BLUEPRINT FOR GLOBAL HEALTH RESILIENCE

June 2021

1
Contents
Contents 2

Summary 3

Introduction 4

Vision 5

Building Health Resilience 7

Lesson Learned: Collaboration across all sectors 8
USAID’s Approach Going forward: Improved collaboration throughout USAID 12
Lesson Learned: Integration within USAID’s Global Health programming 16
USAID’s Approach Going Forward: Integration of service platforms 17
Lesson Learned: Whole-of-society partnerships 19
USAID’s Approach Going Forward: Whole-of-Society partnerships for health integrated
with global health security 20
Lesson Learned: Translate information into action 22
USAID’s Approach Going Forward: Harnessing and using country-level data 22
Lesson Learned: Sustainable financing 25
USAID’s Approach Going Forward: Financing health resilience 25
Lesson Learned: Innovation 26
USAID’s Approach Going Forward: Scaling innovations for health resilience 26

2
Summary
As demonstrated by the COVID-19 pandemic, USAID’s global health programs must work together and
within the full scope of development and humanitarian programs across the Agency, to strengthen
global health security and health resilience. Resilience is the ability of individuals, families, communities,
and countries to maintain and improve their well-being in the face of short and long-term shocks and
stressors, and health and well-being are critical to resilience. Integration of health programming along
with sustainable financing, actionable data, innovation, and whole-of-society partnerships will help
ensure the world is better prepared for the next global crisis and enable countries to be self-reliant
when addressing a range of shocks and stressors.

USAID’s Bureau for Global Health defines health resilience as the ability of people, households,
communities, systems, and countries to mitigate, adapt to, and recover from shocks and stresses, in a
manner that reduces acute and chronic vulnerabilities and facilitates equitable health outcomes. The
Bureau brings several comparative advantages to building health resilience. These include:
● Organizational strengths and experience - we have local expert staff in over 80 countries
supported by global leaders in Washington across a full range of global health and development
programming for over five decades, who address a range of development contexts from fragility
to graduation and who have deep experience within communities;
● Operational strengths - we have the ability to partner with a full range of organizations at global,
regional, and local levels and through a variety of partnership modalities from grants and
contracts to direct government awards and engagement with private sector organizations as
well as multilateral bodies; and
● Technical expertise - USAID has developed technical innovations and approaches targeting
individuals, families, communities, and local and national systems, all of which are critical to
building health resilience.

USAID’s Blueprint for Global Health Resilience was developed amid USAID’s whole-of-agency response
to the COVID-19 pandemic. The purpose of this document, developed for USAID and other global health
practitioners, is to document several "lessons learned" from COVID-19 and past outbreaks and other
system shocks that impact healthcare delivery. USAID will draw on our comparative advantages,
promising practices, and past lessons learned to help strengthen global health security and ensure that
the world is more resilient when faced with shocks and stresses such as the next major health challenge.

3
Introduction

Challenges ranging from current COVID-19 pandemic and other disease outbreaks, conflict, and climate
change have threatened recent global health gains and underscore the urgent need to build health
resilience. These events, frequently occurring in tandem, are threats to families, households, and
communities in their respective countries and the United States; they are national security and public
health concerns. Health resilience requires public health services such as community mobilization,
disease surveillance, and water, sanitation, and hygiene services as well as private sector collaboration.
At its root, health resilience is based upon good governance and sufficient financing. Health resilience
presence or absence is most evident during times of shock or crisis (e.g., global COVID-19 pandemic);
still, it is founded on countries’ ability to support health during times of relative stability and deliver
quality healthcare to their citizens. Countries achieve health resilience by promoting care continuity
through an integrated network, including the public sector, the private sector, faith-based organizations,
civil society, local and international non-governmental organizations (NGOs), and communities. Health

4
resilience increases when the entire health sector, together with its partners, operate in a coordinated
and collaborative manner to optimize resources, are shock-responsive, and adapt as necessary to enable
the whole population access to quality health services when and where they are needed.

The U.S. Government’s global health programs, specifically those developed and implemented by USAID,
have contributed to health resilience for more than 50 years. USAID will prioritize its work around a new
strategic vision to build health resilience through integration and alignment of programs and expertise.
The increasing frequency of novel infectious disease outbreaks and other health and non-health-related
healthcare shocks and stressors within low- and middle-income countries will continue to impact the
U.S. population. It is paramount that USAID partner with countries in enhancing health resilience to
minimize future health risks.

Vision
In line with the Agency’s definition of resilience, USAID’s Bureau for Global Health (GH) defines health
resilience as the ability of people, households, communities, systems, and countries to mitigate, adapt
to, and recover from shocks and stresses, in a manner that reduces acute and chronic vulnerabilities and
facilitates equitable health outcomes. This definition recognizes both the role of ensuring quality,
effective coverage of health and other basic social services for all, and the need for USAID programming
itself to be flexible and adaptive to address the complex, context-specific needs of the communities we
serve. USAID and country partners will achieve health resilience not only through public health
standards, community education, social and behavior change, outreach services, and access to
healthcare facilities, but also by working across sectors to address the social and structural determinants

5
of health. Ultimately, health resilience is essential for maintaining high-performing health systems,
which ensure that the health care needed by people and communities is available and accessible, at
sufficient quality to be effective, without causing financial hardship.

Health resilience is a critical component of a country’s self-reliance. The 2019 USAID Policy Framework
calls upon the Agency to partner with host country governments, private sector organizations, and other
donors to achieve locally led and sustained results, help countries mobilize public and private revenues,
strengthen local systems, capacities, and commitment, and accelerate enterprise-driven development.1
Self-reliant countries are resilient and can plan, manage, adapt, and finance their continued
development, even as challenges arise. In health, this means that countries can address and mitigate
health-related challenges, whether from short- or long-term shocks or stressors. These stressors include
epidemics, natural disasters, conflict, climate change, poor governance, discrimination, marginalization,
gender-based violence (GBV), lack of safe water and sanitation, lack of access to sustainable and
nutritiously produced food year-round, limited access to preventive and promotive health interventions,
etc.

Health resilience is built when country-level health institutions and their partners (e.g., government, the
private sector, non-governmental and faith-based organizations, communities, and families) work
together to improve health and respond to day-to-day stressors (such as stockouts of drugs and supplies
or health worker shortages). For example, the ability to maintain essential services during a crisis such as
COVID-19 was facilitated by prior experience in adapting service delivery models to everyday stressors,
including health worker shortages.

This blueprint for health resilience is explicitly inclusive of women and youth, persons with disabilities,
marginalized groups, and the overall community and societal support systems and structures. It
recognizes the need to address gender and other norms and inequalities that contribute to lower
resilience levels and poor health among these groups. The inclusion of all individuals and families
including marginalized groups regardless of socioeconomic status, education level, or political affiliation
is essential to health resilience in a community.

1
United States Agency for International Development, Policy Framework: Ending the Need for
Foreign Assistance, Washington, DC, 2019.

6
Building Health Resilience
USAID has played a vital role in
preventing, preparing for, responding
to, and recovering from a range of
Health Resilience capacities:
shocks, which has provided lessons to
Absorptive capacity: Prevention and coping
inform health resilience efforts. The
global HIV epidemic required the scale measures to avoid permanent, negative impacts
up of health services at the local level. from shocks and stressors and to maintain
The Ebola outbreak in West Africa health system stability.
revealed the health system (Ex. Implementing task-shifting or task sharing to
weaknesses and the need for optimize health workforce to meet priority
integrated health service delivery so needs.)
that local systems could
simultaneously respond to the Ebola Adaptive capacity: The ability to make changes
outbreak while continuing to provide in response to longer-term change. The capacity
essential services. The current COVID-
of the health system to make adjustments while
19 pandemic highlights the
interconnectedness of local and global
improving overall system performance.
health programs and service delivery. (Ex. Leveraging digital solutions during COVID-19
All of these lessons highlight the for training and/or clinical decision support.)
importance of engaging communities
in preparedness, planning, and Transformative capacity: The enabling
implementation to better understand environment for systemic change. The ability to
community dynamics and structural make fundamental change that addresses
inequalities that influence differential underlying vulnerabilities and contextual
impacts of epidemics (e.g., increased dynamics which impact system performance
risk for GBV, greater difficulty
and progress towards health outcomes.
accessing services among lower-
(Ex. Instituting formal arrangements between
income groups and persons with
disabilities, marginalized ethnic and public and private providers to share resources
religious minorities). These (workers, supplies, etc) during times of crisis.)
communities should be represented in
risk communication, community engagement activities, and health services response. Consequently,
diverse stakeholders’ engagement is needed for informing public health responses.

USAID draws upon a vast and increasing network of partners and implementers (e.g., public sector
groups, private entities, NGOs, professional societies, institutions, and faith-based groups). This network
channels funds, provides technical assistance, and galvanizes leadership quickly for immediate action.
Additionally, USAID and its partners strive to build local capacity to transfer program ownership to
regional entities.

7
Lesson Learned: Collaboration across all sectors
The health sector alone cannot build resilience capabilities that enable prevention and response to all
major events that can impact health. Health resilience requires coordination and transition between and
across health, development, and humanitarian programs to ensure they are appropriately aligned and
include handoffs as necessary to build healthy and resilient families, communities, and countries. For
example, as humanitarian interventions drawdown, recovery must align with ongoing or new
development programs. Similarly, ongoing development programs can be scaled up and adapted to
respond to humanitarian crises. Threats to the community, such as gender-based violence, can increase
during crisis or stress and must be addressed across the portfolio; similarly, community engagement and
community action are essential.

Many novel infectious diseases spillover from animal populations to humans due to unsustainable land
and watershed management practices, decreasing biodiversity, economic growth, and other unchecked
increased interactions between people and animals. For example, the COVID-19 epidemic is just the
latest in a series of zoonotic diseases that plague society. Diseases passed from animals to humans are
on the rise as the world continues to see environment-related stressors such as an unprecedented
destruction of wild habitats by human activity. Furthermore, science suggests that degraded habitats
may encourage more rapid evolutionary processes and diversification of diseases, as pathogens spread
easily from nature to livestock and humans. Therefore, prevention, detection, and response require

8
closer alignment between different sectors, including through a one health2 approach that explicitly
recognizes the congruence of animal-human-environment sectors in promoting health. This approach
should go hand in hand with USAID efforts to ensure biodiversity and protect the environment.

USAID has a depth and breadth of in-country presence with the largest field staff of any international
development institution, and an even larger cohort of experienced national staff, who have intimate
knowledge of domestic capacity and limitations. This presence allows us to determine the most optimal,
feasible, viable, and sustainable investments. In addition to global health expertise, USAID also brings a
breadth of knowledge across the international aid portfolio.

○ Humanitarian Assistance: When complex emergencies occur or disaster strikes, USAID’s

humanitarian assistance response through the Bureau for Humanitarian Assistance (BHA), saves
lives by providing immediate life-saving assistance across the areas of food, water, shelter,
health care, and protection services to people who need them most. USAID ensures that the
protection of people in vulnerable and crisis-affected situations is central to its work by
providing life-saving protection activities, applying safe and accountable programming
principles, and promoting age, sex, and social inclusion. Specifically, USAID has made the
prevention and response to GBV a key component of its humanitarian assistance, recognizing
the critical impact this type of violence has on the lives of women and girls in times of crisis and
conflict.3 USAID’s humanitarian efforts empower communities to become more self-reliant by
preparing them for disasters before they strike. Preparing for and responding to the health-
related impacts of crises and major pandemics requires close coordination across the
humanitarian to development nexus and integrating, layering, and sequencing investments as
outlined in the USAID Resilience Policy. Also, through USAID/BHA’s lead federal coordinator role
in the humanitarian assistance space, USAID has a track record of interagency coordination.
USAID draws on the entire government’s expertise to respond to multifaceted events, including
specific responses to large-scale outbreaks and pandemics.

○ Water, Sanitation, and Hygiene (WASH): Sustained access to safely managed drinking water,
handwashing facilities and supplies and safe sanitation in homes, schools, and health facilities
are critical to resilient and healthy lives.4 This public health infrastructure, backed by strong
institutions, leadership, and good governance, and complemented by community-driven
engagement, is the foundation on which health resilience for individuals, families, and
communities is built.

2
USAID defines one health as a collaborative, transdisciplinary approach that recognizes the interdependence
among the health of the environment, wild and domestic animals, and humans to achieve resilient and sustainable
outcomes across complex systems from local to global levels.
3
United States Agency for International Development, The United States Strategy on Women, Peace, and Security
2019, Washington, DC, 2019.
4
United States Agency for International Development, U.S. Government Global Water Strategy, Washington, DC,
2017.

9
 ○ Agriculture and Food Security: Food insecurity has long-term impacts on the ability of families
and communities to be healthy, develop, and prosper. Good nutrition is fundamental to a
country’s development, yet the cost, availability, and access to safe, nutritious food all year
round remains a major constraint to improving diets across the lifecycle, with specific impacts
on infants, young children, and pregnant and lactating women.5 As countries aim to make more
nutritious food available to their populations, there is a need to mitigate against the impacts of
climate change and risks associated with land use changes that can result in wild animal
populations having more interactions with humans or with livestock which increases the chance
that infectious diseases spillover from one species to another. The increasing utilization of meat
based diets and the transportation of foods to urban settings also increases these risks. Creating
explicit linkages between sectors is critical to health resilience. For example, GH participates in
the Agency’s Nutrition, Water and Resilience Leadership Councils, led by the Bureau for
Resilience and Food Security, to elevate these sub-sectors, enhance intra-agency coordination,
and maximize joint efforts.

○ Biodiversity/Environment: Cross-sectoral development approaches drawn from multiple

development sectors beyond health have shown improved development indicators beyond
achievements possible in single-sector projects. Integrated Population-Health-Environment
(PHE) projects have shown that increased access to and involvement of women in conservation
and natural resource management activities positively impacts both families and the
environment. Pressure on environmental and natural resources has been increasing as the
global population moves past seven billion people and a larger percentage of those living in
urban areas. To increase resilience and mitigate this demographic pressure, countries need to
address interconnected development challenges through various productivity, environmental,
economic, and social solutions, including health; infection prevention and control; and voluntary
family planning and reproductive health. .

5
United States Agency for International Development, USAID MULTI-SECTORAL NUTRITION STRATEGY 2014-2025,
Washington, DC, 2014.

10
 ○ Democracy, Governance and Conflict Prevention: The ability to provide health to a population is
a critical factor in citizen perceptions of and trust in their governments and contributes to
country stability.6 Similarly, country fragility, as evidenced by weak governance and the rule of
law, or frequent unrest and political strife, can impede a country's ability to provide needed
health services. Many national political processes, policies, and legislative actions impact
individuals’ and families’ access to healthcare, potentially in unanticipated ways. Communities
can be influential advocates for health and sources of accountability for quality health service
provision. Close coordination between the democracy and governance sector and the health
sector is needed to ensure effective policies and processes that support equitable access to
services that meet the needs of women, youth, persons with disabilities, and other populations
in vulnerable situations7, address issues of stigma, violence, and discrimination, and promote
transparency and openness.8 Including civil society’s voices in resilience policy and program
design processes ensure that programs meet beneficiaries’ needs and encourage citizen
engagement when crises arise. These actions create societal-level conditions necessary for the
early reporting of disease outbreaks and effective government responses. Similarly, many
different global, regional, and multilateral organizations need to collaborate around global
governance for health resilience to address the transboundary nature of many shocks, including
outbreaks and pandemics.

○ Economic Growth: Economic growth is inextricably linked to health resilience9 -- a strong

economy can facilitate a country's ability to absorb shocks or stressors. Strong, equitable

6
United States Agency for International Development, USAID Strategy on Democracy, Human Rights, and
Governance. Washington, DC, 2019.
7
“Suggested Approaches for Integrating Inclusive Development Across the Program Cycle and in Mission
Operations” Additional Help for ADS 201” defines marginalized groups as “People who are typically denied access
to legal protection or social and economic participation and programs (i.e., police protection, political
participation, access to healthcare, education, employment), whether in practice or in principle, for historical,
cultural, political, and/or other contextual reasons. Such groups may include, but are not limited to, women and
girls, persons with disabilities, LGBTI people, displaced persons, migrants, indigenous individuals and communities,
youth, older people, religious minorities, ethnic minorities, people in lower castes, and people of diverse economic
class and political opinions. These groups often suffer from discrimination in the application of laws and policy
and/or access to resources, services, and social protection, and may be subject to persecution, harassment, and/or
violence. They may also be described as “underrepresented,” “at-risk,” or “vulnerable.” ”
8
United States Agency for International Development, Youth, Peace, and Security Act of 2020. Washington, DC,
2020.
9
Hynes, William & Trump, Benjamin & Love, Patrick & Linkov, Igor. (2020). Bouncing forward: a resilience
approach to dealing with COVID-19 and future systemic shocks. Environment Systems and Decisions. 40.
10.1007/s10669-020-09776-x.

11
 economies possess the ability to absorb shocks and mitigate impacts, especially for vulnerable
populations. A healthy workforce that has sustained access to social protections drives
productivity and inclusive growth. The development of a robust domestic financing system
based on transparency and accountability principles is critical for mounting a sustainable, whole-
of-society crisis prevention and response effort. Stable, diversified, and equitable economies
with strong employment allow individuals, families, and communities to respond to possible
economic uncertainties following an unexpected crisis and reduce financial hardship. A diverse
economy and a strong tax base and system also minimize secondary shocks to domestic revenue
generation, which impacts a country’s health budgets. Finally, inclusive growth can be led by
developing a robust private sector that can also provide redundancies and alternative options
for financing and service delivery during crises and disruptions to government systems.

○ Education: The more educated individuals and families are, the more likely they are to be
healthy; research has shown that a mother’s education is the most important correlation for
child health.10 Conversely, when individuals and families are healthier, they are more likely to
access the available education. Schools are an essential place for conveying biological and health
information, thus enabling people to be healthier overall. In the context of pandemic
preparedness and response to other shocks, education, and the accessibility of new information,
improve individuals, families, and communities’ ability to adopt new behaviors to protect their
health. During a pandemic or emergency, new information about changing conditions and
appropriate actions must be quickly disseminated, continually updated, and trusted and
understood by the population.

USAID’s Approach Going forward: Improved collaboration throughout USAID

USAID will strengthen linkages across its entire programming portfolio (e.g., health, development, and
humanitarian assistance). This approach will promote program efficiency and reinforce synergies
between health and economic development, agricultural production and environment, safe housing,
governance, and education, for example. By better, more deliberately, and more comprehensively
linking its humanitarian assistance efforts to its health and other development programming, USAID will
promote program continuity for beneficiaries transitioning from shocks. USAID will use its internal
expertise, leadership, and proven approaches from Humanitarian Assistance and Global Health Security
to leverage health to support an all of USAID strategy for strengthening resilience. The agency will layer
its health efforts with other multi-sectoral activities to reach the people of greatest need and address
the most significant barriers to resilience (fragility, conflict, disasters, illness, inequality between men
and women, violence, including GBV, etc). Health development efforts in coordination with
humanitarian assistance will optimize coverage and support for populations in vulnerable situations.

10
United States Agency for International Development, U.S. Government Strategy on International Basic
Education, Washington, DC, 2019.

12
Collaboration within USAID programs will improve layering and sequencing of health activities to retain
continuity of care as they shift between humanitarian and development settings.

Health development projects will use adaptive management, conflict-sensitive, and complexity-aware
approaches where appropriate. These approaches will improve projects’ flexibility, effectiveness, and
responsiveness and support spanning the humanitarian assistance (HA) and development assistance
(DA) continuum. In line with USAID’s resilience policy, this multi-phased phased approach recognizes
humanitarian principles and “Do No Harm” approaches. Such an approach may include providing
technical assistance in development practices to humanitarian assistance teams; this assistance would
help bridge the transition between HA and DA efforts and vice versa. Technical assistance in
humanitarian practices to GH teams would continue to support work in conflict/post-conflict settings,
disease outbreaks, and recovery from disasters. Health projects will also explore opportunities for
greater cross-sectoral collaboration to be more effective in building country resilience. Health
approaches may need to be designed for the long-term to ensure that resilience-building efforts can be
fully developed, tested, and sustained over periods of crisis and recovery.

13
14
Illustrative Spotlight: GH Linkages with other Sectors

GH enjoys close coordination and collaboration across the agency on Children in Adversity and overall
Gender and Youth programs, which can be leveraged to support cross-sectoral and sustainable
resilience efforts. For example, GH contributes to the U.S. Government Strategy for Advancing
Protection and Care for Children in Adversity (2019-2023) by funding activities that ensure children
survive and thrive. Increasing the capacity of parents to nurture their children requires coordinated,
multisector support. Immunization dates, postnatal visits, well-child clinics, and care service delivery
platforms for childhood illness provide health workers opportunities to interact with parents and
families. Health workers offer coaching on nurturing, responsive caregiving, healthy parenting, and
reducing childhood violence during these interactions. In partnership with the Children in Adversity
team, GH leverages its routine health care and nutrition programs to promote children’s optimal
development and ensure they grow in a safe and protective family environment.

USAID’s nutrition work is informed by over five decades of global leadership and experience
implementing programs worldwide. Delivering good nutrition requires action across health, food, and
social safety net systems, as well as through humanitarian response. To leverage capacity and
influence across these sectors, USAID implements a Multi-Sectoral Nutrition Strategy, 2014-2025,
which emphasizes maternal nutrition, optimal breastfeeding, dietary diversity, nutrition-sensitive
agriculture, hygiene, food safety, and the delivery of nutrition services in routine health care. USAID,
through the Nutrition Leadership Council, actively coordinates across the Bureaus for Humanitarian
Assistance (BHA), Global Health (GH), and Resilience and Food Security (RFS) to strengthen results-
oriented field programming. USAID also provides leadership for the USG-wide Global Nutrition
Coordination Plan. As the lead coordinator for the Feed the Future initiative, USAID is responsible for
achieving the Global Food Security Act’s nutrition priorities and implementing the whole-of-
government Global Food Security Strategy.

USAID’s work on water, sanitation, and hygiene is guided by the Water for the World Act of 2014 and
the US Global Water Strategy of 2017, including an Agency Water and Development Plan. The plan
outlines how the agency will deliver sustainable WASH services, including water security, and achieve
outcomes through cross-sectoral action in health, infrastructure, governance, finance, and natural
resource management, encompassing public and private sector organizations as well as through the
humanitarian response to development continuum. USAID actively coordinates across the Bureaus for
Humanitarian Assistance (BHA), Global Health (GH), and Resilience and Food Security (RFS) to
strengthen results-oriented field programming.

USAID’s cross-sectoral Population-Environment-Development (PED) work recognizes the

interconnectedness between humans and their environment. The work supports programming to
demonstrate multiple development outcomes that arise through integration with other sector
development programs. Recent programmatic evidence points that investments in maternal and child

15
 health, immunization programs, and voluntary family planning (FP) may help increase the ability of
individuals, households, and communities to be more resilient to human and environmental shocks.

Lesson Learned: Integration within USAID’s Global Health programming

As the COVID-19 pandemic demonstrates, major disruptions affect all programs, especially when those
disruptions are ongoing and sustained - maintaining the continuity of essential services requires timely
adaptation and flexibility. When multiple programs adjust to unexpected circumstances, new
opportunities can be identified to find common and more efficient solutions to serve target populations
by providing more than one service or intervention per contact. For example, in areas with civil unrest in
north-eastern Nigeria, integrated malaria and polio campaigns are vital in delivering life-saving
interventions. In Ghana, the Ministry of Health is currently working to incorporate seasonal malaria
chemoprevention campaigns with tuberculosis (TB) and severe malnutrition screening. The disruption of
health campaigns such as child health days due to COVID-19 has created an opportunity to better
integrate across existing campaigns employed to deliver public health services. Expanded use of digital
technologies across programs to provide virtual and telehealth service during lockdowns has created an
opportunity to integrate better and utilize accessible digital health platforms and at scale. The vast
leverage of community health
workers during COVID-19 and their
critical role in maintaining service
delivery showcases the need to
advance coordination and optimize
investments across programs.
Advanced coordination across
health programming to provide a
more integrated response before
shocks and stressors will enable
more rapid and effective responses
in the future.

Integration within USAID’s Global

Health programming draws upon an
immense depth of knowledge that
includes over 50 years of developing
global best practices implemented
at the country level in partnership
with host country counterparts.
USAID's presence on the ground and
close collaboration with national
health systems allow a unique

16
insight into country capacities. It gives USAID the ability to properly assess the root cause of poor health
outcomes and the optimal solutions for addressing issues in collaboration with global, regional, and local
stakeholders. The extensive knowledge of best practices and context provides a framework to advise
and support a broad spectrum of countries and health challenges.

Illustrative Spotlight: Global Health Programmatic collaboration:

USAID's flagship programs in infectious disease through The President’s Emergency Plan for AIDS
Relief (PEPFAR), the President’s Malaria Initiative (PMI), Global Health Security Agenda (GHSA),
tuberculosis (TB), and neglected tropical diseases (NTD) have established firm foundations for
detecting and responding to infectious disease outbreaks and sustaining epidemic control. USAID can
leverage and amplify these programs to address broader infectious disease threats. These
investments have enabled countries to dramatically reduce the time it takes to identify outbreaks
representing public health events of international concern correctly. These programs and other GH
programs have hired and trained healthcare workers, including laboratory and community health care
workers that can be deployed in the event of pandemics. These programs have built supply chains
that will be able to move vaccines rapidly to communities.

Additionally, these infectious disease programs demonstrate various modalities whereby USAID
effectively cooperates in an interagency and international context. For instance, USAID leads PMI and
is a lead implementing agency for PEPFAR. Also, USAID leads the international focus of a national
comprehensive TB strategy, with alternative agencies leading other components.

USAID’s Approach Going Forward: Integration of service platforms

Ensuring the continuity of essential services and the effectiveness of risk communication and community
engagement across the Global Health portfolio requires integrating programs to address common
challenges. The goal is to care for people, not simply care for conditions. Critical to integration will be
the alignment of USAID investments to support country digital health transformation, as called for in
USAID’s Vision for Action in Digital Health 2020-2024.11 As countries develop both commitment and
capacity to be increasingly self-reliant, the continuity of essential services needs to include program
integration for community-level interventions such as campaigns, mobile services, and essential
infection prevention and coordinated support of community health workers. In addition to addressing
health needs (e.g., clinical services, messaging around infection prevention), programming will also
address underlying norms and inequalities that exacerbate the effect of prevention and mitigation
efforts, such as the increased risk for gender-based violence. Improved health outcomes are achieved
when individuals and communities are at the center of all programming.

11
United States Agency for International Development, A Vision for Action in Digital Health 2020-2024,
Washington, DC 2020.

17
○ Individuals - Global Health programs will seek to understand individuals’ needs, desires, and
limitations regarding their health, to enable positive behaviors. This understanding includes
care-seeking preferences and barriers that inhibit care seeking, overall health literacy, and
respect for privacy, accessibility, and security needs. Global Health will design programs and
interventions to serve individuals’ unique needs, including youth, persons with disabilities and
other populations in vulnerable situations.

○ Families - Global Health programs recognize that family systems are critical to their members’
health and will continue to support them. Programs will address access barriers, including when
gender, social norms, and practices influence families’ decision-making and the ability to access
quality care. These efforts will advance social changes and develop alternative means of
accessing quality care and services. Equipping families and individuals to make informed choices
creates a framework for optimizing health outcomes (e.g., nutrition, immunizations, timing
healthy pregnancies, and other critical health decisions.)

○ Communities - Global Health programs will recognize that community structures (e.g., faith
groups, women’s groups, youth associations, organizations of persons with disabilities,
community leaders, civil society, and local governments) are critical to supporting and
protecting their members’ health. Programs will leverage the role that communities play in
supporting and changing norms, allocating health resources, and delivering care. Global Health
will work through community structures to help families and individuals through promotive,
preventive, and curative practices and perspectives. Programs will address the community
barriers that negatively affect equitable and affordable access to prevention, detection, and care
services.

○ Providers - Global Health programs will support strengthened and better-coordinated provider
teams that deliver holistic, patient-centered, dignified care and ensure cohesion across
community and facility points of service delivery. Working with country governments to better
utilize the entire available workforce and ensure payment of salaries across public and private
sectors will build a stronger, more adaptive, and resilient health workforce to respond to
population health needs.

○ Facilities - Global Health programs will explicitly link public and private sector facilities across
different care levels to communities, families, and individuals. These links are created through
the coordinated outreach from facilities into communities and families; community-based
oversight of health facilities and appropriate referral systems are designed to integrate and
coordinate care. Continued scaling up of quality improvement methodologies across the health
system will ensure that the facilities will be places where individuals, families, and healthcare
workers feel safe and secure in seeking and delivering care. These improvements include
strengthening supply chains and last-mile delivery to prevent essential supply and medicine
stockouts; also, the health care system sets clear care delivery expectations.

18
Lesson Learned: Whole-of-society partnerships
A key lesson from the 2014 West Africa Ebola virus outbreak was that countries cannot respond to
pandemics unless they can also respond to day-to-day stressors (which could include antimicrobial
resistance, food-borne illness, and other types of localized infectious disease outbreaks, health worker
strikes, increases of sexual violence, or simply uneven performance on key preventive interventions,
such as immunizations across different geographic regions). Over the past 50 years, the functions
traditionally assigned to public health agencies such as environmental sanitation, control of infectious
diseases, and hygiene have gradually expanded. These new operations are health promotion,
management of noncommunicable diseases, and access to primary care. The increased scope led to
overlap between the health care sector (e.g., nutrition, maternal and child health, and screening
programs) with other government sectors and society (environment, agriculture, education, industry,
urban planning, and urban health). Pursuing collaborative efforts between public health and healthcare
institutions (whether public or private) can transform the health system.

High performing health care12 not only reflects robust partnerships across society but also enables
countries to sustain efforts across global health programming and expand integrated service delivery for
client-focused care and population-level impact. Strong and resilient country health systems which
reflect linkages and partnerships across public, private and non-governmental sectors that serve to meet
everyday needs can also be effectively mobilized during crises. Such partnerships also align efforts
across health service delivery and public health capacities and reflect important country-level
multisectoral linkages.

USAID’s work in health system strengthening (HSS) is foundational to program-specific global health
activities. Cross-cutting HSS activities support the achievement of all USAID’s global health goals by
addressing common challenges that would be out of the purview of any one program to handle alone.
Activities encompass cross-cutting actions from the national level health system to community health
systems and complement and contribute to core public health functions. HSS efforts support the
development of robust, integrated, and viable financial protection systems. Also, HSS supports the
information systems required for effective surveillance and reporting. HSS efforts work to ensure that
information on data and reporting can be combined with data on workforce location and skills to help
inform optimal workforce allocation and reconfigurations during emergency periods. Thus these efforts,
in turn, support the capacity of countries to hire, retain, and (re)deploy all cadres of health workers and
help to ensure the supplies and funding are allocated where needed and when required, including to
critical public health functions.

USAID HSS efforts are designed to build mechanisms for collaboration and linkages at and between
every level of healthcare, including through referral and cross-referral for healthcare and other
protection services and multi-sectoral collaboration that advances important health, social, and

12
United States Agency for International Development. Access to Universal Health Coverage through High
Performing Health Care. Washington, DC 2019

19
economic outcomes. Activities prioritize the transfer of capacities to local partners and emphasize the
need to ensure effective behaviors by clients, providers, managers, and other stakeholders so that all
are empowered and capable of identifying and addressing challenges as they occur.

Illustrative Spotlight: Support for supply chain platforms:

Health services cannot be sustained without the availability of essential health commodities. USAID
can leverage its robust global health commodities supply chain and long-standing support for
strengthening countries’ supply chains for emerging pandemic threats (e.g., COVID-19). End-to-end
supply chain data visibility is a crucial area of priority and programming in USAID’s portfolio. It is
integral to support the range of essential services across the global health portfolio and those that
emerge. Current forecasting, quantification methodologies, and tools serving other programs can be
built upon and adapted to address commodity needs for emerging pandemic threats (supply and
demand are intertwined). Existing country warehousing and distribution systems must accommodate
a wide range of health commodities. Supply chain resiliency is paramount to overall health resiliency.
Strengthened country regulatory systems is another crucial component that ensures the quality,
safety, and efficacy of products in the supply chain and product-related services (e.g., pharmacy
practices that promote appropriate use and protect against the threat of antimicrobial resistance.)

USAID’s Approach Going Forward: Whole-of-Society partnerships for health integrated with
global health security

Strengthening the intersections between public health and health service delivery is more critical than
ever based on the global experience with the COVID-19 pandemic. Areas of clear overlap include:
strengthening community health platforms to facilitate community-centered program design;
integrating community perspectives into national health dialogues; decentralizing decision-making
processes and authority over critical resources to facilitate locally-led coordination, planning and
implementation; exploring alternative delivery options to mitigate health risks (e.g. social distancing);
exploring alternative and innovative delivery models leveraging digital solutions to improve accessibility,
including those articulated in the USAID Digital Strategy 2020-2024 and A Vision for Action in Digital
Health 2020-202413; strengthening predictive and early warning capabilities, for early identification of
outbreaks; establishing processes for resource tracking and audit efforts, including for emergency and
redeployment of supplies; promoting financial sustainability approaches; and addressing regulations and
policy barriers that limit rapid access to affordable essential health care.

Global Health Security significantly contributes to health resilience worldwide by establishing standards,
training, laboratories and surveillance. Implementation of GHS is further strengthened by stable and
effective public health and health care delivery. USAID’s HSS activities support and complement GHS by
deliberately including work at the intersection of public health and health services. Going forward, these

13
United States Agency for International Development, Digital Strategy 2020-2024, Washington, DC
2020; A Vision for Action in Digital Health 2020-2024, Washington, DC, 2020.

20
activities will consist of comprehensive support for developing, financing, and implementing the laws,
policies, and regulations critical to achieving progress. USAID will strengthen public health system
infrastructure and health financing systems to optimize resources, public health operations, and health
care in all communities. USAID will continue to support community engagement and participation, to
prevent, detect, and respond to public health threats affecting their members. USAID will focus on
stronger community health systems that integrate public, private, non-profit, and faith-based
organizations to address collective challenges. USAID will ensure that community-level partner voices
are central to decision-making, monitoring, management, and accountability processes.

Health resilience is necessary to mitigate against country and global shocks and stressors (both health
and non-health). A prerequisite for health resilience is accessible primary health care. Effective
collaboration between public health and primary health care (whether delivered by the public, faith-
based, NGO, or private sector) also emerges as an essential area for ensuring the sustainability and high-
performance of a health system. GH programs will continue to recognize that a variety of administrative
structures and professional organizations help coordinate care in many countries. In addition, these
entities have important roles to play in ensuring public health and executing public health functions.

Critical public health functions are often in the governments’ purview but require partnerships across
society. Some outcomes of these partnerships include the establishment and enforcement of standards
and regulations for drinking water and sanitation; food and food safety; allocation and distribution of
resources; development and dissemination of technical and clinical guidance; human resource
management; surveillance and preparedness; risk communication; public health research; and
subnational and regional coordination and adherence to International Health Regulations (2005). GH
programs will advise and support governments, private and non-profit organizations, and communities

21
to promote an integrated approach to caring for individuals, communities, health systems, and the
global health security agenda.

Lesson Learned: Translate information into action

Robust information is critical for developing health resilience. Digital and data systems can provide
accurate, timely, and validated data to inform critical public health decisions. Reliable data resources
enable decision-makers to respond to on-going health concerns in a population, identify appropriate use
of personnel and resources, and recognize new infectious disease threats to support prevention,
mitigation of risk, and efficient service provision in crisis times. Consistent and compelling data-driven
responses rely heavily on people to collect, validate, and use data for evidence-based decision-making
processes. This process creates and enables a continuous flow of information between patients, care
providers, communities, and governments to fortify the health system and encourage all stakeholders to
engage consistently. Leveraging innovative and appropriate technologies also supports accountability
and stakeholder engagement while improving data collection, quality, access, and use.

USAID’s Approach Going Forward: Harnessing and using country-level data

USAID global health programs recognize that building resilience and sustainability, especially in the
context of COVID-19 and future or unforeseen threats, will require access and act upon robust data
through population-based demographic and health surveys and censuses, digital health systems, and
logistics management information systems. Such systems (e.g., encapsulating commodity, demographic,
living condition, other contexts, and patient data) will enable countries and health systems to make

22
data-driven decisions regarding providing optimal care to individuals and families while protecting and
ensuring their privacy. High-quality, actionable data will also support programming at the community or
population level to identify access or outcome disparities. Secure data and digital systems have the
potential to improve the targeting of interventions to specific needs based on health literacy and health,
social, and economic conditions. Secure systems will also transparently provide de-identified
information to international program managers and donors like USAID to effectively partner with
countries to optimize program approaches while safeguarding against manipulation by malign state and
non-state actors.

○ Invest in digital infrastructure: To improve the data, communications, and flexible service
delivery that are critical to building resilience, USAID will make investments in health data and
digital infrastructure at the country level, including to support good governance, legal and
commercial policy frameworks, and regulations; build capacity among country institutions and
workforce; strengthen digital health strategies, application and analysis, and routine and crisis
health responses. A comprehensive and systems-level approach supports sustainable and
flexible digital health systems capable of responding to the health system’s ongoing and
emergency needs. Significant investments in a country's digital health architecture are required
to have the ability to assess, contact, and remotely train the health workforce; to track and
address interruptions in key service delivery statistics; to rapidly identify disease outbreaks and
have response structures in place; and to quickly re-optimize supply chains. Well planned, long-
term integrated investments enable interoperability and digitization at the systems-level. Digital
health tools enabled by widespread access, reliable infrastructure, national digital health
strategies, and architectures maximize sustainability and scalability of independent digital
solutions and build country resilience to future health shocks.

○ Develop and maintain accurate information on a population: Demographic and health surveys
and censuses that capture population based data about household context and access to health
services complement data from health information systems to create a comprehensive view of
epidemiology and programmatic opportunities.

○ Incorporate metrics for program management: USAID will continue to collaborate with partners
and countries to incorporate robust monitoring and evaluation approaches into its

23
programming. It has vast experience providing technical assistance for building in-country
monitoring and evaluation capacity, data literacy, third party monitoring, and adaptive
management for decision-making.

24
Lesson Learned: Sustainable financing
Financial planning, preparation, and execution at the national and international levels should recognize
that shocks and stressors are not an anomaly but are perennial development features. National plans
and strategies must include clear priorities with distinct, actionable local and regional activities in the
case of a crisis. Increased attention and funding needs to be provided for vulnerable or low resource
locations/populations in advance of a crisis to improve health outcomes and improve equitable access
to interventions. Stable and effective health financing systems are based on a strong partnership
between the public and private sectors and their communities. The ability to expand budgetary
resources, reprogram existing public funds, and quickly mobilize private sector funding can assure
disaster funds are available in a crisis.

USAID’s Approach Going Forward: Financing health resilience

Building health resilience and sustainability for individuals, families, and communities requires a
continuum of health financing efforts. These efforts promote households’ financial risk protection and
improve access to working capital to meet health systems’ critical financing needs. These efforts
prevent, prepare for and respond to pandemics by de-risking health systems investments, mobilizing
public and private resources, and ensuring patients have ongoing access to health services with
minimized risk of financial hardship. Creating financial sustainability and resilience requires improving
the execution of existing funds, ensuring the use of funds produce maximum impact through employing
high-impact practices, and identifying innovative ways to mobilize sustainable financing. Sustainable
financing comes from a range of public, private, and international sources. It also addresses or corrects
market failures and inefficiencies within the health marketplace of products, approaches, and care
mechanisms.

Health financing capabilities: USAID has a strong technical capacity in public and private sector
financing, including designing and implementing financial protection mechanisms, advising on improving
health budget processes, tracking how resources are allocated and spent, strengthening relationships
between country government health and finance officials, and identifying opportunities for sustainable
blended financing models. USAID enjoys productive partnerships across sectors, such as between global
health and economic growth, both at headquarters and in the field, which allows for consistency of
approach to overall country financing for self-reliance. USAID also enjoys strong partnerships with other
development organizations that work on health finance, ensuring conceptual and technical alignment on
strategies and objectives. Further, USAID has broad, innovative financing capabilities and partnerships
with the Development Finance Corporation (DFC) and other leading financial institutions that can help
mobilize new private-sector resources and invest in resilience. For example, USAID is partnering with the
DFC to expand loan guarantees for working capital to private COVID-19 frontline healthcare providers’
USAID is also exploring partnering with the DFC to strengthen supply chains and invest in the scale-up of

25
local manufacturing for PPE, vaccines, treatments, and diagnostics. Investments made for COVID-19 will
help build local partners’ and supply chains’ capacities against future shocks.

Lesson Learned: Innovation

In the face of unexpected shocks, innovation and adaptation are critical to confronting radically new
challenges. Existing tools and approaches may be ineffective or too expensive to address the many far-
reaching, multifaceted consequences; a resilient response requires adaptations and new ideas that
address health, economic and supply chain barriers, can work in crises, and be scaled quickly.
Nationwide lockdowns, limited health care commodities, and many other disruptions require novel
approaches to delivering health care, safeguarding health care workers, and overcoming transportation
and communication hurdles. In addition, pandemic shocks often create a critical need for new
biomedical discoveries as partner countries need outbreak-specific diagnostics, vaccines and treatments
that are appropriate for low- and middle-income country settings. Ensuring efficient scale up and
distribution of these novel products requires careful planning, coordination, financing options,
marketing and training. Innovations can be crucial to saving lives, supporting the most vulnerable, and
securing the world’s collective health and well-being.

Across multiple health areas, USAID has successfully leveraged a range of tools to support innovation
and enable adoption of new approaches. Also, USAID has successfully launched open innovation
competitions in the face of shocks. Grand Challenges for Development (GCDs) have often proven
catalytic, enabling innovators to build sustainable business models, “crowd in” external funds, and
expand to new countries and markets. Innovations that provide a cost-effective response to a significant
health problem can offer a high return on the USG development investment. USAID’s investments in just
four innovations (not limited to GCDs) generated an estimated $86 million in social benefits, suggesting
a high social rate of return. To improve readiness to scale up successful innovation, USAID also has the
capacity to help connect innovators, investors, and country stakeholders.

USAID’s Approach Going Forward: Scaling innovations for health resilience

Partner to scale: USAID has robust partnerships with the private sector, faith-based organizations, and
civil society as well as with partner country governments. These partnerships facilitate the rapid
adoption of appropriate innovations in the face of a pandemic or other shock and enhance health
resilience. Today, thousands of innovators worldwide are responding to the current COVID-19 crisis by
launching new businesses, pivoting existing business models, developing new products or services and
stabilizing networks of quality health care. Yet many of the innovations used to adapt to the new needs
posed by COVID-19 were developed years ago with investments in research, development, testing, and
scaling. USAID originally funded many innovators, some receiving a USAID grant for the first time, for
other purposes, such as addressing maternal and child health needs or the Ebola outbreak. As a result of
that original funding, these innovators already had trained staff, ongoing operations, and critical
experience providing health services in LMICs equipping them to pivot operations, tools and approaches

26
at the start of the COVID-19 crisis. Innovators have been able to build on catalytic funding from USAID to
develop dual market business models that meet demand in high income countries as well as low and
middle income countries.

The USAID partnership with innovators, investors, countries and partners supports scaling of responses
and enhances long-term sustainability for countries, health interventions, and businesses. In addition,
USAID’s convening power has enabled nontraditional partnerships with the private sector, where
innovators can partner with established multinational companies to expand manufacturing capabilities
and obtain funding from private investors to scale without a dependence on grant funding. Innovations
and their successful development and deployment support countries become more self-reliant and are
an essential component of USAID’s contributions to global public health, data and analytics, health
systems and community strengthening to build health resilience.

27