II 116th CONGRESS 1st Session S. 2698 IN THE SENATE OF THE UNITED STATES October 24, 2019 Mr. Markey introduced the following bill; which was read twice and referred to the Committee on Foreign Relations A BILL To establish a United States Global Health Commission and a United States Global Health Attaché Program , and for other purposes.

1. Short title This Act may be cited as the Global Health Coordination and Development Act . 2. Findings; sense of Congress; and purposes (a) Findings Congress makes the following findings: (1) Of all foreign assistance provided by the United States, global health appropriations are second only to security assistance. (2) Several Federal agencies and departments execute global health activities, including the United States Agency for International Development, the Department of Health and Human Services, the Department of Defense, the Department of Agriculture, and the Department of State. (3) Global health assistance provided by the United States supports— (A) activities carried out by numerous private, corporate, and nongovernmental organizations worldwide; and (B) multilateral organizations, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the World Health Organization. (4) The United States provides foreign assistance to achieve national security, commercial, and humanitarian objectives while demonstrating global leadership. (5) All United States funded foreign assistance programs, regardless of the implementing agency, support the objectives referred to in paragraph (4), but the manner in which the programs achieve the objectives varies widely. (6) The approach for global health assistance provided by the United States is largely program-based or disease-based and often does not allow agencies to work across the health system or on issues of greatest concern to the host country. (7) Such an approach hampers long-term stability, diplomacy with key partnerships, and sustainable capacity building. (b) Sense of Congress It is the sense of Congress that— (1) each global health implementing agency should establish a program for the development of a cadre of health advisors who can serve as United States global health attachés; (2) country or regional health teams and health development partners working groups should be established in all countries with significant United States health investments; and (3) all global health activities supported by the United States Government should be implemented in a coordinated manner. (c) Purposes The purposes of this Act are— (1) to establish a governmental framework and national policy, priorities, and goals that ensure interagency coordination for global health assistance with the overall diplomacy, development, and defense efforts of the United States Government; (2) to establish the Senior United States Global Health Advisor and the United States Global Health Commission at the level of the National Security Council to harmonize the global health goals and priorities of the United States and promote interagency coordination for global health assistance with the overall efforts of the United States Government; (3) to establish an Interagency Global Health Committee to implement the Unified Global Health Strategy and develop policies and frameworks to improve coordination and outcomes; and (4) to establish the United States Global Health Attaché Program to field global health attachés as key interlocutors who coordinate the country or regional health team and ensure effective health assessment, planning, integration, and implementation across all agencies in support of the interests of the United States. 3. Definitions In this Act: (1) Chief of mission The term chief of mission has the meaning given such term in section 102 of the Foreign Service Act of 1980 ( 22 U.S.C. 3902 ). (2) Commission The term Commission means the United States Global Health Commission established under section 4. (3) Committee The term Committee means the Interagency Global Health Committee established under section 6. (4) Country or regional health team The term country or regional health team includes employees of global health implementing agencies operating in a country or designated geographic region. (5) Global health activities The term global health activities means activities conducted in coordination with United States and foreign entities, including foreign governments— (A) to improve health care, the provision of public health services, responses to public health emergencies, and global health security; and (B) to strengthen health systems and infrastructure, including the training and education of health workers. (6) Global health implementing agencies The term global health implementing agencies means— (A) the Department of State; (B) the United States Agency for International Development; (C) the Department of Health and Human Services; (D) the Department of Defense; (E) the Department of Agriculture; and (F) the Department of Commerce. (7) Regional The term regional refers to a geographic region as designated by a global health implementing agency. (8) Strategy The term Strategy means the Unified Global Health Strategy formulated under section 5. 4. United States Global Health Commission (a) Establishment Not later than 90 days after the date of the enactment of this Act, the President, working through the National Security Council, shall establish a commission to improve the interagency coordination, stewardship, accountability, outcomes, and impact of global health investment by the United States. (b) Designation The commission established under subsection (a) shall be known as the United States Global Health Commission . (c) Chairperson; advisor The President shall appoint a noncabinet-level senior staff member to the National Security Council to serve as— (1) the Chairperson of the Commission; and (2) the Senior United States Global Health Advisor. (d) Membership (1) In general The Commission shall be composed of— (A) the Chairperson; (B) a commissioners group (referred to in this section as the principal group ); (C) a staff group; and (D) any working group that the principal group determines to be necessary to carry out the duties under this section. (2) Principal group The principal group shall be composed of— (A) 12 voting members, of whom— (i) 1 shall be appointed from each global health implementing agency by the head of the respective agency from among senior officials responsible for global health, emergency assistance, development, or a similar area; (ii) 3 shall be appointed by the President from among individuals from academic or research institutions with expertise in global health policy, foreign relations, or public health emergencies; and (iii) 3 shall be appointed by the President from among individuals from the international development community with expertise in health, community, or economic development; and (B) 2 nonvoting, ex officio members, of whom— (i) 1 shall be the President of the National Academy of Medicine; and (ii) 1 shall be an employee of the Government Accountability Office who shall be appointed by the Comptroller General of the United States. (3) Staff group (A) Composition The staff group described in paragraph (1)(C) shall be composed of representatives of the National Security Council, the global health implementing agencies, the Government Accountability Office, and the National Academy of Medicine, as designated by the head of the respective agency. (B) Function The staff group shall advise, provide subject-matter expertise to, and support the activities of, the Commission. (e) Periods of appointment; vacancies (1) Periods of appointment (A) Governmental officials Each member of the principal group appointed under subsection (d)(2)(A)(i) shall serve at the discretion of the head of the respective agency. (B) Nongovernmental officials Each member of the principal group appointed under clause (ii) or (iii) of subsection (d)(2)(A) shall serve for a period of not fewer than 2 years and not more than 5 years. (2) Vacancies A vacancy in the Commission— (A) shall not affect the powers of the Commission; and (B) shall be filled in the same manner as the original appointment. (f) Meetings (1) In general The Commission shall meet at the call of the Chairperson. (2) Initial meeting Not later than 180 days after the date of the enactment of this Act, the Commission shall hold its initial meeting. (3) Principal group The principal group shall meet not less frequently than twice each year. (4) Staff group The staff group described in subsection (d)(1)(C) shall meet as determined by the Chairperson based on the activities of the Commission. (g) Bylaws (1) In general Not later than 180 days after the date of the enactment of this Act, the Commission shall develop bylaws for the operation of the Commission. (2) Elements The bylaws developed under paragraph (1) shall include— (A) information on the membership of the Commission; (B) the number of annual meetings required for the principal group and the staff group; (C) the decision-making process of the Commission; (D) the process by which disputes are resolved; and (E) such other information and policies as the Commission considers appropriate. (h) Primary responsibilities The Commission shall— (1) develop an integrated, comprehensive global health strategy, in accordance with section 5 and in cooperation with global health implementing agencies, to ensure that global health activities and programs supported by the United States are consistent with the strategic priorities and policies of the United States; (2) recommend methods to improve alignment, coordination, planning, and implementation to ensure the greatest possible impact and overall effectiveness of United States global health efforts and programs; (3) in coordination with the Committee, advise the National Security Council on global health issues that potentially impact the domestic health status, defense operations, development programs, diplomacy efforts, and strategic interests of the United States; (4) advise the Committee on country and regional challenges; (5) based on the priorities of the United States, recommend countries or regions that would greatly benefit from— (A) receiving a global health attaché under section 7; and (B) the establishment of a country or regional health development implementation plan under section 8; (6) recommend agenda items and provide other recommendations and advice to the Committee; and (7) facilitate cooperation between the United States Government and academic and research institutions, civil society, international nongovernmental organizations, and other public and private entities. (i) Reports (1) Initial report Not later than 1 year after the date of the enactment of this Act, the Commission shall submit to the President and Congress an initial report that includes— (A) the bylaws and membership of the Commission; (B) a description of the methodology for the development of the Strategy; and (C) a description of progress made toward developing the Strategy. (2) Biennial report (A) In general Not later than 1 year after the submission of the initial report under paragraph (1), and biennially thereafter, the Commission shall submit to the President and Congress a report on the activities of the Commission during the period covered by the report. (B) Elements Each report submitted under subparagraph (A) shall include— (i) any updates to the Strategy since the submission of the most recent report; (ii) a description of major global health threats of concern to the United States Government; (iii) recommendations for improving alignment, coordination, planning, and implementation to ensure the greatest possible impact and overall effectiveness of United States global health efforts and programs; and (iv) a description of opportunities for future engagement on global health. (j) Personnel matters (1) Senior United States Global Health Advisor Section 5313 of title 5, United States Code, is amended by adding at the end the following: Senior United States Global Health Advisor. . (2) Compensation of members A member of the Commission who is not an officer or employee of the Federal Government shall be compensated at a rate equal to the daily equivalent of the annual rate of basic pay prescribed for level IV of the Executive Schedule under section 5315 of title 5, United States Code, for each day (including travel time) during which the member is engaged in the performance of the duties of the Commission. (3) Travel expenses A member of the Commission shall be allowed travel expenses, including per diem in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5, United States Code, while away from their homes or regular places of business in the performance of services for the Commission. (k) Nonapplicability of FACA The Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the Commission. 5. Unified Global Health Strategy (a) In general Not later than 18 months after the date of the enactment of this Act, the Commission shall formulate an integrated, comprehensive global health strategy, to be known as the Unified Global Health Strategy , that communicates to Federal agencies, nongovernmental organizations, and allied partners of the United States the overall health assistance priorities of the United States. The Strategy shall be— (1) aligned with the National Security Strategy of the United States; and (2) based on— (A) highest-impact, evidence-based outcomes and the mission, strategy, assessment, planning, and guidance documents of each global health implementing agency; and (B) recommendations from the National Security Council on issues that impact national security. (b) Requirements The Strategy shall— (1) describe the overarching, integrated strategic vision for health-related foreign assistance vertically and horizontally across the global health implementing agencies and to implementing partners; (2) establish and communicate the global health goals and priorities of the United States Government for the purpose of improving the coordination, partnerships, and implementation of global health and foreign assistance effectiveness; (3) communicate the role of global health with respect to the overall foreign development goals of the United States; (4) provide consensus on global health efforts across the global health implementing agencies regarding foreign assistance health policy that demonstrates the collective commitment of all interagency partners to transparency, accountability, and a unified approach to maximizing the impact of United States investments; and (5) ensure that the health programs of the United States Government align, to the maximum extent possible, with country and regional health and development priorities to achieve long-term sustainability, security, and stability. (c) Effective date (1) In general The Strategy shall take effect upon approval by the President. (2) Approval by President (A) Sense of Congress It is the sense of Congress that the President should approve the Strategy not later than 90 days after receiving the Strategy from the Commission. (B) Explanation to Congress If the President has not approved the Strategy within 90 days after receiving it from the Commission, the President shall submit to Congress a written statement explaining the reason for the delay and a timeline for approval of the Strategy. (3) Prohibition on delegation The President may not delegate the responsibilities under this subsection. (d) Updates (1) In general The Commission shall update the Strategy not less frequently than once every 5 years. (2) Consideration of country-level plans In updating the Strategy pursuant to paragraph (1), the Commission shall consider the country or regional health development implementation plans developed under section 8. 6. Interagency Global Health Committee (a) In general Not later than 180 days after the date of the enactment of this Act, the President shall establish the Interagency Global Health Committee to implement the Strategy, improve the coordination of global health efforts, and oversee the United States Global Health Attaché Program. (b) Chairperson (1) In general The President shall appoint, by and with the advice and consent of the Senate, the Chairperson of the Committee. (2) Ambassador-at-Large for Global Health The Chairperson shall have the rank of Ambassador-at-Large for Global Health. (3) Responsibilities The Chairperson shall— (A) chair the Committee and ensure that the responsibilities of the Committee are carried out; (B) be impartial with respect to any global health implementing agency; and (C) ensure coordination and synergy of effort in global health programming and policies among the relevant global health implementing agencies. (c) Membership of Committee The Committee shall be composed of— (1) the Chairperson; (2) representatives from each global health implementing agency, who shall be appointed by the head of the applicable agency; and (3) representatives from any other Federal agency, as the Chairperson considers appropriate to implement the Strategy and oversee the United States Global Health Attaché Program. (d) Subcommittees (1) Global Health Attaché Board (A) In general The Committee shall establish a permanent subcommittee, to be known as the Global Health Attaché Board , to advise and oversee the United States Global Health Attaché Program, in accordance with subsection (e)(4) and section 7. (B) Chairperson The Secretary of State shall designate the Chairperson of the Global Health Attaché Board from among employees of the Bureau of Oceans and International Environmental and Scientific Affairs of the Department of State. (2) Subcommittees and working groups The Chairperson of the Committee may establish such other subcommittees and working groups as the Chairperson considers necessary to carry out the responsibilities of the Committee. (e) Responsibilities The Committee shall— (1) develop a 5-year plan of actions and milestones to implement the Unified Global Health Strategy; (2) develop and establish integrated national policies for global health that will guide Federal agencies in development, programming, and implementation of global health efforts; (3) coordinate the global health assistance efforts of the United States Government to ensure greater alignment, programmatic impact, and overall effectiveness; (4) develop, design, and oversee all aspects of the United States Global Health Attaché Program, in accordance with section 7, including with respect to the selection of the countries or regions in which global health attachés will be posted; (5) develop guidance for the country and regional health development implementation plans under section 8; (6) facilitate cooperation between Federal agencies and international counterparts for planning and implementation of global health programs and efforts; and (7) promote Federal interagency coordination and planning across all global health activities, including logistical planning and coordination and the sharing of data and information associated with global health programs, development, and information that may impact investment outcomes. (f) 5-Year plan Not later than 270 days after the date on which the Strategy takes effect, the Committee shall submit to Congress the 5-year plan of actions and milestones developed under subsection (e)(1). (g) Reports (1) Initial report Not later than 18 months after the date of the enactment of this Act, the Committee shall submit to the President and Congress an initial report that includes— (A) the structure, membership, and bylaws of the Committee; (B) a statement of the activities and accomplishments of the Committee since the establishment of the Committee; and (C) an update on the development and implementation of the United States Global Health Attaché Program established under section 7. (2) Biennial report Not less frequently than biennially, the Committee shall submit to Congress through the President a concise report containing— (A) a description of progress on or setbacks or updates to the plan of actions and milestones developed under subsection (e)(1); (B) a statement of the activities and accomplishments of the Committee since the submission of the most recent report; (C) a statement detailing with particularity the recommendations of the Committee with respect to improving coordination, accountability, outcomes, and impact of global health investment by the United States; and (D) an update on the development and implementation of the United States Global Health Attaché Program established under section 7, including post locations for and training of global health attachés, outcome measures, and recommendations to increase the impact of the program. 7. United States Global Health Attaché Program (a) Establishment of Program There is established a United States Global Health Attaché Program (referred to in this section as the Program ). (b) Program management The Secretary of Health and Human Services shall manage the Program under the oversight and direction of the Committee. (c) Global health attachés (1) In general Each global health attaché shall serve on behalf of a chief of mission and the global health implementing agencies to assist in the coordination, strategic planning, and implementation of all global health assistance in the country or region in which the global health attaché is posted. (2) Eligibility An individual is eligible to serve as a global health attaché if the individual— (A) is an employee of the Federal Government, such as a member of the uniformed services or the Foreign Service, or other civilian Federal employee, in a position at, or with promotion potential to, level 15 of the General Schedule (or equivalent); (B) has expertise and experience in public health or global health; (C) has leadership experience within 1 or more of the global health implementing agencies; (D) is a United States citizen; and (E) has a security clearance at the secret level or above. (3) Global health attaché education and training (A) Requirements (i) In general The Committee shall establish requirements for a global health attaché education and training program (referred to in this section as the education and training program ). (ii) Elements The requirements established under clause (i) shall ensure that each global health attaché— (I) receives education and training on— (aa) the strategic planning process of the United States Government; (bb) the role of the global health implementing agencies in foreign assistance, and the organizational structure and global health and development programs of such agencies; (cc) effective communication with foreign and domestic media, including strategic communication; (dd) the impact of international affairs; (ee) the public health issues affecting host countries and regions; and (ff) such other health-related training that the Committee considers necessary to create highly effective global health diplomats; (II) completes the training for Foreign Service officers described in section 708 of the Foreign Service Act of 1980 ( 22 U.S.C. 4028 ), or equivalent training; and (III) meets foreign language proficiency requirements established by the Secretary of State for Foreign Service officers under section 702 of the Foreign Service Act of 1980 ( 22 U.S.C. 4022 ) and receives appropriate language training consistent with such section. (B) Curriculum development The institution described in section 701 of the Foreign Service Act of 1980 ( 22 U.S.C. 4021 ) (commonly known as the Foreign Service Institute ) and the Uniformed Services University of the Health Sciences, in cooperation with appropriate Federal agencies, academic institutions, and other entities, shall— (i) develop a comprehensive curriculum for the education and training program, consistent with the requirements established pursuant to subparagraph (A); and (ii) submit such curriculum to the Committee for approval. (C) Administration The education and training program shall be administered by 1 or more training institutions, as determined by the Committee. (D) Eligibility for participation by other individuals An individual who is not a candidate for the position of global health attaché may participate in some or all of the education and training program if such individual is— (i) a health official of a global health implementing agency; or (ii) an in-country staff member of a global health implementing agency. (4) Credentials The Secretary of State shall— (A) notify the receiving state of each global health attaché posted to such state, in accordance with Article 10 of the Vienna Convention on Diplomatic Relations, done at Vienna April 18, 1961; and (B) provide the appropriate diplomatic credentials to each global health attaché, at the request of the Committee. (5) Postings and accreditations (A) In general Each global health attaché— (i) shall be posted in a country as determined by the Committee; and (ii) may be accredited to 1 or more countries in a region as determined by the Committee. (B) Criteria to establish a global health attaché office The Committee shall make determinations about where to establish global health attachés based on— (i) the strategic interests and priorities of the United States; (ii) large development and humanitarian assistance investments made by the United States; (iii) the strategic importance of health to the security and stability of the country or region; and (iv) such other criteria as the Committee considers appropriate. (6) Responsibilities Each global health attaché shall— (A) serve as the senior health advisor to the diplomatic mission of the United States in the country or region in which the global health attaché is posted; (B) convene and coordinate the country or regional health team on behalf of the chief of mission of the country or region in which the global health attaché is posted; (C) oversee the development of the country or regional health development implementation plan for the country or region in which the global health attaché is posted; (D) represent the United States Government regarding health matters to foreign governments, multilateral and international organizations, and public and private entities; and (E) perform such other duties that align with advancing the global health interests of the United States, as determined by the chief of mission and the Committee. (7) Periodic reports (A) In general Each global health attaché shall periodically submit country or regional updates to regional and headquarters components of the global health implementing agencies, through the chief of mission, as determined by the Committee. (B) Elements Each report submitted under subparagraph (A) shall include a description of any health-related threats or critical concerns that may affect the national security, development efforts, or commercial interests of the United States. (C) Headquarters component defined In this paragraph, the term headquarters component means the senior leadership and policymaking section of a global health implementing agency. (8) Supervision Each global health attaché shall work under the supervision of— (A) the chief of mission of the country in which the global health attaché is posted; and (B) the chiefs of mission of the countries to which the global health attaché is accredited. (9) Employment (A) Salary and benefits The employer of each global health attaché at the time the global health attaché applies for the position of global health attaché shall continue to provide the salary and benefits for the global health attaché. (B) Other expenses The Secretary of State shall provide to each global health attaché— (i) allowances comparable to those provided by the Secretary to Foreign Service officers under sections 5922 through 5924 of title 5, United States Code; (ii) reimbursement for travel and related expenses set forth in section 901 of the Foreign Service Act of 1980 ( 22 U.S.C. 4081 ); and (iii) reimbursement for administrative services consistent with the International Cooperative Administrative Support Services Handbook. (10) Impartiality In carrying out their responsibilities under this section, global health attachés— (A) shall represent the interests and the priorities of the United States Government; and (B) may not show favoritism to any particular Federal agency. 8. Country or regional health development implementation plans (a) In general Each country or regional health team, under the direction of the global health attaché for the country or region, shall develop a country or regional health development implementation plan for the respective country or region. (b) Guidance The Committee shall develop guidance for the country and regional health development implementation plans, including with respect to— (1) the elements of and templates for the plans; and (2) policies and processes relating to plan approval, consultation, and submission. (c) Plan described (1) In general Each country or regional health development implementation plan developed under subsection (a) shall be a country- or regional-level operational plan— (A) for supporting the health goals of the host country or countries; and (B) for ensuring that the national security priorities of the United States are met. (2) Contents Each country or regional health development implementation plan developed under subsection (a) shall include— (A) a comprehensive assessment of the health sector in the applicable country or region, including the strengths and weaknesses of the health system; (B) an analysis of the key funders and stakeholders within the health system; (C) a plan of action with milestones describing how global health activities will be implemented during the period covered by the country or regional health development implementation plan; (D) health links to non-health-related activities, such as military assistance and infrastructure projects; (E) metrics for measuring the impact of the plan; (F) opportunities for increased engagement of the United States and any consequences of failing to increase engagement; (G) a determination of the role of each agency in the execution of the plan; (H) a request for resources needed to ensure— (i) the success of the plan; and (ii) the sustainability of the health sector of the host country; and (I) such other content as the Committee considers appropriate. (3) Objectives Each country health development implementation plan shall— (A) align with and support the Integrated Country Strategy and the Mission Resource Request for the country; and (B) align the President's Emergency Plan for AIDS Relief (commonly known as PEPFAR ) and all other global health plans of the United States Government with the overall goals of the country or region— (i) to mitigate redundancy of resources; and (ii) to improve the impact of efforts. (d) Submission; updates (1) Submission to chief of mission Not later than 270 days after a global health attaché is first posted to a country or region, the global health attaché shall submit a country or regional health development implementation plan developed under subsection (a) to the appropriate chief of mission. (2) Approval; submission to Committee If the chief of mission approves the plan submitted under paragraph (1), the chief of mission shall submit the plan to the Committee. (3) Updates Not less frequently than once every 2 years, the country or regional health team shall update the country or regional health development implementation plan. (e) Health development partners working group (1) In general Not later than 180 days after a global health attaché is first posted to a country or region, the country or regional health team shall establish a health development partners working group in each country or region with a global health attaché to support implementation of country or regional health development implementation plans and to improve synergy with respect to such implementation. (2) Membership Each working group established pursuant to paragraph (1) shall be composed of representatives from— (A) the country or regional health team; (B) civil society partners of the United States; (C) international organizations to which the United States provides funding; (D) the government of each host country; and (E) 1 or more allied partners of the United States, as the chief of mission considers appropriate. (f) Integration of global health activities The country or regional health team in each country or region with a global health attaché shall integrate global health activities within the country or region with other development programs and activities, as appropriate— (1) to advance the interests of the United States; and (2) to create sustainable capacity for the host country or region. 9. Authorization of appropriations There are authorized to be appropriated such sums as may be necessary to carry out this Act.