Introduction
Within the wake of COVID-19, the world has a brand new international well being, multilateral financing mechanism often known as the Pandemic Fund. Based mostly on the World Financial institution, and formally launched in November 2022, it’s the first mechanism with the precise function of offering sustained financing to assist nations construct their capability to stop, put together for, and reply to epidemics and pandemics. Whereas there had been discussions for years about rising the quantity of multilateral financing (i.e., donor funding channeled by way of an intergovernmental entity) directed to pandemic preparedness, it wasn’t till COVID-19 that policymakers and donors have been spurred into motion to create a proper mechanism for this function. The U.S. authorities has been a key champion of the Pandemic Fund since President Biden got here into workplace in 2021 and the U.S. has offered extra funding than every other donor up so far.
Given how nascent the fund is, there are nonetheless many unknowns and unanswered questions on how it is going to be carried out, the scope and period of its work, and the way it matches into the broader set of world well being efforts. To assist make clear these matters, this transient opinions the evolution and institution of the Pandemic Fund, describes the Fund’s governance and operations, and discusses key points and challenges for the Fund – significantly associated to U.S. engagement – because it continues to make its transition from idea to implementation.
Historical past and Growth
There have lengthy been requires elevated international cooperation and extra worldwide funding for constructing pandemic preparedness and response (PPR) capabilities worldwide. In 2005, World Well being Group (WHO) member states agreed to a revised algorithm for prevention of and response to worldwide well being crises, often known as the Worldwide Well being Rules (IHRs) and, amongst different issues, dedicated to construct up core capacities for PPR. Nevertheless, progress towards assembly established capability benchmarks was sluggish and led to efforts to direct extra consideration and funding to PPR, such because the institution of the International Well being Safety Agenda in early 2014, simply earlier than the emergence of the most important Ebola outbreak in historical past. In consequence, quite a few professional commissions, panels, and worldwide establishments pointed once more to vital weaknesses in international PPR capabilities and beneficial higher worldwide coordination and elevated funding. Whereas a couple of incremental modifications have been enacted post-Ebola, it was clear that main gaps in PPR capabilities worldwide remained and funding was restricted in comparison with estimated want. Even earlier than COVID-19 emerged, some specialists have been already calling for elevated multilateral funding for PPR together with by way of multilateral growth banks just like the World Financial institution.
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When COVID-19 precipitated a worldwide disaster beginning in 2020, broader curiosity in multilateral PPR funding was re-ignited. Stories from excessive stage worldwide panels and professional commissions such because the G20 Joint Process Pressure and the Impartial Panel for Pandemic Preparedness and Response beneficial elevated funding and utilizing multilateral growth banks to channel further help for PPR. Endorsements and help for the concept of a “monetary middleman fund” (FIF) for PPR got here from the Biden White Home, the WHO Director-Normal, the European Union, and lots of different policymakers, organizations, and specialists. In April 2022, G20 finance ministers agreed to determine such a fund and in June 2022, the World Financial institution accredited the creation of a “monetary middleman fund for pandemic preparedness and response (FIF).” The FIF was formally established in September 2022, and formally launched because the renamed “Pandemic Fund” in November 2022 (see Field 1 for a fuller timeline of occasions within the growth of the Pandemic Fund).
The choice to accommodate the Fund on the World Financial institution mirrored the Financial institution’s position in internet hosting related mechanisms. Whereas the Pandemic Fund is the primary FIF centered on PPR particularly, there are at the very least two dozen different FIFs hosted by the World Financial institution, together with a lot of different international health-focused FIFs such because the Coalition for Epidemic Preparedness Improvements (CEPI), the International Fund to Struggle HIV/AIDS, Tuberculosis and Malaria, and the International Finance Facility for Ladies, Youngsters and Adolescents. Every FIF has its personal distinctive guidelines and approaches to governance, financing, implementation, funding quantities, and different traits.
Mission, Governance, and Operations
The Fund has solely lately been formally launched, and particulars of how it’s ruled and the way it operates have needed to be crafted over a comparatively compressed time interval. Stakeholders together with donors, beneficiary governments, worldwide companies such because the WHO and World Financial institution, and civil society teams have all helped form these particulars since mid-2022, and a few facets proceed to evolve because the Fund strikes additional into its implementation section. A number of paperwork have been launched by the World Financial institution and the Fund to explain the way it works, together with: a Board paper on establishing the Fund, a Governance Framework, and an Operations Guide. The Fund additionally launched its first Name for Proposals, which outlines in additional element the method for submission, overview, and distribution of funding.
This part summarizes publicly obtainable details about the Fund’s governance and operations, and opinions key points and debates that emerged as insurance policies have been developed.
Mission
In keeping with the Governance Framework, the first goal of the Fund is to “present a devoted stream of further, long-term funding for essential pandemic PPR capabilities” to help and reinforce present capability constructing efforts. Extra particularly, the Fund is designed so as to add worth by: 1) mobilizing further sources of financing, together with philanthropic and personal sector funding extra broadly, 2) leveraging its assets to incentivize extra spending by way of matching home assets, co-financing and/or “concessional” lending, and three) harmonizing spending for PPR and well being methods by bringing actors collectively and linking financing with nation stage planning and prioritization processes.
Because the Fund was being developed, the significance of this additionality was emphasised continuously. Relatively than being one other car to re-direct present authorities donor financing to international well being safety, the Fund is supposed to attract in funding that might not in any other case be obtainable and use its funding in such a method to encourage extra spending by home governments and the non-public sector on pandemic preparedness actions.
Monetary Standing
As of Might 22, 2023, 26 donors (together with nations, philanthropic foundations, and non-profit organizations) had pledged an estimated whole of $1.9 billion in help of the Pandemic Fund, a few of which consists of future commitments. The overall quantity acquired from donors and obtainable to be used (as of Might 22, 2023) is reported as $1.1 billion, $300 million of which is devoted to funding initiatives ensuing from the primary name for proposals.
The three largest donors to this point by whole quantity dedicated (together with paid and unpaid funds) are: the U.S. ($700 million), European Fee/European Union (EU/EC, $464 million), and Germany ($123 million). Counting solely quantities paid in, the three largest donors thus far are the US ($450 million), the EU/EC ($248 million), and Italy ($106 million). Determine 1 reveals an inventory of donor paid and unpaid contributions, by paid in quantities.
Governance
Policymakers confronted many questions and debates about methods to construction the Fund’s governing our bodies to make sure some steadiness in decision-making and oversight between donors, worldwide companies, governments, non-public sector and civil society, and different stakeholders. Particularly, there was a push from some low- and middle-income governments, advocates, and civil society representatives for his or her inclusion in Fund governance, a place supported by the US. In the end, a choice was made to include a broad set of stakeholders into the Fund’s governance construction, as follows:
- A Governing Board (the “Board”) is the principal decision-making physique for the Fund, answerable for discussing and approving plans, priorities, ideas, budgets, modifications to governance and operations, and extra. The Board has a complete of 21 voting seats (with an equal variety of alternates) divided amongst a number of constituencies as follows (members as of March 2023 listed right here):
- 9 for “Contributors” (i.e., representatives from donor governments such because the U.S.)
- 9 for “Co-investors” (i.e., representatives from Fund-eligible nation governments)
- One for philanthropic/basis contributors
- Two for representatives from civil society/group teams (one for the “International North” and one for the “International South”).
- There are additionally non-voting members on the Board, together with a consultant from the G20, the Chair and Vice-Chair of the Technical Advisory Panel (see beneath), plus every other representatives from entities as accredited by the Board. There are further Observer seats as properly, together with representatives from the Trustee, Implementing Companies, and the Secretariat (extra on these beneath).
- A Technical Advisory Panel (TAP) is the principal advisory physique to the Board, comprised of as much as 20 specialists drawn from a spread of PPR-relevant fields and observe areas. The TAP has tasks for advising the Board on technical, monetary, and different issues, together with overview, evaluation, and proposals associated to proposals for funding. A senior WHO official (presently Mike Ryan) is the TAP Chair, and a “non-WHO” professional (presently Pleasure St. John from the Caribbean Public Well being Company) is the Vice Chair. Past these 20 (membership proven right here), further specialists could also be known as to contribute on an as-needed foundation. TAP members serve for 2 years, as much as two consecutive phrases.
- The Secretariat is the workplace answerable for day-to-day FIF operations and performs duties together with convening Board and TAP conferences, creating the requires proposals, compiling progress and analysis reviews, liaising with exterior companions, and different actions. Positioned on the World Financial institution, the Secretariat is comprised of a small workers of “skilled and administrative workers employed by the World Financial institution or seconded to the World Financial institution from WHO.”
- The Trustee for the pandemic FIF is the World Financial institution, which is answerable for receiving and holding funds from contributors, offering monetary oversight and agreements, reviewing monetary reviews, and different duties.
The present Board is comprised of interim members put in place because the Fund was first established. A “Board reset,” which can end in turnover of some people presently occupying Board seats, is scheduled for Might 2023.
Operations
The Fund’s Operations Guide describes key present operational facets as follows:
Funding modalities, eligibility, and implementing companies
The Fund can obtain donor funding from governments, intergovernmental organizations, in addition to accredited non-governmental entities reminiscent of foundations/philanthropies. Any donor to the Fund enters an settlement with the Trustee (the World Financial institution), and contributions from non-governmental entities are topic to overview and approval by the Governing Board. Contributions may be made as one-time funds or installments for as much as eight years. All contributions are pooled for subsequent allocation by the Governing Board (extra on this beneath). No donor contributions may be earmarked upfront for particular initiatives or recipients.
Pooled donor funds are to be directed in help of related capability constructing actions at nationwide, regional, and/or international ranges. International locations which might be eligible to obtain World Financial institution funding (i.e., the World Financial institution-defined IBRD and/or IDA nations) are eligible to obtain Pandemic Fund help. Regional entities which might be specialised technical establishments supporting public well being and/or strengthening preparedness capability and established by governments of a number of eligible nations, in addition to regional growth communities and financial organizations, are additionally eligible for funding. Governments and entities that obtain funding are often known as Beneficiaries.
Funding just isn’t offered on to Beneficiaries, nonetheless. As an alternative, the Pandemic Fund channels funding by way of a pre-determined set of “Implementing Companies” that associate with Beneficiaries to hold out actions that advance the Fund’s mission. The Pandemic Fund can’t present grants for initiatives that don’t contain an Implementing Company. At the moment, the Fund has named the next 13 Implementing Companies as eligible:
- Multilateral Growth Banks: African Growth Financial institution, Asian Growth Financial institution, Asian Infrastructure Funding Financial institution, European Funding Financial institution, Inter-American Growth Financial institution, Worldwide Finance Company, World Financial institution
- United Nations Establishments: Meals and Agriculture Group, UNICEF, World Well being Group
- Different Multilateral & International Well being Organizations: Coalition for Epidemic and Preparedness Improvements (CEPI), Gavi the Vaccine Alliance (Gavi), the International Fund to Struggle AIDS, Tuberculosis and Malaria (International Fund).
The Governing Board can approve further Implementing Companies, topic to a overview and accreditation course of.
Funding Proposal Evaluation and Approval
Pandemic Fund grants shall be allotted by way of a technique of proposal submissions, overview, and Board approval. The Secretariat will problem periodic requires proposals and related funding envelopes, asking for proposals from eligible events for investments in particular PPR focus areas. Proposals could also be submitted by a number of nations and/or regional entities, and should determine at the very least one accredited Implementing Company to help challenge implementation. The Secretariat receives and screens proposals to make sure compliance with the Fund’s governance and operations framework. Amongst different necessities, every proposal should embrace an outline of its monitoring and analysis method, and these outcomes should be tied to a particular outcomes framework that measures progress in elevating preparedness scores in response to customary analysis measures such because the WHO’s Joint Exterior Analysis (JEE) or State Celebration Self-Evaluation Report (SPAR) and the World Group for Animal Well being’s Efficiency of Veterinary Companies (PVS) Pathway software.
Every proposal that meets compliance requirements shall be despatched to the TAP for overview and scoring. The TAP will overview submissions for adherence to the standards within the request for proposals, in addition to different facets reminiscent of technical soundness, price effectivity, match throughout the broader context of PPR and well being financing, affect, and fairness. Every proposal shall be scored in response to particular standards and a system developed and accredited upfront by the Governing Board. The TAP will submit its written assessments and scores to the Governing Board by way of the Secretariat, for last overview and approval. The Governing Board then decides on allocations for accredited proposals primarily based on their assessed advantage and assets obtainable for distribution.
In January 2023, the Pandemic Fund requested potential Beneficiaries to submit preliminary expressions of curiosity for funding and thru February had acquired a reported 650 such submissions. On March 3, 2023 the Fund launched its first official name for proposals, which focuses on a number of of the next technical areas: 1) illness surveillance methods, 2) laboratory methods, and/or 3) strengthening human assets/public well being workforce capability. The Fund is making obtainable $300 million for this spherical of proposals, with submissions required by Might 2023 and last funding choices anticipated by July 2023.
U.S. Engagement
The U.S. has publicly and actively supported the trouble to direct further multilateral financing for COVID-19 and PPR efforts extra broadly since President Biden took workplace in January 2021. Quickly after his inauguration the President launched a Nationwide Technique for the COVID-19 Response and Pandemic Preparedness that emphasised the necessity for extra funding for PPR, and known as on the U.S. Treasury to work with the World Financial institution and others to advertise further financing by way of multilateral monetary establishments. On the U.S.-hosted first International COVID-19 Summit in September 2021, the White Home particularly known as for the creation of a pandemic monetary middleman fund to be housed on the World Financial institution, and dedicated the primary funding towards the mechanism. The U.S. Treasury, because the lead authorities company for engagement with multilateral financing establishments, has performed an ongoing position in advocating for and advancing the event of the Pandemic Fund, with U.S. Treasury Secretary Janet Yellen continuously voicing help and calling for extra donor engagement and financing for this mechanism. The U.S. presently occupies considered one of 9 “Contributor” (donor nation) seats on the Pandemic Fund Board.
Because the Fund as advanced, the U.S. authorities has sought to form its governance and operational facets in accordance U.S. priorities. Many U.S. priorities for the Fund, as expressed by U.S. officers in response to preliminary World Financial institution proposals, have been carried out within the present Fund method. For instance, the U.S. pushed for a extra inclusive Board and governance construction that features recipient nation and civil society illustration, and sought to broaden the set of implementing companions to incorporate present international well being establishments reminiscent of Gavi, CEPI, and the International Fund.
So far, the U.S. has each pledged and paid in additional funding to the mechanism than every other single donor. The U.S. made an preliminary dedication of $250 million for the Fund in September 2021, and in Might 2022 introduced it was rising its dedication to $450 million. In Might 2023, the U.S. introduced it could direct an extra $250 million to the Fund (pending Congressional notification), which brings the full of pledged U.S. contributions to $700 million. This may characterize 37% of all donor commitments made thus far. As of Might 2023, the quantity the U.S. has paid in ($450 million) represents about 40% of all financing acquired by the Fund to this point. U.S. contributions have been drawn from a mixture of COVID emergency supplemental funding and funding offered to USAID for international well being safety.”
For its half, Congress has drafted payments in help of extra multilateral financing for pandemic preparedness, together with by way of a brand new fund. The Home handed a worldwide well being safety invoice in 2021 that, amongst different actions, approved U.S. engagement with and contributions to a brand new multilateral fund for pandemic preparedness. Whereas that invoice was not handed by Congress in 2021, a lot of the language and expression of help for the Fund was finally integrated into the 2023 Nationwide Protection Authorization Act, which handed into legislation in December 2022. That laws authorizes as much as $5 billion in U.S. contributions to the Pandemic Fund over 5 years ($1 billion per yr), and descriptions necessities reminiscent of that U.S. contributions to the Fund are to not exceed one-third of all donor contributions to the mechanism. White Home price range requests in FY 2023 and FY 2024 every requested Congress to offer $500 million for the Fund, however thus far Congress has not appropriated any further funding (past already present COVID-19 emergency funding). Nonetheless, in last appropriations payments for FY 2022 and FY 2023, Congress offered the administration with the authority to switch funding for international well being applications extra usually to the Pandemic Fund.
Coverage Points
The Pandemic Fund remains to be fairly new, having launched solely final yr and simply now readying its first spherical of funding. As such, most of the particulars about its insurance policies, procedures, and operations are nonetheless being negotiated and fleshed out, with some modifications and clarifications certain to return sooner or later. Nonetheless, sufficient is understood at this level to determine key challenges and points the Fund faces, now and going ahead. These embrace:
- Restricted donor funding to this point and unsure future help. Donors have promised over $1.9 billion to the Fund (together with commitments made for future years) and paid in over $1.1 billion thus far. Nevertheless, these funding quantities fall far wanting the $10 billion or extra every year beneficial by the World Financial institution, WHO, and different teams. It stays unclear whether or not and the way this funding hole may be stuffed as consideration to COVID-19 fades, and as donors and well being methods face funding constraints and competing priorities. Whereas there seems to be robust demand for Pandemic Fund grants – the primary name for proposals generated submissions from greater than 100 nations requesting funding totaling over $7 billion – the longer-term sustainability of the Fund stays in query with out extra financing, and its reliance on the generosity of donors within the coming years locations it in a doubtlessly precarious monetary state of affairs.
- Method and skill to catalyze co-financing is unclear. Because the Pandemic Fund’s Governance Framework makes clear, a key goal for the mechanism is to make use of its assets to leverage further investments for pandemic preparedness and response from philanthropies and the non-public sector, in addition to by nation governments. Nevertheless, solely a restricted quantity of funding has been dedicated by philanthropies to this point, together with from the Gates Basis ($15 million), Wellcome Belief (about $12 million), and Rockefeller Basis ($15 million), which collectively comprise round 2 % of all commitments to the Fund. As well as, it’s nonetheless unclear how the Fund will “crowd in” further PPR financing from home governments, significantly given the difficult fiscal environments confronted by many low and center earnings nations. A Board working group beneficial towards strict co-financing necessities linked to grants however did advocate co-financing be pursued when potential. The primary name for proposals features a set of ideas for co-investments, making clear that mobilizing further authorities spending is inspired however not an absolute requirement. Whereas guidelines and rules could evolve for future funding rounds, it is going to be necessary to look at if and the way a lot co-financing is mobilized within the first spherical of funding with out particular necessities for it, and the way profitable the Fund may be in crowding in further funds from different sources.
- Differing views on priorities by geography, exercise, earnings stage, and different facets of challenge funding. The Fund has to decide on methods to spend a restricted quantity of funding throughout a broad set of potential initiatives, which might embody preparedness and response, animal and human well being, native and international capacities, early-stage analysis and last-mile supply, and extra. For its preliminary spherical, the Fund has centered on sure nation and regional-level technical areas reminiscent of laboratory methods and public well being workforce, however that leaves out different areas in want of funding. Going ahead, choices to focus in some areas however not others are more likely to be contentious. For instance, what the correct break up between funding country-level, regional-level, and international capacities is. Some advocates have argued for setting a particular goal reminiscent of 70/20/10 throughout these three ranges, respectively, however no onerous and quick rule but applies. As well as, the Board must select methods to steadiness financing throughout a spread of nation earnings ranges, and disparate wants.
- Questions on governance processes and guaranteeing consultant decision-making. At lower than a yr outdated, most of the Fund’s governance procedures and norms are nonetheless being negotiated and developed, however already there are questions on the way it will navigate decision-making processes and guaranteeing fairness and illustration, reminiscent of:
- Whereas some steps have been taken towards inclusive governance reminiscent of having civil society and recipient nation illustration on the Board, as sought by the U.S. and international well being advocates, it’s not but clear the extent to which decision-making shall be influenced by these stakeholders versus donor governments. There are the identical variety of Board seats (9 every) for “Co-investor” and “Contributor” nations plus two seats for civil society, however energy imbalances can nonetheless exist in such conditions in observe. Additional, the 2 civil society representatives (one from the International North and one from the International South) have been tasked with representing massive, various worldwide constituencies, and retaining knowledgeable of and adequately representing the total array of points and issues of their constituencies is a serious problem.
- Considerations about potential conflicts of curiosity have additionally been raised, reminiscent of that “Co-investor” nations have a stage of affect over funding choices and in addition stand to profit from funding choices. The Board has been creating a set of tips to handle this and different potential conflicts of curiosity, nevertheless it stays to be seen how the Fund rolls out and implements the rules, and the way strong they change into. Because it stands, the Fund’s Operations Guide states all people related to decision-making and/or implementation “should open up to the Secretariat any precise or potential conflicts of curiosity…and recuse themselves from decision-making or deliberations in relations to issues the place conflicts come up.” Different international well being financing mechanisms (together with Gavi and International Fund) have needed to navigate this problem to some extent however it is going to be significantly necessary for the Fund because it establishes itself, builds belief and seeks legitimacy for its work.
- Making certain transparency of decision-making and operations for the Fund shall be necessary. Some notable steps towards higher transparency have already been taken, together with having the Secretariat manage (occasional) open conferences with exterior stakeholders reminiscent of civil society representatives to offer info and settle for enter, posting Board assembly minutes detailing choices and different necessary info, and creating an internet site with up to date donor funding info, information, and different assets. Because the overview course of for grants begins and funding begins to be awarded, transparency about how choices are made, together with quantities, recipients, and initiatives funded, are possible to assist keep belief amongst events. To this finish, the Board launched the instrument and scoring method that shall be utilized by the TAP to rank and rating proposals within the first spherical of funding. It’s anticipated that outcomes from the opinions shall be made public to an extent, together with posting and sharing of the Fund’s total outcomes and outcomes.
- Stage of integration and coordination with present international well being and PPR efforts stays to be seen. The Fund was designed to be additive and construct upon ongoing PPR and international well being efforts. Amongst its key ideas are that it “enhances the work of present establishments” and that it’s going to “function an integrator moderately than change into a brand new silo that solely furthers fragmentation.” A method it seeks to do that is by requiring its funding be channeled by way of present establishments (i.e., “Implementing Companies”) moderately than constructing a brand new vertical funding construction. The Fund additionally requires that proposals tackle how their initiatives would combine with and construct upon present plans and PPR frameworks Joint Exterior Evaluations (JEEs), the Worldwide Well being Rules (IHR), and country-level Nationwide Motion Plans for Well being Safety (NAPHS) or different plans, and proposals should define how totally different key actors will coordinate their efforts. Nonetheless, because the Fund strikes from idea to implementation it is going to be price monitoring how efficient these ideas are and the way carefully it adheres to this imaginative and prescient. Relying on the main target and scope of initiatives, nations might must combine throughout many disparate and fragmented actors, together with different multilateral efforts, bilateral applications, and overlapping (however doubtlessly individually funded) main well being care, common well being protection or well being system strengthening efforts. Already, this problem has emerged. The International Fund, one of many Pandemic Fund’s 13 accredited implementing entities, submitted an expression of curiosity to the Fund, however has since determined to not formally apply for funding in spherical one, whereas it continues to evaluate coordination and synergies between the 2 organizations.
- Demonstrating affect within the subsequent few years shall be necessary however difficult. As a brand new entity, the Fund doesn’t but have a monitor document it will possibly level to and certain faces a comparatively brief time window to reveal its effectiveness to donors, companions, and communities. Setting bold however attainable targets and goals shall be necessary, particularly ones that may be measured, quantified and progress tracked towards. To this finish, the Fund’s Outcomes Framework outlines monitoring and analysis necessities for funding recipients, with every implementing company required to report yearly to the Secretariat on progress in response to customary metrics just like the JEE and SPAR. The Secretariat will then present an annual, total outcomes report for the Board. The challenges could include definitively demonstrating affect, particularly if metrics are onerous to interpret and/or might take time (maybe years) to enhance. There shall be a steadiness between making fast progress to indicate donors that funds are having an affect, and permitting sufficient time for chosen initiatives to be carried out. As well as, on condition that the final word purpose is to assist nations forestall epidemics and pandemics, it is going to be tough to measure such an impact past these middleman metrics.
- Future U.S. funding for the Pandemic Fund, in addition to coordination of this help throughout the context of present international well being applications, stays to be decided. The way forward for U.S. funding for the Fund is unknown, because the Biden Administration has thus far been in a position to primarily faucet pre-existing funds from COVID-19 emergency appropriations, together with international well being safety funds. Extra quantities, particularly appropriated by Congress for the Fund, are usually not a given. Within the present interval of divided authorities and price range constraints, upfront of a Presidential election yr, it’s not clear there’s a bipartisan consensus on extra U.S. help for the Fund – not to mention the $1 billion yearly that the White Home helps and Congress has approved for this function. Additionally, given the already long-standing U.S. help for bilateral and multilateral international well being efforts reminiscent of PEPFAR and the International Fund, in addition to a lot of devoted bilateral international well being safety applications, it stays to be seen how the U.S. will steadiness its help for the Pandemic Fund with that for its different applications. Any additional U.S. contributions to the brand new mechanism may come along with discretionary funding quantities Congress gives for different U.S. international well being applications, doubtlessly resulting in rigidity about the correct steadiness. Additional, in locations the place U.S.-funded international well being applications and Pandemic Fund supported initiatives happen collectively geographically, U.S. applications may need to think about how greatest to coordinate and, the place acceptable, combine efforts.