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US-Based Advocacy Organizations Share Priorities on Pandemic Preparedness

November 22, 2022

Eric Meyer
Deputy Assistant Secretary of the Treasury for Africa and the Middle East
United States Department of Treasury

Mary Beth Goodman
Coordinator for Global COVID Response and Health Security
United States Department of State

Dear Mr. Meyer and Ms. Goodman,

As US-based organizations with decades of experience working on pandemic responses and preparedness, we write regarding the future of the The Pandemic Fund for pandemic preparedness and response (PPR). Our aim is to ensure that the Fund supports programs with the greatest potential to strengthen PPR, is optimally effective and accountable for results, and recognizes the critical role of country voices and community actors in protecting against future pandemics.

We wrote earlier regarding the Pandemic Fund’s governance and the range of entities eligible for funding. We deeply appreciate the role the Biden Administration played in ensuring the inclusion of low- and middle-income countries and civil society in the Pandemic Fund’s governance and in expanding the definition of eligible funding recipients to include existing global health initiatives that are already contributing to PPR, including Gavi and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Now that the basic ground rules for Fund governance have been set, we know you agree that it is essential that the Fund deliver on its mandate. The Fund will be able to do so only if it fully reflects the substantial lessons learned in the global health field over the past quarter-century about what works and what doesn’t in responding to pandemics.1 In particular, the successful response to HIV, the ongoing global pandemic that was, in many regions, on its way to control in the years preceding COVID-19, has conclusively demonstrated the transformative value of international solidarity, shared ownership, community engagement and leadership, transparency and accountability for results, and responses grounded in principles of human rights and gender equality.

We believe that the Fund will only be successful and worthy of additional funding if and when it has approved and implemented an allocation framework and modalities aligned to these best practices. Decades of evidence shows that the details of funding modalities and governance can be the deciding factors between high-impact, equitable investments, and harmful missed opportunities.

To ensure that Fund lives up to its promise and optimizes its impact in preparing for the next pandemic, we make the following recommendations and urge the Administration to leverage its influence to translate these into the Pandemic Fund’s operating rules, practices and principles:

1. Fund funding should prioritize strengthening the PPR capacities of countries and communities. The Fund has identified three priorities for funding: strengthening country-level PPR capacity; building regional and global capacity; and technical assistance, analytics and convening. Recent experience with COVID-19 underscores how profound and well-documented health and community system capacity gaps undermine pandemic responses and resilience in many low- and middle-income countries, impeding a genuinely global response to a global challenge. We recommend allocations to the three major areas of investment are roughly 70% to building country capacity; 20% to regional and global priorities; and 10% to technical support, analysis and convening (with country or regional experts or entities, such as Africa CDC, prioritized for funding for the provision of technical assistance). To build essential PPR capacities, the Fund should:

  • Prioritize proposals to strengthen primary health care, in order to build robust health delivery systems that can address current health priorities as well as future problems that will arise in the event of a pandemic or other emergency;
  • Prioritize proposals that advance progress towards World Health Organization thresholds for each cadre of health workers, with specific attention to increasing the number of community health workers and nurses and addressing gaps in remote settings; and
  • Avoid projectized or siloed PPR investments, and prioritize the implementing entities that are best positioned to integrate PPR investments into existing primary health care delivery systems and build on and leverage existing investments in HIV, tuberculosis, malaria, and COVID-19.

2. Fund modalities must reflect lessons learned from what works in global health. To maximize the likelihood that Fund support will catalyze country-owned and -driven programming that is tailored to specific national needs and informed by the input of affected communities, the upcoming Call for Proposals should:

  • Explicitly prioritize funding through entities that use proven models for inclusive, country-led planning that are transparent and that engage and are accountable to diverse stakeholders, including communities and civil society. Implementing entities that cannot demonstrate inclusive community design and monitoring should not be eligible for country-level investments;
  • Allow for aggregate, multi-country proposals from entities that meet these planning and engagement requirements;
  • Prioritize predictable multi-year funding, as opposed to short-term projects or pilots; and
  • Allow Pandemic Fund support for implementing entities to run through their existing operational models. Avoid requirements and processes onerous to implementing countries by working directly with such partners as the Global Fund, Gavi and Africa CDC to shape reporting requirements, fiduciary systems and other operating requirements.

3. Programs and other activities supported through the Fund must respect and promote human rights. Pandemic responses can replicate and often worsen underlying inequities and human rights abuses with especially dire consequences for marginalized populations. This was evident during COVID-19, which was associated with a surge in gender-based violence2 and in human rights violations against the most vulnerable groups.3 The Fund must ensure – both in the language of its Call for Proposals and in its monitoring and accountability – that all services funded through the Fund are human rights-based, including priority attention to the needs of the most vulnerable populations, including ensuring comprehensive access to health, legal, and social services as essential services during periods of pandemic restriction. A holistic approach to pandemic preparedness would address racial, social, gender and economic inequalities that both drive, and perpetuate, pandemics.

4. The Fund must be fully transparent in its decision-making and funding. Transparency is essential for building trust in the Fund and for providing meaningful information to potential applicants of the criteria and processes the Fund is using to make awards. The Fund should publish online all proposals submitted, the outcome of technical reviews, approved grant agreements, outcomes monitoring, and financial disbursements to implementers.

5. The Fund must demonstrate a robust commitment to accountability for results. In part through the leadership of the U.S. Government, the HIV response has pioneered cutting-edge procedures for accountability in global health funding and practice, with ongoing and transparent monitoring of progress towards agreed targets, outcomes and policy and programmatic milestones. Drawing from these HIV-related lessons, each Fund grant should outline how the activities it supports will advance PPR and delineate time-bound targets. The Fund should mandate regular, verifiable reporting on results and make monitoring data available online in an easy-to-understand format that is accessible to diverse stakeholders.

6. The Fund must require meaningful engagement of civil society and communities in proposal development, selection of program implementing entity/entities, and program oversight. PPR is only effective when civil society and communities are meaningfully included. The Pandemic Fund must build on existing best practices and ensure that the board rejects any proposal that does not meet minimum standards for civil society participation.

7. The Fund must have a plan, and verification processes, to ensure its funding is additional. We appreciate the Fund’s stated commitment to additionality in its mobilization of resources, but this commitment now needs to be meaningfully operationalized. In collaboration with key global health partners, including but not limited to Gavi and the Global Fund, the Fund must develop transparent metrics for measuring and reporting on additionality. Donors who are found by transparent monitoring to have violated the additionality principle should be disqualified from participating on the Fund board.

The Fund has the potential to be an important vehicle for building the world’s PPR capacity. Realizing this potential requires that the Fund take on board the lessons learned about the most effective ways to prevent and respond to existing and future pandemics. Capacity to meet the needs of local affected communities and caregivers is paramount. We urge the Biden Administration to leverage its influence to ensure that the Fund lives up to its promise and that no country or community is left behind in our efforts to prepare the world for future health crises.

Sincerely,

AVAC
Friends of the Global Fund to Fight AIDS, TB, and Malaria
Health GAP
ONE Campaign
RESULTS
Elizabeth Glaser Pediatric AIDS Foundation
PrEP4All

CC: Antony Blinken, Secretary of State
Janet Yellen, Secretary of the Treasury
Xavier Becerra, Secretary of Health and Human Services
Jake Sullivan, National Security Advisor, National Security Council
Loyce Pace, Assistant Secretary for Global Affairs, Health and Human Services
Beth Cameron, Senior Advisor for Global Health Security, USAID

1 Kates J, Michaud J, Isbell M. Civil Society inclusion in a New Financial Intermediary Fund: Lessons from Current Multilateral Initiatives. June 2022. Washington D.C: Henry J. Kaiser Family Foundation.
2 UN Women. Measuring the Shadow Pandemic: Violence Against Women During COVID-19. 2021. New York: UN Women.
3 UNAIDS. Rights in a Pandemic: Lockdowns, rights and lessons from HIV in the early response to COVID-19. Geneva: Joint United Nations Program on HIV/AIDS.