (USAID) and the Department of Health and Human
Services’ (HHS) Centers for Disease Control and Prevention (CDC) as
the lead U.S. agencies for activities aimed at building international GHS
capacity. 2 According to a 2019 report, the U.S. government pledged $1
billion to support activities in countries with which it had partnered to build
health security capacity through the GHSA, known as GHSA partner
countries. 3
House Report 114-693 contained a provision for us to review the use of
funds provided to promote GHS and to address emerging health threats
overseas. This report examines, for the 5 fiscal years before the onset of
the COVID-19 pandemic, (1) the status of USAID’s and CDC’s GHS
funding and activities and (2) U.S. agencies’ assessments, at the end of
fiscal year 2019, of GHSA partner countries’ capacities to address
infectious disease threats and of any challenges these countries faced in
building capacity. 4
This report is a public version of a sensitive report that we issued in
February 2021. 5 USAID and CDC deemed some of the information in our
February report to be sensitive, which must be protected from public
disclosure. Therefore, this report omits sensitive information about
capacity scores assigned to specific countries, certain country-specific
examples, names of countries associated with certain other examples,
and some challenges that countries faced. Although the information in
this report is more limited than that in the sensitive report, this report
addresses the same objectives and uses the same methodology.
2According to agency officials, U.S. agencies’ activities to strengthen GHS and their
activities to address the GHSA are complementary and constitute a comprehensive
approach to addressing threats from infectious diseases.
3Global Health Security Agenda, Advancing the Global Health Security Agenda: Results
and Impact of U.S. Government Investments (August 2019).
4In this report, GHS activities refers to activities that USAID and CDC officials identified as
being related to GHS and the GHSA, including activities that USAID and CDC fund
through awards to implementing partners. The agencies may sometimes refer to such
activities as projects.
5GAO, Global Health Security: USAID and CDC Funding, Activities, and Assessments of
Countries’ Capacities to Address Infectious Disease Threats before COVID-19 Onset,
GAO 21-213SU (Washington, D.C.: Feb. 4, 2021).
Page 2 GAO-21-359 Global Health Security
To address these objectives, we analyzed relevant agency documents
and data, reviewed interagency and international organizations’
documents, and interviewed agency officials regarding USAID’s and
CDC’s GHS efforts overseas in fiscal years 2015 through 2019.
• To examine the status of USAID’s and CDC’s funding and activities,
we analyzed USAID’s and CDC’s data on funding that they had
obligated and disbursed as of March 31, 2020, for GHS activities from
funds appropriated in fiscal years 2015 through 2019—the most
recent data at the time of our analysis. 6 We used data on awards to
the organizations that implemented these activities—known as
implementing partners—to determine the distribution of funding
among USAID and CDC implementing partners as well as across
countries. 7 We also conducted data testing to check for missing or
anomalous data and obvious errors, reviewed related documentation,
and discussed the accuracy and completeness of the data with
USAID and CDC officials. We found these data to be sufficiently
reliable for the purpose of describing the status of GHS funding and
activities. 8
• To examine U.S. agencies’ assessments, at the end of fiscal year
2019, of GHSA partner countries’ capacities to address infectious
disease threats and of challenges the countries faced in building
capacity, we reviewed indicator scores in fiscal year 2019 GHSA
capacity gains progress reporting submitted by U.S. interagency
teams in GHSA partner countries to USAID and CDC on November 1,
2019, for 17 countries where the U.S. government provided GHS
support. We used this information to describe the 17 countries’ GHS
capacity, as assessed by these GHSA country teams, before the
6USAID and CDC used funds appropriated for GHS to support their internal operating
expenses, but the agencies primarily used the funds to award contracts, grants, or
cooperative agreements to implementing partners to carry out GHS activities overseas. In
this report, implementing partners refers to entities such as nongovernmental
organizations and host-country governments that are awarded U.S. government contracts,
grants, or cooperative agreements to carry out GHS activities overseas. Nongovernmental
organizations include international humanitarian aid organizations, international and local
private voluntary organizations, and other entities.
7Our analysis of the distribution of funding among USAID and CDC implementing partners
and across countries does not include USAID’s and CDC’s internal operating expenses.
8The scope of our work begins with fiscal year 2015 because it was the first year that both
USAID and CDC provided funding for GHS activities. USAID used appropriated funding
for various GHS-related activities to address infectious disease threats before fiscal year
2015, according to USAID officials; CDC did not receive an appropriation for GHS until
fiscal year 2015, according to CDC officials.
Page 3 GAO-21-359 Global Health Security
official onset of the COVID-19 pandemic. We also compared the fiscal
year 2019 indicator scores with baseline indicator scores submitted in
calendar years 2016 and 2017 to identify any changes. In addition, we
met with USAID and CDC headquarters officials to discuss both
agencies’ processes for analyzing the assessed indicator scores and
how, if at all, the agencies use the scores to make decisions about
funding and activities. Further, we reviewed challenges identified in
the fiscal year 2019 GHSA capacity gains progress reporting, and we
categorized these challenges to determine the types that occurred
most frequently among the countries.
• To address both of our objectives, we analyzed documents related to
USAID’s and CDC’s GHS activities in four countries—Ethiopia,
Senegal, Indonesia, and Vietnam. We selected the four countries, on
the basis of our review of U.S. agencies’ GHS funding and activities
data and documents, to reflect activities that accounted for a
significant amount of total GHS funding; the presence of staff from
multiple U.S. agencies; and diversity among the countries’ locations in
Africa and Asia, where USAID and CDC provided GHS assistance.
We interviewed USAID and CDC officials in Washington, D.C., and
Atlanta, Georgia, respectively. In addition, in December 2019, we met
with U.S. agency officials, implementing partner organizations,
international organizations, and host government officials when we
visited Addis Ababa, Ethiopia, and Dakar, Senegal. In March 2020,
we conducted teleconferences with U.S. agency officials in Jakarta,
Indonesia, and in Hanoi, Vietnam.
See appendix I for more details of our scope and methodology.
The performance audit on which this report is based was conducted from
February 2019 to February 2021 in accordance with generally accepted
government auditing standards. Those standards require that we plan
and perform the audit to obtain sufficient, appropriate evidence to provide
a reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives. We
subsequently worked with USAID and CDC from November 2020 to April
2021 to prepare this version of the original sensitive report for public
release. This public version was also prepared in accordance with
generally accepted government auditing standards.
Page 4 GAO-21-359 Global Health Security
Background
Infectious Disease Threats New and reemerging diseases can spread quickly across the globe. In
addition to COVID-19, such diseases in recent years have included avian
influenza in Asia; Ebola, yellow fever, and cholera in Africa; the Middle
East Respiratory Syndrome in the Middle East; and Zika virus in the
Americas. Numerous other outbreaks, including Rift Valley fever,
Crimean–Congo hemorrhagic fever, and Lassa fever, have also
threatened the global community. 9
Many pathogens of global health security concern are zoonotic—that is,
transmissible between animals and humans. Over the last 60 years, such
pathogens have accounted for more than 70 percent of emerging
infectious diseases. Population growth has caused people to live in closer
proximity to one another and to animal reservoirs of zoonotic pathogens,
increasing the opportunity for pathogens to cross between animals and
humans. Environmental changes have also altered the distribution of
mosquitos and other disease vectors. 10 Furthermore, the misuse of
antibiotics and emergence of pathogens with antimicrobial resistance
(AMR) affect the human, animal, and agricultural sectors. Finally, the
deliberate or accidental release of dangerous pathogens from
laboratories or other facilities remains an ongoing global health security
threat.
U.S. GHS Efforts According to the U.S. GHS Strategy, the U.S. government recognizes the
growing need to address epidemic-prone infectious disease threats—
whether naturally occurring, unintentional, or deliberate—that pose a risk
to all countries. The strategy states that global health security does not
focus on specific infectious disease threats but instead focuses on early
identification of a threat, regardless of the specific pathogen and its mode
of emergence. The strategy also notes that the U.S. government has
supported GHS work, including a commitment to the GHSA. 11 Figure 1
9For our reports related to past pandemics and other infectious disease outbreaks, see
https://www.gao.gov/coronavirus/past_pandemic-related_reports.
10Disease vectors are living organisms that can transmit infectious pathogens between
humans or from animals to humans, according to the World Health Organization.
11In addition, the U.S. GHS Strategy notes that the U.S. government has related, ongoing
activities that are not considered core global health security activities but support activities
that contribute to strengthening global health security. Such global health activities include
those intended to control pandemic influenza, polio, tuberculosis, and malaria, and also
include the President’s Emergency Plan for AIDS Relief.
Page 5 GAO-21-359 Global Health Security
shows a timeline of recent key global events and U.S. efforts related to
GHS.
Figure 1: Timeline of Recent Key Global Events and U.S. Efforts Related to Global Health Security
a
The U.S. government subsequently added the Caribbean Community—a grouping of 20 countries
comprising 15 member states and five associate members—and Malaysia as partner countries.
GHSA The GHSA is a multisectoral, multilateral effort launched in 2014 to
accelerate progress toward compliance with the World Health
Page 6 GAO-21-359 Global Health Security
Organization’s (WHO) International Health Regulations (IHR), among
other relevant international frameworks and agreements. 12 According to a
report produced by U.S. agencies, the IHR was adopted by 196 WHO
member states and sets requirements for each state to prepare for health
emergencies of all types. 13
As of December 2020, the GHSA had 69 member countries, including the
United States. GHSA members also include international and
nongovernmental organizations and private sector stakeholders. The
United States declared its commitment in 2014 to partner with at least 30
countries and implemented this commitment by supporting GHS activities
in 17 GHSA “Phase I” partner countries and 15 “Phase II” partner
countries in fiscal years 2015 through 2019 (see fig. 2). 14 Phase I
countries were those where the U.S. government committed to provide
funding to help build GHS capacity. Phase II countries were those that the
U.S. government committed to help develop 5-year road maps to
coordinate and guide implementation of GHS activities. 15
12World Health Organization, International Health Regulations, 3rd ed. (Geneva: 2005).
WHO defines these regulations—also known as “IHR (2005)”—as a legally binding
instrument of international law that has its origin in the International Sanitary Conventions
of 1851 and was concluded in response to increasing concern about the links between
international trade and the spread of disease.
13Department of Health and Human Services et al., Implementing the Global Health
Security Agenda: Progress and Impact of U.S. Government Investments (February 2018).
14As of 2016, the U.S. government had identified 14 GHSA member countries and one
region, the Caribbean Community, as Phase II GHSA partners. In this report, we present
the Caribbean Community as a single country and therefore count the total number of
Phase II countries as 15.
15In November 2018, the United States renewed its commitment to the GHSA for another
5 years, beginning in 2019. The May 2019 U.S. GHS strategy stated that the United
States would use an evidence-, risk-, and feasibility-based process to establish
geographic priorities beyond fiscal year 2019. In October 2019, the U.S. GHSA
Interagency Review Council, a policy-making entity, established a new term, U.S. GHSA
partner countries—referring to countries that would receive either intensive or targeted
U.S. support—to replace the terms Phase I partner countries and Phase II partner
countries. Beginning in fiscal year 2020, countries receiving intensive support comprised
the 17 Phase I countries as well as Nigeria and the Democratic Republic of the Congo.
Countries receiving targeted support are those where a U.S. agency is addressing GHS
issues; however, the United States has no established list of such countries, according to
agency officials. Because we focused our review on funding and activities using funds
appropriated in fiscal years 2015 through 2019, we examined GHS work related to Phase
I and Phase II countries.
Page 7 GAO-21-359 Global Health Security
Figure 2: U.S. Government–Supported GHSA Partner Countries, Fiscal Years 2015–2019
a
The Caribbean Community is a grouping of 20 countries comprising 15 member states and five
associate members. We are showing the Caribbean Community as a single country.
GHSA Joint External The GHSA includes a collaborative assessment process, known as the
Evaluation Joint External Evaluation (JEE), to measure countries’ status and
progress in building the necessary capacities to prevent and reduce the
likelihood of outbreaks, detect threats early, and respond to threats
rapidly and effectively. 16
The JEE is completed in two stages: (1) an initial self-evaluation
conducted by the host country, using the JEE tool, and (2) an in-country
evaluation conducted by an external team of subject matter experts in
close collaboration with the host country. First published by WHO in
16According to WHO, the JEE process is voluntary.
Page 8 GAO-21-359 Global Health Security
February 2016, the JEE tool is a data-gathering instrument designed to
evaluate countries’ capacities to implement the IHR, including all GHSA-
relevant capacities across all relevant sectors at a national level.
Countries that complete the JEE can use the data and lessons learned
from the evaluation process to inform country-level planning and priority
setting.
In 2014, GHSA members identified and developed 11 technical areas 17 to
facilitate regional and global collaboration to achieve GHSA goals and
objectives, according to CDC. 18 These 11 technical areas and associated
indicators were included in the JEE tool to assist in measuring and
monitoring the status of countries’ GHS capacity building (see fig. 3).
Figure 3: Technical Areas of Global Health Security Capacity
17The GHSA technical areas are often referred to as action packages.
18WHO updated the JEE tool in January 2018. U.S. officials informed us that they began
in 2020 to use the updated tool when assessing countries’ progress in building GHS
capacity. For the purposes of our report, which covers fiscal years 2015 through 2019, we
focused on the first edition of the JEE tool, which was published in February 2016.
Page 9 GAO-21-359 Global Health Security
The JEE provides objectives for each of the 11 technical areas, as
illustrated in table 1.
Table 1: Global Health Security Agenda Technical Areas and Examples of Objectives in Joint External Evaluation Tool
Technical area Example of objective as stated in Joint External Evaluation Tool
Antimicrobial resistance Support work being coordinated by the World Health Organization (WHO), the United Nations Food and
(AMR) Agriculture Organization (FAO), and the World Organization for Animal Health (OIE) to develop an
integrated global package of activities to combat antimicrobial resistance, spanning human, animal,
agricultural, food and environmental aspects.
Zoonotic disease Adopted measured behaviors, policies, or practices that minimize the transmission of zoonotic diseases
from animals into human populations.
Biosafety and A whole-of-government national biosafety and biosecurity system, ensuring that especially dangerous
biosecurity pathogens are identified, held, secured and monitored in a minimal number of facilities according to best
practices; biological risk management training and educational outreach are conducted to promote a
shared culture of responsibility, reduce dual use risks, mitigate biological proliferation and deliberate use
threats, and ensure safe transfer of biological agents; and country-specific biosafety and biosecurity
legislation, laboratory licensing, and pathogen control measures are in place as appropriate.
Immunization A functioning national vaccine delivery system—with nationwide reach, effective distributions, access for
marginalized populations, adequate cold chain, and ongoing quality control—is able to respond to new
disease threats.
National laboratory Real-time biosurveillance with a national laboratory system and effective modern point-of-care and
system laboratory-based diagnostics.
Real-time surveillance Strengthened foundational indicator- and event-based surveillance systems that are able to detect events
of significance for public health, animal health, and health security; improved communication and
collaboration across sectors and between subnational (local and intermediate), national, and international
levels of authority regarding surveillance of events of public health significance; improved country and
intermediate level/regional capacity to analyze and link data from and between strengthened, real-time
surveillance systems, including interoperable, interconnected electronic reporting systems.
Reporting Timely and accurate disease reporting according to WHO requirements and consistent coordination with
FAO and OIE.
Workforce development State parties should have skilled and competent health personnel for sustainable and functional public
health surveillance and response at all levels of the health system and the effective implementation of the
International Health Regulations (IHR) (2005).
Emergency response Countries have a public health emergency operation center (EOC) functioning according to minimum
operations common standards; maintaining trained, functioning, multisectoral rapid response teams and “real-time”
biosurveillance laboratory networks and information systems; and trained EOC staff capable of activating a
coordinated emergency response within 120 minutes of the identification of a public health emergency.
Linking public health In the event of a biological event of suspected or confirmed deliberate origin, a country will be able to
and security authorities conduct a rapid, multisectoral response, including the capacity to link public health and law enforcement,
and to provide and/or request effective and timely international assistance, including to investigate alleged
use events.
Medical A national framework for transferring (sending and receiving) medical countermeasures and public health
countermeasures and and medical personnel among international partners during public health emergencies.
personnel deployment
Source: World Health Organization, Joint External Evaluation Tool: International Health Regulations (2005) (Geneva: 2016). | GAO-21-359
Page 10 GAO-21-359 Global Health Security
USAID and CDC Roles, According to the U.S. GHS Strategy, USAID and CDC have been the
Responsibilities, principal implementers of international GHS capacity–building activities
for the U.S. government, although many departments and agencies
Organization, and Funding contribute to U.S. GHS-related work. 19 As the strategy outlines, both
Sources for GHS USAID and CDC are to implement and coordinate their agencies’
programs to build capacity relevant to GHS. In addition, both agencies
are to lead, in conjunction with relevant departments and agencies, efforts
in antimicrobial stewardship and infection prevention and control.
Moreover, both agencies manage GHS funding and activities centrally
and also maintain staff in some overseas locations to provide support
from the field. USAID and CDC staff in some countries participate in U.S.
interagency teams in GHSA partner countries.
According to the U.S. GHS Strategy, at the country level, the ambassador
convenes an interagency GHSA country team to develop and execute
GHSA annual work plans. The ambassador or designate, such as the
Department of State (State) economic officer, chairs the team, which
consists of staff representing additional agencies such as HHS and the
Departments of Defense and Agriculture. GHSA country teams report
progress on specific JEE metrics on a semi-annual basis and discuss
work plans, priorities, challenges, and successes at least once each year.
USAID In USAID’s Bureau for Global Health in Washington, D.C., the Office of
Infectious Disease manages the bureau’s activities and engagement
related to infectious diseases, including emerging threats and pandemic
preparedness and response. The Office of Infectious Disease is
responsible for technical direction and leadership and for external
engagement on infectious disease issues, including working with external
partners, providing technical support to USAID’s field missions and
programs, and centrally managing infectious disease funding and
programs. Additionally, USAID staff serve as GHS advisors in some
USAID field missions.
USAID uses two funding sources to support its GHS activities: (1) the
fiscal year 2015 Global Health Programs appropriation for Ebola
19According to the U.S. GHS Strategy, other U.S. government entities and agencies
contributing to GHS-related work include the National Security Council; Office of
Management and Budget; Office of Science and Technology Policy; Departments of State,
the Treasury, Defense, the Interior, Agriculture, Health and Human Services,
Transportation, and Homeland Security; Environmental Protection Agency; Federal
Bureau of Investigation; National Institutes of Health; and Food and Drug Administration.
Page 11 GAO-21-359 Global Health Security
response and preparedness—which this report refers to as the Ebola
appropriation for USAID 20—and (2) the Global Health Programs
appropriations account. The Ebola appropriation for USAID does not
expire, and the appropriation to the Global Health Programs account
occurs annually, according to USAID officials. 21 USAID officials told us
that the Office of Infectious Disease plans for GHS funds to be allocated
to various activities worldwide and consults with USAID officials in the
field missions during the planning process before obligating funds. In
addition, USAID officials informed us that the central management of
GHS funds allows for flexibility to address any unexpected, acute, or
short-term infectious disease that might arise in a country, consistent with
the nature of GHS work.
CDC Four CDC centers collaborate to carry out the agency’s global health
security work: (1) the Center for Global Health, (2) the National Center for
Emerging and Zoonotic Infectious Diseases, (3) the National Center for
Immunization and Respiratory Diseases, and (4) the Center for
Preparedness and Response. In the Center for Global Health, at CDC
headquarters in Atlanta, the Division of Global Health Protection leads
CDC’s global health security efforts, working with partner countries to
help build key public health capacities. Additionally, CDC staff work on
GHS in overseas field locations. These staff include Division of Global
Health Protection staff who work on GHS full time and staff outside the
division who may also work on other global health issues, according to
CDC officials.
Through the fiscal year 2015 appropriation to HHS for Ebola response
and preparedness—which this report refers to as the Ebola appropriation
to HHS—CDC received $597 million to support national public health
institutes and GHS. This appropriation expired at the end of fiscal year
2019. 22 According to CDC officials, in the first year of receiving
20Consolidated and Further Continuing Appropriations Act, 2015, Pub. L. No. 113-235,
Div. J, title IX, 128 Stat. 2130, 2693 (2014). Beginning in fiscal year 2015, a portion of the
Ebola appropriation for USAID was used to fund activities related to GHS, which is one of
the four pillars of the 2014 U.S. Government Strategy for Reducing Transmission of the
Ebola Virus Disease in West Africa. These four pillars are (1) controlling the outbreak, (2)
mitigating the second-order impacts of the crisis, (3) building coherent leadership and
operations, and (4) strengthening global health security.
21The data we present for the Global Health Programs appropriations account do not
include any funds from the Ebola appropriation for USAID.
22Pub. L. No. 113-235, Div. G, title VI, 128 Stat. at 2520. According to CDC officials,
before fiscal year 2015, CDC did not have an appropriation for GHS.
Page 12 GAO-21-359 Global Health Security
appropriated funds for GHS, CDC developed 5-year funding proposals to
allocate GHS funding to the 17 Phase I countries, which the Office of
Management and Budget approved. CDC officials noted that CDC
adjusted funding levels annually on the basis of various factors, such as a
shift in priorities or the inability to hire personnel in the projected time
frame, and that the Office of Management Budget approved these
adjustments.
As of March 31, 2020, USAID and CDC had obligated a combined total of
USAID and CDC more than $1.2 billion for GHS activities and had disbursed about $1
Obligated Over $1.2 billion using funds appropriated in fiscal years 2015 through 2019. 23
USAID and CDC funding supported GHS activities aimed at building
Billion and Disbursed countries’ capacity to prevent, detect, and respond to infectious disease
About $1 Billion to threats by bolstering capacity in the 11 technical areas identified by the
GHSA in 2014. USAID obligated and disbursed funding from both the
Build GHS Capacity Ebola appropriation for USAID and the Global Health Programs
in at Least 34 appropriations account, while CDC obligated and disbursed funding
exclusively from the Ebola appropriation to HHS. Together, the agencies
Countries from Fiscal supported GHS activities in at least 34 countries, including 25 GHSA
Years 2015–2019 partner countries, through agreements awarded to implementing
partners. 24
Appropriations
23USAID provided us with two sets of funding and activities data corresponding to the two
funding sources that it used to support its GHS activities: (1) the fiscal year 2015 Ebola
appropriation for USAID and (2) fiscal years 2015 through 2019 appropriations to the
Global Health Programs account. USAID officials explained that the agency reported data
for the two funding sources differently because these data sets represent GHS activities
with different time frames, appropriations, and reporting requirements. With regard to GHS
funding from the Ebola appropriation for USAID, which does not expire, USAID reported
obligations and disbursements data categorized by the fiscal year when it obligated these
funds to specific award agreements. With regard to GHS funding from the Global Health
Programs appropriations account—which, according to agency officials, must be allocated
and obligated within 2 years of appropriation—USAID reported obligations and
disbursements categorized by the fiscal year of appropriation, regardless of the date of
obligation. CDC reported obligations and disbursements for global health security
activities implemented in fiscal years 2015 through 2019 from the Ebola appropriation to
HHS, which expired at the end of fiscal year 2019. CDC categorized these obligations and
disbursements by the fiscal year in which it obligated funds for those activities.
24USAID provided funding for GHS activities in at least 33 countries, including 16 of the 17
Phase I countries and eight of the 15 Phase II countries. CDC provided funding for GHS
activities in all 17 Phase I countries, including Pakistan; USAID did not provide funding for
GHS activities in Pakistan.
Page 13 GAO-21-359 Global Health Security
USAID and CDC Had As of March 31, 2020, USAID and CDC had obligated a combined total of
Obligated More Than $1.2 more than $1.2 billion and disbursed about $1 billion of this amount for
GHS activities from funds appropriated in fiscal years 2015 through 2019
Billion and Disbursed
(see fig. 4).
About $1 Billion for GHS
Activities as of March Figure 4: USAID’s and CDC’s Combined Total Obligations and Disbursements for
2020 from Fiscal Years Global Health Security Activities from Fiscal Years 2015–2019 Appropriations, as of
March 31, 2020
2015–2019 Appropriations
Page 14 GAO-21-359 Global Health Security
Zoonotic Disease Threats USAID and CDC used the majority of the funds they obligated for GHS to
Most global infectious diseases have zoonotic award agreements to implementing partners to carry out GHS activities. 25
origins, according to officials of the U.S. According to USAID and CDC officials, both agencies’ GHS activities
Agency for International Development
(USAID) and Centers for Disease Control and aimed at preventing, detecting, and responding to infectious disease
Prevention (CDC). The officials said that threats. Consistent with this aim, USAID and CDC officials noted that
mitigating zoonotic diseases through efforts
such as animal health monitoring and
USAID’s and CDC’s GHS activities in fiscal years 2015 through 2019
response is an important aspect of building were intended to help build GHSA countries’ capacity to prevent, detect,
global health security (GHS) capacity. and respond to infectious diseases in the 11 GHSA technical areas.
According to USAID officials in Washington,
D.C., GHS includes programming focused on
the detection of zoonotic pathogens that Although USAID and CDC cover some of the same technical areas,
circulate in wildlife and livestock but also
have the potential to affect human
officials described a number of ways in which the two agencies
populations. coordinate to avoid overlapping activities. According to USAID
USAID and CDC officials in Ethiopia, headquarters officials as well as USAID and CDC officials we spoke with
Vietnam, and Indonesia told us that advances in Ethiopia, Indonesia, Senegal, and Vietnam, USAID and CDC
in GHS for animal health required further
investment and that capacities in this area collaborate at the headquarters and country levels to ensure that the two
had not grown to the same extent as agencies avoid duplicative efforts, pursue complementary activities, and
capacities related to human health. According
to USAID officials, longstanding underfunding prevent gaps in the assistance provided to the countries. For example,
and relative neglect of animal health USAID headquarters officials explained that if both agencies are working
capacities by national governments have
contributed significantly to this disparity,
on strengthening laboratory and training techniques, the two agencies
which is now beginning to be addressed. may coordinate their efforts, with USAID providing assistance at the
USAID Activity to Communicate about laboratory facility and working with the government ministries and CDC
Zoonotic Disease Risk
providing training for laboratory technicians.
In addition, CDC headquarters officials noted that country-level officials
work closely with GHSA country teams, which include USAID officials, to
make GHS programming decisions. Moreover, CDC headquarters
officials reported regular communication with USAID officials that informs
CDC’s subsequent programming decisions. 26 Agency officials we
interviewed also said that USAID and CDC collaborate to develop
interagency work plans at the country level to ensure the two agencies’
activities are harmonized.
25Both agencies also use some funds that they have allocated for GHS to support their
own operating expenses.
26USAID and CDC staff in some overseas locations participate in interagency GHSA
country teams that may also include staff from State, HHS, and the Departments of
Defense and Agriculture.
Page 15 GAO-21-359 Global Health Security
Figure 5 shows facilities where USAID and CDC supported activities that
we observed in Ethiopia and Senegal, which were both Phase I countries.
Figure 5: Examples of Facilities in Ethiopia and Senegal Where USAID and CDC Supported GHS Activities
Page 16 GAO-21-359 Global Health Security
USAID Had Obligated
About $655 Million and
Disbursed Nearly $500
Million for GHS Activities
as of March 2020 from
Fiscal Years 2015-2019
Appropriations
USAID Funding As of March 31, 2020, USAID reported having obligated about $655
million and disbursed about $500 million for GHS activities from funds
appropriated in fiscal years 2015 through 2019. USAID obligated and
disbursed this funding from two sources: the Ebola appropriation for
USAID and the Global Health Programs appropriations account. Figure 6
shows the amounts that USAID obligated and disbursed from these two
sources.
Figure 6: USAID Obligations and Disbursements for Global Health Security
Activities from Fiscal Years 2015–2019 Appropriations, as of March 31, 2020
a
”Ebola appropriation for USAID” refers to the fiscal year 2015 Global Health Programs appropriation
for Ebola response and preparedness. Consolidated and Further Continuing Appropriations Act,
2015, Pub. L. No. 113-235, Div. J, title IX, 128 Stat. 2130, 2693 (2014).
Page 17 GAO-21-359 Global Health Security
Ebola appropriation for USAID. In fiscal years 2015 through 2019, USAID
obligated funding from the Ebola appropriation for USAID for activities in
18 countries, according to USAID data (see fig. 7).
Figure 7: USAID Obligations in Fiscal Years 2015-2019 for Countries Where the
Agency Supported GHS Activities with Fiscal Year 2015 Ebola Appropriation for
USAID, as of March 31, 2020
Note: “Ebola appropriation for USAID” refers to the fiscal year 2015 Global Health Programs
appropriation for Ebola response and preparedness. Consolidated and Further Continuing
Appropriations Act, 2015, Pub. L. No. 113-235, Div. J, title IX, 128 Stat. 2130, 2693 (2014). The data
shown do not include $33 million in global awards and $13 million in regional awards and do not
include funding for USAID’s internal operating expenses.
Global Health Programs appropriations account. According to USAID
officials, in fiscal year 2019, USAID began to track country-level GHS
funding from the Global Health Programs appropriations account, starting
with funding for fiscal year 2018, to address congressional reporting
Page 18 GAO-21-359 Global Health Security
specifications. 27 Officials explained that USAID developed the capability
to track country-level funding partly in response to our recommendation in
a May 2019 report. 28 Officials also noted that USAID is not able to
comprehensively track country-level GHS funding from the Global Health
Programs appropriations account for fiscal years 2015 through 2017.
However, for the Ebola appropriation for USAID, the agency has country-
level GHS funding data for fiscal years 2015 through 2019.
USAID Activities USAID primarily categorizes its GHS activities according to the three
types of GHS assistance—infectious disease prevention, detection, and
response—with many activities addressing more than one type. For
example, officials stated that surveillance activities address both
prevention and detection of infectious diseases. As a result,
disaggregating the specific amount of funding used for each type of
assistance would be difficult, according to agency officials. However,
USAID reporting associates specific funding awards with the relevant
types of assistance.
Our analysis of USAID data on funding for GHS activities found the
following: 29
• Of 65 awards identified in USAID data, 29 involved disease
prevention, 19 involved disease detection, and 40 involved disease
response. Many of the implemented activities involved multiple types
of assistance.
• Of 43 implementing partners identified in USAID data, the top three
implementing partners (i.e., those that received the largest amounts of
GHS funding) received 59 percent of USAID’s total obligations to
implementing partners. The top three partners were the United
27Consolidated Appropriations Act, 2018, Pub. L. No. 115-141, Div. K, § 7019(e), 132
Stat. 348, 874.
28See GAO, Emergency Assistance for Zika: USAID Supported Activities Overseas but
Could Improve Funds Tracking and Response Planning, GAO-19-356 (Washington, D.C.:
May 13, 2019). We recommended that USAID take steps to ensure that in responding to
future public health emergencies of international concern, the agency is able to compile
funding information by country. In response, USAID established a requirement and
process in July 2019 to track funding obligated for preparedness and response activities
supporting a public health emergency of international concern on a by-country basis.
29Our analysis of USAID funding for GHS activities focused on obligations as of March 31,
2020, from funds appropriated in fiscal years 2015 through 2019. In addition, our analysis
included funding obligated to external USAID implementing partners but excluded funding
for internal operating expenses.
Page 19 GAO-21-359 Global Health Security
Nations’ Food and Agriculture Organization; the University of
California, Davis; and the University of Minnesota.
• The 10 implementing partners to which, as of March 31, 2020, USAID
had obligated the largest amounts from funds appropriated in fiscal
years 2015 through 2019 received 89 percent of USAID’s total
obligations to implementing partners. See appendix II for a list of
these implementing partners and the amounts obligated.
Using funds appropriated in fiscal years 2015 through 2019, USAID
supported GHS activities in at least 33 countries, including 24 of the 32
GHSA partner countries. Specifically, USAID provided funding for
activities in 16 of 17 Phase I countries, eight of 15 Phase II countries, and
nine other countries at high risk for global infectious disease threats,
according to information available from USAID. USAID reporting indicates
that the agency did not provide funding for GHS activities in one Phase I
country (Pakistan) and seven Phase II countries (Georgia, Haiti,
Kazakhstan, Mozambique, Peru, Ukraine, and the Caribbean
Community). 30 According to USAID officials, USAID focused its GHS
funding on countries with the highest risk of zoonotic virus emergence.
Figure 8 shows the countries where USAID supported GHS activities
using funds appropriated in fiscal years 2015 through 2019.
30USAID officials explained that because of funding constraints and security concerns—
particularly concerns about the safety of staff drawing samples from animals in the field—
USAID did not identify Pakistan as a high-priority country and thus did not provide funding
for GHS activities in this Phase I country in fiscal years 2015 through 2019.
Page 20 GAO-21-359 Global Health Security
Figure 8: Countries Where USAID Supported Global Health Security Activities with
Fiscal Years 2015-2019 Appropriations, as of March 31, 2020
Note: USAID also supported some global health security activities through global and regional
funding awards, which may have included activities in countries that are not shown.
Examples of USAID’s GHS activities in Phase I countries include the
following:
• In Senegal, USAID has supported the Infectious Disease Detection
and Surveillance project. According to implementing partners, this
project has assisted laboratories in Senegal in building capacity for
detection surveillance through training sessions and diagnostic
Page 21 GAO-21-359 Global Health Security
support for disease detection and has supported border surveillance
efforts.
• In Guinea, USAID provided support to build the central veterinary
laboratory’s capacity to conduct core tests for diseases such as avian
influenza and rabies, according to the GHSA country team. USAID
has also coordinated with a reference laboratory at the University of
California, Davis, to provide simultaneous analysis of animal samples
to Guinea and the United States, ensuring that data and findings are
available to inform Guinea’s health policy. Additionally, USAID
provided 11 solar freezers and 200 coolers to facilitate specimen
transport from regional laboratories to national laboratories for
advanced diagnostics.
• In Ethiopia, USAID supported the One Health Workforce project,
which provided training to current and future One Health workers in
the classroom, online, and in the field to create a workforce with
technical expertise and practical skills to address emerging infectious
disease threats. 31 USAID provided this training in coordination with
experts in medicine, nursing, public health, education and
development, environmental health, and veterinary medicine, among
other disciplines. While supporting the project, USAID officials helped
establish the One Health National Steering Committee. According to
officials we interviewed in December 2019, although the USAID
project had ended, the committee continued to meet regularly to
provide high-level government coordination for GHS. Committee
members told us that their priority areas included coordinating joint
responses to outbreaks and developing the One Health Workforce
project. 32
31One Health is a collaborative, multisectoral, and transdisciplinary approach implemented
at the local, regional, national, and global levels to achieve optimal health outcomes with
respect to the interconnection between people, animals, plants, and their shared
environment. USAID’s One Health Workforce project supports workforce development in
universities in Africa and Southeast Asia.
32According to USAID officials, the One Health Workforce–Next Generation project, which
launched in October 2019, is a follow-on to the One Health Workforce project and is
actively engaged in nine countries in Africa and eight countries in Southeast Asia. USAID
officials noted that, as in the original One Health Workforce project, the One Health
Workforce–Next Generation project aims to enhance global health security by
empowering university networks and their member institutions to develop and deliver
sustainable training and programs that address complex One Health challenges, such as
infectious disease and antimicrobial resistance threats.
Page 22 GAO-21-359 Global Health Security
CDC Had Obligated $596
Million and Disbursed
Nearly $525 Million for
GHS Activities as of March
2020 from Funds
Appropriated in Fiscal
Year 2015
CDC Funding As of March 31, 2020, CDC reported having obligated $596 million and
disbursed about $524 million for GHS activities from funds appropriated in
fiscal year 2015. CDC obligated and disbursed this funding from a single
source, the Ebola appropriation to HHS. CDC has the ability to track this
funding at the country level, and it categorizes funding for activities that
span more than one country as cross cutting.
CDC Activities CDC officials told us that the agency focused its obligations for GHS
support on activities in the following “core 4” areas:
1. disease surveillance and outbreak response—establishing routine
surveillance for priority diseases and developing information
technology tools and systems;
2. emergency management—providing countries with the knowledge
and resources, including emergency operations centers to help mount
a fast, coordinated response when outbreaks happen;
3. safe laboratory systems and diagnostics—building the capacity to
identify disease threats close to the source and inform decision-
making; and
4. development of the workforce—training frontline responders,
laboratorians, disease detectives, emergency managers, and other
health professionals who are responsible for taking the lead when
crisis strikes.
CDC officials noted that, similar to USAID, CDC does not track GHS
funding by type of assistance, because many of its activities address
Page 23 GAO-21-359 Global Health Security
multiple types of assistance or cover multiple technical areas. Our
analysis of CDC data on funding for GHS activities found the following: 33
• Many of CDC’s activities involved awarding funds to host
governments to implement GHS activities, which comprised about 25
percent of total awards to recipients for GHS-related assistance.
Examples shown by CDC data include funding awarded to the
Ethiopian Public Health Institute, Pakistan’s National Institute of
Health, and the Uganda Virus Research Institute.
• Of 105 implementing partners identified in CDC data, the top three
implementing partners (i.e., those that received the largest amounts of
GHS funding) received 25 percent of CDC’s total obligations to
implementing partners. These three partners were WHO, the African
Field Epidemiology Network, and the Task Force for Global Health.
• The 10 implementing partners to which, as of March 31, 2020, CDC
had obligated the largest amounts from funds appropriated in fiscal
year 2015 received 46 percent of CDC’s total obligations to
implementing partners. See appendix II for a list of these
implementing partners and obligated funding amounts.
CDC supported GHS activities in all 17 Phase I countries. Figure 9 shows
CDC’s total obligations for GHS activities in these countries from funds
appropriated in fiscal year 2015.
33Our analysis of CDC funding for GHS activities focused on obligations as of March 31,
2020, from funding appropriated in fiscal year 2015. In addition, our analysis included
funding obligated to external CDC implementing partners but excluded funding for internal
operating expenses.
Page 24 GAO-21-359 Global Health Security
Figure 9: CDC Obligations in Fiscal Years 2015-2019 for Countries Where the
Agency Supported GHS Activities from Fiscal Year 2015 Appropriation to HHS, as
of March 31, 2020
Note: “Appropriation to HHS” refers to the fiscal year 2015 appropriation to HHS for Ebola response
and preparedness. Consolidated and Further Continuing Appropriations Act, 2015, Pub. L. No. 113-
235, Div. G, title VI, 128 Stat. 2130, 2520 (2014). The data shown do not include $119 million in
cross-cutting awards, which involve work across multiple countries, and do not include funding for
CDC’s internal operating expenses.
Examples of CDC’s GHS activities include the following:
• In Ethiopia and Senegal, participants in the Field Epidemiology
Training Program told us about field applications of skills that they had
learned in the classroom. Graduates of the program had also
participated in regional detection and response efforts, including
assisting with the response to an Ebola outbreak in West Africa,
according to the participants we spoke with.
Page 25 GAO-21-359 Global Health Security
• In Ethiopia and Senegal, we observed national emergency operation
centers where staff collect data, such as data on reported incidents of
suspected infectious diseases, to monitor possible outbreaks. At
these centers, CDC has provided software and technical training for
staff to build the countries’ capacity to monitor and respond to
outbreaks.
• In Vietnam, CDC collaborated with WHO Vietnam to conduct a
systematic review of sentinel surveillance for influenza-like illness,
according to the GHSA country team. CDC previously had provided
technical and financial assistance to establish and operate this
disease surveillance system and subsequently, in 2016, transferred
operations to the government of Vietnam. Findings from the review
informed Vietnam’s revision and finalization of official national
guidelines for such surveillance efforts.
Our analysis of U.S. officials’ assessments of the 17 Phase I countries’
U.S. Assessments GHS capacities at the end of fiscal year 2019 found that the majority of
Showed Some GHS the countries had developed some capacity in most of the technical areas
developed by the GHSA in 2014. In addition, our analysis of the
Capacity in Most assessments found that for most of the countries, indicator scores for the
Phase I Countries, majority of the 11 technical areas had remained stable or increased from
baseline scores in 2016 and 2017. Our analysis of the assessments also
but Countries Faced found that the countries faced eight types of challenges to building GHS
Several Challenges capacity, including weaknesses in government institutions, constrained
resources, and insufficient human capital. 34
JEEs Assessed GHS For each of the 11 GHSA technical areas, the JEEs for most Phase I
Capacity in the 11 countries in 2016 and 2017 assessed one to four attributes, known as
indicators—a possible total of 31 indicators—to assist the countries in
Technical Areas Using 31
building GHS capacity. Table 2 shows the technical areas and indicators
Indicators assessed in the JEEs.
34In this public version of our sensitive report (GAO-21-213SU), we have omitted specific
details of country scores, examples, and challenges that USAID and CDC deemed
sensitive.
Page 26 GAO-21-359 Global Health Security
Table 2: Global Health Security Capacity Indicators Assessed in Joint External Evaluations (JEE) of GHSA Technical Areas in
2016 and 2017
Technical area Indicators
Antimicrobial resistance (AMR) • AMR detection
• Surveillance of infections caused by AMR pathogens
• Health care–associated infection prevention and control programs
• Antimicrobial stewardship activities
Zoonotic disease • Surveillance systems in place for priority zoonotic diseases/pathogens
• Veterinary or animal health workforce
• Established and functional mechanisms for responding to infectious zoonoses and
potential zoonoses
Biosafety and biosecurity • Whole-of-government biosafety and biosecurity system in place for human, animal,
and agriculture facilities
• Biosafety and biosecurity training and practices
Immunization • Vaccine coverage (measles) as part of national program
• National vaccine access and delivery
National laboratory system • Laboratory testing for detection of priority diseases
• Specimen referral and transport system
• Effective modern point-of-care and laboratory-based diagnostics
• Laboratory quality system
Real-time surveillance • Indicator- and event-based surveillance systems
• Interoperable, interconnected, electronic real-time reporting system
• Analysis of surveillance data
• Syndromic surveillance systems
Reporting • System for efficient reporting to WHO, FAO, and OIE
• Reporting network and protocols in country
Workforce development • Human resources available to implement IHR core capacity requirements
• Applied epidemiology training program in place
• Workforce strategy
Emergency response operations • Capacity to activate emergency operations
• Emergency operations center operating procedures and plans
• Emergency operations program
• Case management procedures implemented for IHR-relevant hazards
Linking public health and security • Public health and security authorities linked during a suspected or confirmed
authorities biological event
Medical countermeasures and personnel • System in place for sending and receiving medical countermeasures during a public
deployment health emergency
• System in place for sending and receiving health personnel during a public health
emergency
Legend: FAO = Food and Agriculture Organization of the United Nations, IHR = International Health Regulations, OIE = World Organisation for Animal
Health, WHO = World Health Organization.
Source: World Health Organization, Joint External Evaluation Tool. International Health Regulations (2005), 1st ed. (Geneva: 2016). | GAO-21-359
Page 27 GAO-21-359 Global Health Security
Note: In 2014, the United States and other nations launched the Global Health Security Agenda
(GHSA) to accelerate progress toward a world safe and secure from infectious disease threats. In
2014, GHSA members identified and developed 11 technical areas to facilitate regional and global
collaboration in achieving GHSA goals and objectives, according to Centers for Disease Control and
Prevention officials. JEEs conducted in 16 countries in fiscal years 2016 and 2017 assessed one to
four indicators for each technical area as attributes to assist countries in building capacity.
USAID and CDC Officials USAID and CDC headquarters officials review reports on Phase I
Use GHSA Progress countries’ progress in building GHS capacity, which GHSA country teams
have submitted twice each year since fiscal year 2017. In completing
Reports and JEE Scores
these GHSA progress reports, the teams use the indicator scores from
to Assess Countries’ the 2016 and 2017 JEEs as baseline measurements of each country’s
Progress and Plan Future capacities to respond to infectious disease threats, and they use these
Assistance baselines to assess the effectiveness of U.S. efforts to help the countries
build GHS capacities. 35 In 2016 and 2017, 16 of the 17 Phase I countries
that received U.S. GHS assistance participated in a JEE with an external
evaluation team. 36
Guidance for completing the GHSA progress reports indicates that
officials should develop their reporting using the capacity levels identified
in the JEE tool. According to the guidance, the reports should provide
scores for indicators in each technical area and should include examples
of U.S. efforts to support capacity building for each area. Table 3 shows
the five capacity levels and the attributes associated with each level, with
examples from the technical area national laboratory system.
35According to WHO, the JEE is a voluntary, collaborative evaluation process that is
completed in two stages: (1) an initial self-evaluation conducted by the host country, using
the JEE tool, and (2) an in-country evaluation conducted by an external evaluation team of
subject matter experts in close collaboration with the host country. First published by
WHO in February 2016, the JEE tool is a data-gathering instrument designed to evaluate
IHR capacities for health security, including all GHSA-relevant capacities across all
relevant sectors at a national level. According to WHO, countries can use the data and
lessons learned from the evaluation process to inform country-level planning and priority
setting.
36A JEE had not been conducted for the one remaining Phase I country as of May 2020.
Page 28 GAO-21-359 Global Health Security
Table 3: Capacity Levels for GHSA Indicators Identified in Joint External Evaluation (JEE) Tool
Capacity levels Description Examples from national laboratory system technical area
Level 1: No capacity Attributes of a capacity are National laboratory system is not capable of conducting any core tests.
not in place No system is in place to transport specimens.
No diagnostic testing strategies are documented.
There are no national quality standards for health laboratories.
Level 2: Limited Attributes of a capacity are in National laboratory system is capable of conducting one to two core tests.
capacity the development stage (some System is in place to transport specimen from less than 50% of country for
are achieved and some are advance diagnostics.
being implemented).
Minimal diagnostic capacity exists.
National quality standards have been developed, but there is no system for
verifying their implementation.
Level 3: Developed Attributes of a capacity are in National laboratory system is capable of conducting three to four core tests.
capacity place; however, the capacity’s System is in place to transport specimens from 50% to 80% of country for
sustainability in country may advance diagnostics.
be uncertain, as indicated by
its lack of inclusion in the Diagnostic testing strategies are documented but not fully implemented.
operational plan in the Licensing system for health laboratories, including conformity with national
National Health Sector quality standards, exists but is not required for all laboratories.
Planning or lack of secure
funding.
Level 4: Demonstrated Attributes of a capacity are in National laboratory system is capable of conducting five or more core tests.
capacity place, are sustainable for a System is in place to transport specimens from at least 80% of country.
few more years, and can be
measured by the inclusion of Diagnostic testing strategies are documented and fully implemented.
the attributes or International Mandatory licensing of all health laboratories is in place, and conformity to
Health Regulations (2005) national quality standards is required.
core capacities in the national
health sector plan.
Level 5: Sustainable Attributes of a capacity are Country has national system for procurement and quality assurance.
capacity functional and sustainable, Specimen transport system is in place for all of country and funded from
and the country is supporting country budget.
other countries in
implementing the capacity. Country has sustainable capacity for performing diagnostic testing, with no
more than 20% dependence on donor funding.
Mandatory licensing of all health laboratories is in place, and conformity to
an international quality standard is required.
Source: World Health Organization, Joint External Evaluation Tool, 1st ed. (Geneva: 2016). | GAO-21-359
Note: The JEE tool, developed by the World Health Organization, is an evaluation process that U.S.
officials use to monitor progress in building capacity to prevent, detect, and respond to infectious
disease threats in countries receiving assistance from the United States as part of the Global Health
Security Agenda (GHSA). In 2014, the United States and other nations launched the GHSA to
accelerate progress toward a world safe and secure from infectious disease threats. To assist
countries in building capacity, JEEs conducted in 16 countries in 2016 and 2017 assessed one to four
capacity indicators for each of 11 technical areas, assigning a score for each indicator. The JEE tool
provides contextual questions and examples to help evaluators assign the scores.
Page 29 GAO-21-359 Global Health Security
Officials at USAID headquarters stated that at least annually, they review
the GHSA progress reports submitted by the GHSA country teams. 37
According to the officials, they use the reports to track the countries’
progress in building GHS capacity, identify successes and areas for
improvement, determine follow-up actions, and develop future
programming for each country and technical area. Officials at USAID
headquarters said that they discuss follow-up actions during calls with
GHSA country teams, who may incorporate the actions in the interagency
annual GHS work plans that they develop for the countries. According to
USAID officials, the GHSA progress reports, in combination with other
information related to topics such as security concerns and country
governance, assist them in making programming and resource decisions.
In addition to using the GHSA progress reports to monitor each country’s
progress in building capacity, officials at USAID headquarters use the
reports to review countries’ collective progress, by country and across the
technical areas. The officials explained that some technical area activities
benefit from collaborative regional efforts, such as ensuring quality
standards for laboratories. During our visit to Senegal, U.S. officials
stated that technical experts in laboratory standards and testing in that
country have shared their expertise with other countries in the region,
using knowledge gained from U.S.-funded training (see fig. 10 for an
example of equipment used in such training).
37GHSA country teams comprise staff from USAID, CDC, State, and the Departments of
Defense and Agriculture.
Page 30 GAO-21-359 Global Health Security
Figure 10: Equipment Used in Senegal’s Institute for Health Research Epidemiology
Surveillance Training
CDC officials at headquarters stated that they use the GHSA progress
reports to inform discussions of technical support for GHS development
and to plan future activities. According to these officials, they review
changes in average indicator scores in technical areas to identify
indicators needing additional support and indicators showing capacity
increases. Officials also stated that they conduct country-specific analysis
of indicator score changes over time and analyze ranges of JEE country
scores across various geographic regions to obtain regional project
updates and inform future planning. Further, CDC headquarters officials
said that they review contributions made by CDC officials on GHSA
country teams to the draft GHSA progress reports. According to the
officials, they use the final reports submitted by the teams to track
progress and articulate the effects of U.S. GHSA activities.
CDC officials also discuss the GHSA progress reports with other
agencies’ officials. CDC officials on the country teams told us that they
work closely with officials of the other represented agencies, including
USAID, State, and the Department of Defense, to make programming
decisions. CDC headquarters officials stated that they discuss the
progress reports with interagency colleagues during interagency GHS
calls.
Page 31 GAO-21-359 Global Health Security
U.S. Progress Reports
Submitted before COVID-
19 Onset Showed Some
GHS Capacity in Most
Technical Areas and
Countries
Analysis of Indicator Scores by Our analysis of the GHSA progress reports for fiscal year 2019 for the 17
Technical Area Phase I countries found that the indicator scores for most of the 11
technical areas showed some GHS capacity. 38 As seen in table 4, for
seven of the 11 technical areas—zoonotic diseases, immunization,
national laboratory system, real-time surveillance, reporting, workforce
development, and emergency response operations—the largest numbers
of indicator scores were at level 3, which the JEE tool defines as
“developed capacity.” For three of the 11 technical areas—antimicrobial
resistance, biosafety and biosecurity, and medical countermeasures and
personnel deployment—the largest numbers of indicator scores were at
level 2, which the JEE tool defines as “limited capacity.” For the remaining
technical area, linking public health and security authorities, the largest
number of indicator scores was at level 2 and level 3, which each had five
scores.
Table 4: Numbers of Indicator Scores at Each Capacity Level for All Phase I Countries, by GHSA Technical Area, at the End of
Fiscal Year 2019
Level 1: Level 2: Level 3: Level 4: Level 5: Total
Limited Developed Demonstrated Sustained number of
Technical area No capacity capacity capacity capacity capacity scores
Antimicrobial resistance 5 26 25 6 0 62
Zoonotic diseases 0 9 32 9 0 50
Biosafety and biosecurity 1 16 13 1 0 31
Immunization 0 2 13 11 1 27
National laboratory system 4 15 34 13 0 66
Real-time surveillance 0 9 29 25 0 63
Reporting 0 4 18 1 0 23
Workforce development 0 8 22 18 0 48
38Although GHSA country teams assess countries’ progress in building GHS capacity at
the midpoint and end of each fiscal year, we focused our analysis on the assessments at
the end of the fiscal year.
Page 32 GAO-21-359 Global Health Security
Level 1: Level 2: Level 3: Level 4: Level 5: Total
Limited Developed Demonstrated Sustained number of
Technical area No capacity capacity capacity capacity capacity scores
Emergency response 4 9 30 12 4 59
operations
Linking public health and 0 5 5 2 0 12
security authorities
Medical countermeasures 3 9 4 5 1 22
and personnel deployment
Total 17 112 225 103 6 463
Source: GAO analysis of U.S. agencies’ Global Health Security Agenda (GHSA) capacity gains progress reporting. | GAO-21-359
Note: In 2014, GHSA members identified and developed 11 technical areas to facilitate regional and
global collaboration in achieving GHSA goals and objectives, according to Centers for Disease
Control and Prevention officials. The Joint External Evaluation (JEE) tool, which is used to assess
countries’ capacities in the technical areas, includes one to four indicators for each technical area—a
total of 31 indicators—as attributes to assist a country in building capacity. U.S. officials submitted
indicator scores related to existing U.S. government–supported programs in 17 Phase I countries for
fiscal year 2019. If no U.S.-supported programs related to a given indicator, U.S. officials did not
submit an indicator score for that indicator. When scores were recorded for both human health and
animal health capacities, our analysis used the lower of the two scores.
According to the JEE tool, a level 3 indicator score means that attributes
of a capacity are in place but the capacity’s sustainability may be
uncertain, as indicated by a lack of secure funding, among other factors.
For example, according to the GHSA progress report for one country for
fiscal year 2019, the score for one of the indicators for the technical area
emergency response operations moved from level 2 to level 3 because of
new documented procedures for transferring suspected Ebola outbreak
patients from the airport to a treatment unit.
Emergency response operations was one of three technical areas that
had the highest number of level 3 indicator scores; the other two technical
areas were national laboratory system and zoonotic diseases. Emergency
response operations also had the highest number of indicators with level
5 scores. According to the JEE tool, a level 5 indicator score means that
attributes of a capacity are functional and sustainable and the country is
supporting other countries in its implementation.
In contrast, antimicrobial resistance had the highest number of indicators
with level 1 scores. According to the JEE tool, a level 1 indicator score
means that attributes of a capacity are not in place. USAID and CDC
have built programs to address these gaps in the antimicrobial resistance
technical area.
Page 33 GAO-21-359 Global Health Security
Analysis of Indicator Scores by Our analysis of the GHSA progress reports for fiscal year 2019 for the 17
Country Phase I countries found that most of the countries had some GHS
capacity. For 13 of the countries, the largest numbers of indicator scores
were at level 3. For one country, the largest number of scores was at
level 4, and for three countries, the largest numbers of scores were at
level 2.
For one country, U.S. officials gave a level 1 score to the indicator
“System in place for sending and receiving health personnel during a
public health emergency” for the technical area medical countermeasures
and personnel deployment. According to the fiscal year 2019 GHSA
progress report, the government of this country had incorporated the
concept of a public health corps and management of personnel only as
an element of the organizational structure of the emergency operations
center. According to the JEE tool, a country would demonstrate level 2
capacity in this technical area if it had drafted plans for sending and
receiving health personnel during a public health emergency. A country
would demonstrate level 3 capacity if it had conducted tabletop exercises
to demonstrate decision making and protocols for sending or receiving
health personnel from another country during a public health emergency.
For another country, U.S. officials assessed the indicator “Capacity to
activate emergency operations” for emergency response operations at
level 5, because staff at the emergency operations center had received
numerous trainings and participated in tabletop exercises and had been
activated for Ebola preparedness activities.
Most Indicator Scores in
2019 Had Remained
Stable or Risen, by
Technical Area and
Country, Relative to
Scores in 2016 and 2017
Analysis of Indicator Scores by Our analysis found that the majority of indicator scores for each of the 11
Technical Area technical areas in GHSA progress reports submitted to USAID and CDC
for fiscal year 2019 had either remained stable or increased relative to the
Page 34 GAO-21-359 Global Health Security
baseline scores in 2016 and 2017. 39 For example, for antimicrobial
resistance, 60 of 62 scores had either remained stable or increased, while
two scores had decreased. Table 5 shows the number of indicator scores
that remained stable, increased, or decreased for each technical area.
Table 5: Numbers of Indicator Scores for Phase I Countries That Remained Stable, Increased, or Decreased, by GHSA
Technical Area, from 2016/2017 to 2019
Technical area Remained stable Increased Decreased Total number of scores
Antimicrobial resistance 25 35 2 62
Zoonotic diseases 24 25 1 50
Biosafety and biosecurity 16 12 3 31
Immunization 20 3 4 27
National laboratory system 30 24 12 66
Real-time surveillance 41 16 6 63
Reporting 10 13 0 23
Workforce development 21 21 6 48
Emergency response operations 24 32 3 59
Linking public health and security authorities 5 6 1 12
Medical countermeasures and personnel 14 8 0 22
deployment
Total 230 195 38 463
Source: GAO analysis of U.S. agencies’ Global Health Security Agenda (GHSA) capacity gains progress reporting. | GAO-21-359
Notes: In 2014, GHSA members identified and developed 11 technical areas to facilitate regional and
global collaboration in achieving GHSA goals and objectives, according to Centers for Disease
Control and Prevention officials. The Joint External Evaluation (JEE) tool, which is used to assess
countries’ capacities in the technical areas, includes one to four indicators for each technical area—a
total of 31 indicators—as attributes to assist countries in building capacity. We analyzed indicator
scores for the 17 Phase I countries that received U.S. GHS assistance in fiscal years 2015 through
2019. Our analysis included only those indicators with (1) baseline scores produced by countries and
external evaluators in 2016 and 2017 and (2) scores submitted by U.S. officials in GHSA progress
reports for fiscal year 2019. In some cases, a country may have had fewer than 31 indicator scores
because no baseline score was provided for the indicator or no score was submitted for fiscal year
2019. Specifically, if no U.S. government–supported program relating to an indicator existed for a
technical area at the end of fiscal year 2019, no score was recorded for that area. Thus, the total
39Our analysis compared scores for a total of 31 indicators in 11 technical areas from
JEEs conducted in 2016 and 2017 for 16 of the 17 Phase I countries with scores for those
indicators in GHSA progress reports submitted for fiscal year 2019 for the 16 countries.
The JEE scores were produced by countries’ self-evaluations and by external experts
from WHO, and the scores in GHSA progress reports were produced by U.S. officials in
GHSA country teams using the evaluation tools that were used for the JEEs. For the one
remaining Phase I country where a JEE had not yet been conducted, we used baseline
scores from this country’s GHSA self-assessment tool, which U.S. officials provided in
their fiscal year 2017 GHSA progress report for that country. We counted only indicators
for which both a baseline score and score from the end of fiscal year 2019 were available.
For more information about our methodology, see appendix I.
Page 35 GAO-21-359 Global Health Security
number of indicators recorded for each technical area may vary by country. When scores were
recorded for both human health and animal health capacities, our analysis used the lower of the two
scores.
Antimicrobial resistance, with one to four indicators reported per country,
had the largest number of increased indicator scores. The score for at
least one indicator for this technical area increased for 13 of the 17 Phase
I countries, and the scores for all four indicators increased for five
countries. For example, one country’s 2016 JEE found that the country
had many of the components needed for surveillance related to
antimicrobial resistance. However, additional work was required to
develop a national antimicrobial resistance detection and surveillance
system capable of generating high-quality data for evidence-informed
national policies, strategies, and plans and for timely operational and
tactical response for mitigation and control. According to the GHSA
progress reports for fiscal years 2018 and 2019, the U.S. government
provided technical assistance to develop and implement national
antimicrobial resistance plans, conducted training, and provided funding
to support quality-assurance practices in laboratories.
Reporting, with one or two indicators reported per country, had the
highest percentage of increased indicator scores of any of the technical
areas. For example, the 2016 JEE report for one country stated that the
country had some reporting capacities but had limitations in its capacity
for information sharing between human and animal health organizations.
According to GHSA progress reports from fiscal years 2018 and 2019,
U.S. government efforts in this country contributed to developing
processes for coordination between the human and animal health sectors
and assisted in international simulation exercises to demonstrate these
capacities. The country subsequently used these developed capacities to
enhance coordination between the two sectors during a yellow fever
outbreak in August 2019.
National laboratory system, with one to four indicators reported per
country, had the largest number and highest percentage of decreased
indicator scores of any technical area. Our analysis found that at least
one indicator score for national laboratory system decreased in six
countries. For example, for two of the four indicators, scores in one
country’s GHSA progress report for fiscal year 2019 were lower than the
scores in the country’s JEE report for 2017. In fiscal year 2019, U.S.
officials assessed separate scores for animal health and human health
Page 36 GAO-21-359 Global Health Security
capacities 40 for these indicators and gave lower scores for animal health
capacities than for human health capacities. 41 In contrast, the 2017 JEE
reported a single score for each indicator rather than separate scores for
animal health and human health. 42 Figure 11 shows examples of USAID’s
and CDC’s activities to support the national laboratory systems in
Ethiopia and Senegal.
40Some GHSA progress reports submitted for fiscal year 2019 include two sets of
scores—for animal health capacities and for human health capacities—for certain
indicators. USAID officials told us that State and other agencies had encouraged
embassies to estimate both sets of scores where feasible and that reviewing both scores
had helped them track progress in the two sectors. USAID officials also noted that
underfunding and relative neglect of animal health capacities by national governments had
been a major contributor to disparities between animal health and human health
capacities and that such disparities were beginning to be addressed.
41When scores were recorded for both human health capacities and animal health
capacities, our analysis used the lower of the two scores. For more information about our
methodology, see appendix I.
42USAID officials told us that beginning with GHSA progress reports for fiscal year 2020,
U.S. officials started to use the second edition of the JEE tool, published in 2018, which
provides greater clarity about the animal health component of GHS. The second edition of
the JEE tool clarifies differences between national capacities for human and animal health
and recommends separate indicator scores for human health capacities and animal health
capacities.
Page 37 GAO-21-359 Global Health Security
Figure 11: Examples of USAID’s and CDC’s Activities to Support Ethiopia’s and Senegal’s National Laboratory Systems
Page 38 GAO-21-359 Global Health Security
USAID’s PREDICT-2 Project Across all 31 indicators, increased scores were most common for one of
While in Senegal, we met with implementing the zoonotic diseases indicators, “Mechanisms for responding to
partners of the U.S. Agency for International infectious and potential zoonotic disease are established and functional,”
Development (USAID) who worked on
PREDICT-2, an activity that involved the
and one of the emergency response operations indicators, “Capacity to
surveillance of zoonotic diseases. Before the activate emergency operations under the emergency response systems.”
project was implemented, Senegal had no Scores for both indicators increased in 11 countries. For example, the
capacity for zoonotic disease surveillance,
according to these officials. 2016 JEE for one country found that the country needed to develop an
This activity was implemented by the integrated national surveillance plan that brought together human and
following partners in Senegal: the Interstate animal health capacities. The GHSA progress reports for this country for
School of Veterinary Science and Medicine of
Dakar, the Senegalese Institute of fiscal years 2018 and 2019 show that the U.S. government contributed to
Agricultural Research, and the Cheikh Anta developing mechanisms for intersectoral collaboration and for timely and
Diop University, in coordination with district
veterinary and public health professionals.
systematic information exchange between the animal and human health
Monkey from Bandia Reserve in Senegal, sectors. The reports for those fiscal years also show that the U.S.
Studied during Surveillance Activities for government contributed to developing training activities in the country to
USAID’s PREDICT-2 Project
increase skills and capacity for managing zoonotic diseases.
Among the 31 indicators, decreased scores were most common for a
national laboratory system indicator, “Specimen referral and transport
system.” The score for this indicator decreased for six countries. For
example, the 2016 JEE for Ethiopia identified as challenges the lack of
linkage between public health and animal health diagnostic laboratory
systems and the absence of mechanisms for sharing specimens between
public health and animal health laboratories. The fiscal year 2018 GHSA
progress report stated that the U.S. government was contributing to
efforts to establish specimen referral guidelines for Ethiopia and provide
Ethiopian officials with technical assistance and training in specimen
transport. (See fig. 12 for examples of specimens in a laboratory at the
Ethiopian Public Health Institute.)
Page 39 GAO-21-359 Global Health Security
Figure 12: Specimen Samples in Laboratory at Ethiopian Public Health Institute
Analysis of Indicator Scores by Our analysis comparing indicator scores in GHSA progress reports for
Country fiscal year 2019 with the baseline scores in 2016 and 2017 found that the
majority of scores for each Phase I country remained stable or increased.
For example, 14 of 24 indicator scores for one country had either
remained stable or increased and eight scores had decreased.
For the country with the largest number of increased indicator scores, 25
of 31 scores increased (about 81 percent). All of this country’s indicator
scores increased for five technical areas: antimicrobial resistance,
zoonotic disease, emergency response operations, linking public health
and security authorities, and medical countermeasures and personnel
deployment.
Regarding the fifth technical area, medical countermeasures and
personnel deployment, the JEE conducted in 2017 for the country found
that it did not have a national plan for the transfer of medical and
deployment resources. The GHSA progress reports for fiscal years 2018
and 2019 indicate that the U.S. government provided assistance to build
the country’s capacities in this technical area by conducting simulation
and tabletop exercises, developing and adopting emergency supply chain
management tools, facilitating training in inventory management, and
supporting the government’s efforts to develop and implement a national
plan and policies for medical countermeasures. According to the reports,
Page 40 GAO-21-359 Global Health Security
this U.S. assistance built capacity for the country to respond to monkey
pox and cholera outbreaks in 2018.
For the country with the highest percentage of increased indicator scores,
23 of 26 scores increased (about 89 percent). At least one score
increased in eight of the 11 technical areas. For example, the scores for
all four indicators for the technical area real-time surveillance increased
from the baseline scores in 2017. According to the GHSA progress report
for fiscal year 2019, U.S. government efforts supported the establishment
of a hospital-associated infections surveillance network specifically for
bloodstream and urinary tract infections. The success of the program led
the government to consider implementing a national surveillance network
for all major hospital-associated infections.
For the country with the largest number and highest percentage of
decreased indicator scores, eight of 24 scores decreased (about 33
percent). 43 USAID headquarters officials stated that this country’s
challenging security environments, as well as other challenges it faces,
made building health security difficult.
Common Challenges to The GHSA progress reports submitted by the interagency GHSA country
Building GHS Capacity in teams for fiscal year 2019 for 16 of the 17 Phase I countries identified
challenges affecting the countries’ efforts to develop GHS capacity. 44 Our
Fiscal Year 2019 Included
analysis of these 16 reports found eight distinct types of challenges.
Weaknesses in Figure 13 shows the eight types of challenges and the numbers of
Government Institutions, progress reports identifying at least one instance of each type.
Resource Constraints, and
Insufficient Human Capital
43According to the GHSA progress report for this country for fiscal year 2018, some
scores that the GHSA country team reported were lower than the JEE scores produced by
external evaluators in 2017. According to the GHSA progress report, the country team
lowered the score on the basis of its understanding of the country’s capacity in each
technical area.
44One GHSA country team did not complete the challenges section of the GHSA progress
report for fiscal year 2019.
Page 41 GAO-21-359 Global Health Security
Figure 13: Types of Challenges Identified in GHSA Progress Reports and Number of
Reports Identifying Each Type, Fiscal Year 2019
The three most common types of challenges identified were weaknesses
in government institutions, resource constraints, and insufficient human
capital. All 16 GHSA progress reports that identified challenges in fiscal
year 2019 cited weaknesses in government institutions, while 15 reports
cited resource constraints and 12 reports cited insufficient human capital.
Weaknesses in government institutions ranged from administrative
hurdles and procedural delays to a lack of planning and political will on
the part of a host government. Resource constraints involved funding
deficiencies stemming from competing government priorities or broader
fiscal concerns. Challenges related to human capital included inadequate
staffing, limited competence, and insufficient training to carry out GHS
activities. The following are examples of these three types of challenges
that the GHSA progress reports identified in fiscal year 2019:
• Weaknesses in government institutions (16 countries). The report
for one country stated that the government was slow to prepare and
sign a decree establishing a national epidemiologic surveillance
network for veterinarians.
• Resource constraints (15 countries). The report for another country
stated that the national budgetary allocation for sustaining
Page 42 GAO-21-359 Global Health Security
surveillance and laboratory activities was insufficient, particularly for
animal health.
• Insufficient human capital (12 countries). The report for a third
country stated that fewer than 10 veterinarians were trained in field
epidemiology despite a country-wide need for an estimated 100
trained veterinarians.
We observed resource constraints in Ethiopia, where local public health
employees showed us damaged facilities at a regional veterinary lab (see
fig. 14). U.S. officials noted that available U.S. funding went to training
staff at the lab rather than making improvements to the facilities. U.S.
officials in Ethiopia also described infrastructure challenges, noting that a
lack of transportation infrastructure and challenging terrain sometimes
made it difficult to transport specimens in remote areas.
Figure 14: Damaged Exterior Door and Exposed Wiring at Bahir Dar Veterinary Lab
in Ethiopia
Several of the reported challenges also involved U.S. government actions
related to funding and personnel. For example, the GHSA progress report
Page 43 GAO-21-359 Global Health Security
for one country stated that an in-country CDC staffing shortage had
limited CDC staff’s ability to provide technical assistance and engage with
health leaders, policy makers, and physician trainees. Officials at USAID
headquarters in Washington, D.C., and at CDC headquarters in Atlanta
indicated that some challenges can be overcome with additional U.S.
government funding, specialized support, or diplomatic efforts. In addition,
USAID headquarters officials noted that they work with overseas field
missions to advocate for changes to policies and practices that adversely
affect USAID’s programs. However, USAID and CDC officials stated that
many other challenges, such as security issues and institutional delays,
remain outside the U.S. government’s control.
For additional examples of the eight types of challenges identified in
GHSA progress reports for fiscal year 2019, see table 6.
Table 6: Examples of Challenges Identified in 16 GHSA Progress Reports for Fiscal Year 2019
Challenge type Selected examples Number of reportsa
Weaknesses in government institutions • Implementation of One Health at the decentralized level was 16
weak.b
• Leadership vacancies led to delays in activities, including those
related to surveillance, laboratory systems, and workforce
development.
Resource constraints • Resources were lacking for training in regional veterinary 15
laboratories.
• Economic contraction and government fiscal problems crippled
public health institutions.
Insufficient human capital • Staff in national antimicrobial resistance reference laboratory 12
faced difficulties in meeting testing standards.
• Animal health surveillance and laboratory human resources
faced shortages.
Coordination problems • Synergy was lacking between GHSA technical partners 9
implementing similar projects.
• Intersectoral coordination was lacking.
Data sharing problems • Absence of data sharing on animal disease outbreaks 6
hampered multisectoral collaboration.
• Because of a strike by the main public health union, no data
would be reported from service delivery points.
Unstable security environments • Political conflict at regional level limited on-site support. 6
• Government response was slow in areas targeted by a militant
group.
Insufficient infrastructure • Unstable electricity had the potential to impede proper 5
functioning of laboratory equipment.
• Persistent lack of internet connection prevented rapid remote
support from experts.
Page 44 GAO-21-359 Global Health Security
Challenge type Selected examples Number of reportsa
Data quality problems • Variation in data quality made use of the data difficult. 3
• Reporting on disease events was limited, not timely, and not
accurate.
Other • Physical relocation of government ministries hindered access 1
to country officials.
Source: GAO analysis of U.S. agencies’ Global Health Security Agenda (GHSA) capacity gains progress reporting (GHSA progress reports). | GAO-21-359
a
For fiscal year 2019, the GHSA progress reports for 16 of the 17 Phase I countries included a
section on challenges. The remaining country’s GHSA progress report did not include this section, so
we omitted that progress report from our analysis of the challenges.
b
One Health is a collaborative, multisectoral, and transdisciplinary approach implemented at the local,
regional, national, and global levels to achieve optimal health outcomes with respect to the
interconnection between people, animals, plants, and their shared environment. USAID’s One Health
Workforce project supports workforce development in universities in Africa and Southeast Asia.
We provided a draft of the sensitive report to USAID, HHS, State, and
Agency Comments DOD for review. USAID’s comments on the sensitive report are reprinted
in appendix III. HHS, State, and DOD provided technical comments,
which we incorporated as appropriate.
In its comments, USAID concurred with our findings and conclusions. In
particular, USAID highlighted that U.S. agencies’ assessments of Phase I
countries’ capacities, as detailed in our report, identified GHS capacities
that USAID and CDC helped to upgrade. USAID also commented that our
report recognized its collaboration with CDC and others to prevent,
detect, and respond to threats of infectious disease at home and abroad.
In addition, USAID noted that its programs support the U.S. GHS Strategy
and include investments in One Health approaches that recognize that
the future well-being of humans, animals, and the environment are
inextricably linked.
We are sending copies of this report to the appropriate congressional
committees and the Administrator of USAID; the Director of CDC; and the
Secretaries of State, Health and Human Services, and Defense. In
addition, the report is available at no charge on the GAO website at
https://www.gao.gov.
Page 45 GAO-21-359 Global Health Security
If you or your staff have any questions about this report, please contact
David Gootnick at (202) 512-3149 or gootnickd@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this report. GAO staff who made key
contributions to this report are listed in appendix IV.
David Gootnick
Director, International Affairs and Trade
Page 46 GAO-21-359 Global Health Security
Appendix I: Objectives, Scope, and
Appendix I: Objectives, Scope, and
Methodology
Methodology
House Report 114-693 contained a provision for us to review the use of
funds provided to promote global health security (GHS) and to address
emerging health threats overseas. This report examines, for the 5 fiscal
years before the onset of the Coronavirus Disease 2019 (COVID-19)
pandemic in December 2019, (1) the status of the U.S. Agency for
International Development’s (USAID) and the Centers for Disease Control
and Prevention’s (CDC) GHS funding and activities and (2) U.S.
agencies’ assessments, at the end of fiscal year 2019, of Global Health
Security Agenda (GHSA) partner countries’ capacities to address
infectious disease threats and of any challenges these countries faced in
building capacity. 1 The scope of our work begins with fiscal year 2015
because it was the first year that both USAID and CDC provided funding
for GHS activities. 2
This report is a public version of a sensitive report that we issued in
February 2021. 3 USAID and CDC deemed some of the information in our
February report to be sensitive, which must be protected from public
disclosure. Therefore, this report omits sensitive information about
capacity scores assigned to specific countries, certain country-specific
examples, names of countries associated with certain other examples,
and some challenges that countries faced. Although the information in
1According to agency officials, U.S. agencies’ activities to strengthen global health
security and their activities to address the GHSA are complementary and constitute a
comprehensive approach to addressing threats from infectious diseases. USAID and CDC
used appropriated funding for GHS to support their internal operating expenses, but the
agencies used the funding primarily to award contracts, grants, or cooperative agreements
to implementing partners to carry out GHS activities overseas. In this report, implementing
partners refers to entities such as nongovernmental organizations and host-country
governments that are awarded U.S. government contracts, grants, or cooperative
agreements to carry out GHS activities overseas. Nongovernmental organizations include
international humanitarian aid organizations, international and local private voluntary
organizations, and other entities. In this report, GHS activities refers to activities or
projects that USAID and CDC officials identified as being related to GHS and the GHSA,
including those funded by USAID and CDC through awards made to implementing
partners.
2USAID used appropriated funding for various GHS-related activities to address infectious
disease threats before fiscal year 2015, according to USAID officials. CDC did not receive
an appropriation for GHS until fiscal year 2015, according to CDC officials.
3GAO, Global Health Security: USAID and CDC Funding, Activities, and Assessments of
Countries’ Capacities to Address Infectious Disease Threats before COVID-19 Onset,
GAO 21-213SU (Washington, D.C.: Feb. 4, 2021).
Page 47 GAO-21-359 Global Health Security
Appendix I: Objectives, Scope, and
Methodology
this report is more limited than that in the sensitive report, this report
addresses the same objectives and uses the same methodology.
To examine the status of USAID’s and CDC’s funding and activities, we
analyzed USAID’s and CDC’s data on funding that they had obligated and
disbursed as of March 31, 2020, for GHS activities from funds
appropriated in fiscal years 2015 through 2019—the most recent data at
the time of our analysis. We used data on awards to the organizations
that implemented these activities—known as implementing partners—to
determine the distribution of funding among USAID and CDC
implementing partners as well as among countries. 4 We also conducted
data testing to check for missing or anomalous data and obvious errors,
reviewed related documentation, and discussed the accuracy and
completeness of USAID’s and CDC’s data with agency officials. We found
the data to be sufficiently reliable for the purpose of describing the status
of GHS funding and activities.
USAID provided us with two sets of funding and activities data,
corresponding to the two funding sources that it used to support GHS
activities: (1) the fiscal year 2015 Global Health Programs appropriation
for Ebola response and preparedness (Ebola appropriation for USAID)
and (2) fiscal years 2015 through 2019 appropriations to the Global
Health Programs account. USAID officials explained that USAID reported
data for the Ebola appropriation for the two funding sources differently
because these data sets represent GHS activities with different time
frames, appropriations, and reporting requirements. With regard to GHS
funding from the Ebola appropriation for USAID, which does not expire,
USAID reported obligations and disbursements categorized by the fiscal
year when it obligated these funds to specific award agreements. With
regard to GHS funding from the Global Health Programs appropriations
account—which, according to agency officials, must be allocated and
obligated within 2 years of appropriation—USAID reported obligations
and disbursements categorized by the fiscal year of appropriation,
regardless of the date of obligation.
CDC reported obligations and disbursements for global health security
activities implemented in fiscal years 2015 through 2019 from the fiscal
year 2015 appropriation to the Department Health and Human Services
for Ebola response and preparedness, which expired at the end of fiscal
4Our analysis of the distribution of funding among USAID and CDC implementing partners
and across countries does not include USAID’s and CDC’s internal operating expenses.
Page 48 GAO-21-359 Global Health Security
Appendix I: Objectives, Scope, and
Methodology
year 2019. CDC categorized these obligations and disbursements by the
fiscal year in which it obligated funds for those activities.
To examine U.S. agencies’ assessments of GHSA partner countries’
capacities to address infectious disease threats, we reviewed (1)
assessments of scores for capacity indicators in 11 technical areas in
reports on GHSA partner country’s progress in building GHS capacity—
which we refer to as GHSA progress reports—in fiscal year 2019, that
interagency teams of U.S. officials in the countries submitted to USAID
and CDC on November 1, 2019, and (2) scores recorded for the same
capacity indicators in the Joint External Evaluations (JEE) completed for
16 of the 17 Phase I countries in calendar years 2016 and 2017.
According to USAID officials, when they began GHSA reporting, there
was only one phase I country without a JEE. Because a JEE had not yet
been conducted for this country as of May 2020, we used baseline scores
from its GHSA self-assessment tool, which U.S. officials provided in their
fiscal year 2017 GHSA progress report for the country. In some cases,
baseline scores may have changed over time on the basis of U.S.
officials’ assessments; however, because of difficulties associated with
identifying the full universe of such changes, we used the original JEE
scores or GHSA self-assessment, as recommended by USAID officials.
We reviewed the indicator scores submitted in the GHSA progress
reports for fiscal year 2019 to assess the GHS capacity of the 17
countries prior to the onset of the COVID-19 pandemic. We also
compared the scores at the end of fiscal year 2019 with the scores in
JEEs and GHSA self-assessment tool from 2016 and 2017 to determine
whether the scores, by both country and technical area, had remained
stable, increased, or decreased. Where scores were recorded for both
animal health and human health capacities, we used the lower of the two
scores in our analysis. When no score was recorded for an indicator
either in 2016 and 2017 or in 2019, we omitted that indicator from our
analysis for the country.
To examine U.S. agencies’ assessments of challenges that partner
countries faced in building capacity, we reviewed challenges identified by
U.S. officials in fiscal year 2019 GHSA progress reports and categorized
the challenges to determine the types that occurred most frequently
Page 49 GAO-21-359 Global Health Security
Appendix I: Objectives, Scope, and
Methodology
across countries. 5 Furthermore, we met with USAID and CDC
headquarters officials to discuss both agencies’ processes for analyzing
the assessed indicator scores and how, if at all, the agencies use the
scores to make decisions on funding and activities.
To address both of our objectives, we analyzed documents related to
USAID’s and CDC’s GHS activities in four countries—Ethiopia, Senegal,
Indonesia, and Vietnam—and interviewed officials in the United States
and those four countries. We selected the four countries, on the basis of
our review of agency-provided GHS funding and activities data and
documents, to reflect activities that accounted for a significant amount of
total GHS funding; the presence of staff from multiple U.S. agencies; and
geographic diversity in and among countries in Africa and Asia, where
USAID and CDC provided GHS assistance. We interviewed USAID and
CDC officials in Washington, D.C., and Atlanta, Georgia, respectively. In
addition, in December 2019, we met with U.S. agency officials,
implementing partner organizations, international organizations, and
government officials in Addis Ababa, Ethiopia, and in Dakar, Senegal. In
Ethiopia and Senegal, we also visited offices, toured facilities, and
observed operations of GHS activities supported by USAID and CDC. In
March 2020, we conducted teleconferences with U.S. agency officials in
Jakarta, Indonesia, and in Hanoi, Vietnam.
The performance audit on which this report is based was conducted from
February 2019 to February 2021 in accordance with generally accepted
government auditing standards. Those standards require that we plan
and perform the audit to obtain sufficient, appropriate evidence to provide
a reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives. We
subsequently worked with USAID and CDC from November 2020 to April
2021 to prepare this version of the original sensitive report for public
release. This public version was also prepared in accordance with
generally accepted government auditing standards.
5Our analysis included challenges identified by U.S. officials in 16 of the 17 Phase I
countries in fiscal years 2015 through 2019. We were unable to include one country in our
analysis, because the GHSA country team did not complete the challenges section of the
GHSA progress report for that country for fiscal year 2019.
Page 50 GAO-21-359 Global Health Security
Appendix II: Implementing Partners That
Appendix II: Implementing Partners That
Received Largest Amounts of Obligated Funds
for GHS
Received Largest Amounts of Obligated
Funds for GHS
Table 7 shows the 10 implementing partners to which the U.S. Agency for
International Development (USAID) and Centers for Disease Control and
Prevention (CDC) had each obligated the largest amounts of funding for
global health security (GHS) activities as of March 31, 2020, from funds
appropriated in fiscal years 2015 through 2019. 1
1USAID provided us with two sets of funding and activities data corresponding to the two
funding sources that it used to support GHS activities: (1) the fiscal year 2015 Global
Health Programs appropriation for Ebola response and preparedness (Ebola appropriation
for USAID) and (2) fiscal years 2015 through 2019 appropriations to the Global Health
Programs account. USAID officials explained that USAID reported data for the two funding
sources differently because these data sets represent GHS activities with different time
frames, appropriations, and reporting requirements. With regard to GHS funding from the
Ebola appropriation for USAID, which does not expire, USAID reported obligations and
disbursements categorized by the fiscal year when these funds were obligated to specific
award agreements. With regard to GHS funding from the Global Health Programs
appropriations account—which, according to agency officials, must be allocated and
obligated within 2 years of appropriation—USAID reported obligations and disbursements
categorized by the fiscal year of appropriation, regardless of the date of obligation. CDC
reported obligations and disbursements for global health security activities implemented in
fiscal years 2015 through 2019 from the fiscal year 2015 appropriation to the Department
of Health and Human Services for Ebola response and preparedness, which expired at
the end of fiscal year 2019. CDC categorized these obligations and disbursements by the
fiscal year in which it obligated funds for those activities.
Page 51 GAO-21-359 Global Health Security
Appendix II: Implementing Partners That
Received Largest Amounts of Obligated Funds
for GHS
Table 7: USAID and CDC Implementing Partners That Received Largest Amounts of Obligated Funds for Global Health
Security from Fiscal Years 2015-2019 Appropriations, by Total Amount Obligated as of March 31, 2020
Implementing partner Amount obligated, in dollars
USAID
Food and Agriculture Organization of the United Nations 168,980,370
University of California, Davis 131,351,316
University of Minnesota 52,202,482
Development Alternatives, Inc. 36,572,512
World Health Organization 30,464,077
Management Sciences for Health, Inc. 28,575,000
ICF Incorporated, LLC 26,290,000
Gavi Alliance 20,000,000
International Federation of Red Cross and Red Crescent Societies 19,014,120
The Johns Hopkins University 18,724,598
CDC
World Health Organization 34,123,072
African Field Epidemiology Network 22,364,910
Task Force for Global Health, Inc. 21,535,767
Association of Public Health Laboratories 13,653,059
Emory University 10,110,069
PATH 9,720,764
Ethiopian Public Health Institute 9,585,017
Infectious Diseases Institute 8,684,322
International Medical Corps 7,653,216
American Society for Microbiology 7,611,439
Source: GAO analysis of U.S. Agency for International Development (USAID) and Centers for Disease Control and Prevention (CDC) funding data. | GAO-21-359
Notes: The 10 implementing partners shown for each agency are those to which, respectively, (1)
USAID obligated the largest total amounts from the fiscal year 2015 Global Health Programs
appropriation for Ebola response and preparedness and fiscal years 2015 through 2019
appropriations to the Global Health Programs and (2) CDC obligated the largest total amounts from
appropriations in fiscal year 2015 for global health security activities in fiscal years 2015 through
2019. USAID and CDC officials informed us that global health security funding awarded to United
Nations organizations, including the Food and Agriculture Organization and World Health
Organization, was separate from the U.S. government’s annual contributions to these organizations.
Page 52 GAO-21-359 Global Health Security
Appendix III: Comments from the U.S.
Appendix III: Comments from the U.S. Agency
for International Development
Agency for International Development
Page 53 GAO-21-359 Global Health Security
Appendix III: Comments from the U.S. Agency
for International Development
Page 54 GAO-21-359 Global Health Security
Appendix III: Comments from the U.S. Agency
for International Development
Page 55 GAO-21-359 Global Health Security
Appendix III: Comments from the U.S. Agency
for International Development
Page 56 GAO-21-359 Global Health Security
Appendix IV: GAO Contact and Staff
Appendix IV: GAO Contact and Staff
Acknowledgments
Acknowledgments
David Gootnick, (202) 512-3149 or GootnickD@gao.gov
GAO Contact
In addition to the contact named above, Joyee Dasgupta (Assistant
Staff Director), Claudia Rodriguez (Analyst-in-Charge), Victoria Lin, Alexander
Acknowledgments Webb, Neil Doherty, Reid Lowe, and Grace Lui made key contributions to
this report. The team benefited from the expert advice and assistance of
Robert Copeland, Alexandra Edwards, and Justin Fisher.
(104663)
Page 57 GAO-21-359 Global Health Security
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