Breakthroughs Blog: Congress

In many ways, 2024 has been a year marked by change—the first new year since the official end of the COVID-19 pandemic and a record number of elections ushering in political transitions around the world. With the global spotlight shifting to antimicrobial resistance (AMR) and tuberculosis (TB) reclaiming the designation as the top infectious disease killer from COVID-19, it may seem, at first glance, that the world has moved on from the pandemic that dominated every aspect of life for the better part of four years. However, with a deeper look, it’s clear that the global community is still reacting to and learning from the pandemic—for better or worse.As the year comes to an end, GHTC is reflecting on the global health innovation news and policies that shaped 2024.1. New disease outbreaks arise around the world, spurring need for and progress in R&D.In 2024, disease outbreaks continued to dominate the headlines—from the first reports of avian flu in the United States in March to the rapid global spread of the clade 1b mpox strain over the summer to the outbreak of the deadly Marburg virus in Rwanda beginning in September. Each of these incidents exposed devastating gaps in our prevention and response toolkit and spurred important steps forward on research and development (R&D) and access.For example, in response to the worrisome spread of avian flu, both the World Health Organization (WHO) and the US government launched efforts to accelerate the development of mRNA vaccines that could be deployed in case of human-to-human transmission of the currently spreading strain of avian flu or redirected to target another form of pandemic influenza if needed. Additionally, following declarations from the Africa Centres for Disease Control and Prevention and WHO designating mpox a public health emergency this past August, WHO prequalified the first vaccine against mpox and approved the first mpox test for emergency use, with the goal of accelerating global access to these critically needed tools. The outbreak also provoked new research to develop improved vaccines against mpox and the broader range of orthopox viruses, with early studies of mRNA mpox vaccines in macaques and mice demonstrating promising results.This fall, as cases of Marburg were on the rise in Rwanda, and with no currently approved vaccines or treatments available, researchers fast-tracked efforts to evaluate tools to stem the current outbreak and curb future ones. Rwandan health authorities initiated an open label vaccine trial in health workers and others at heightened risk, and there has since been a randomized clinical trial arm launched, which will offer critical efficacy data. Additionally, scientists launched the first-ever clinical trial for a Marburg treatment this year.Beyond accelerating innovation against these outbreaks, 2024 also brought exciting research advancements targeting other pathogens scientists believe are most likely to cause the next pandemic, including trials that could lead to the first-ever approved vaccines for Sudan ebolavirus and Lassa fever, as well as further efforts to improve coronavirus vaccines and simplify and speed up vaccine development and manufacturing.2. Pandemic preparedness policy reforms march forward while post-COVID political backlash in United States grows.Multilateral efforts to strengthen the world’s pandemic preparedness and response architecture moved incrementally forward this year. At the World Health Assembly (WHA) in May, member states adopted several amendments to the International Health Regulations—an existing framework codifying international responsibilities during a pandemic—, including new commitments to solidarity and equity on financing and ensuring access to medical products. The World Bank-hosted Pandemic Fund, a financing mechanism launched in 2022 to help low- and middle-income countries strengthen their preparedness and response capacities, also raised $982 million in new contributions and an additional $1.8 billion in co-financing this year, as well as awarded $500 million in grants to countries to strengthen surveillance, laboratory, and workforce capacities and fast-tracked an additional $129 million for the mpox response. Under the Brazilian presidency, G20 nations established a voluntary coalition to strengthen local and regional production of health products, which, while focused foremost on neglected diseases, could also strengthen capacities critical for pandemic preparedness and response. Unfortunately, despite some progress on negotiations toward a new pandemic accord, countries failed to reach sufficient consensus before the end of this year, and negotiators are now pushing to wrap up by the next WHA in May of 2025.At the same time as some progress was achieved on the international front, in the United States, post-COVID political backlash has deepened and become more entrenched through congressional scrutiny and reform agendas targeting the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). Though the fiscal year 2025 budget is not expected to be finalized until next year, the health-related spending bill introduced by the House proposes spending cuts to CDC and a reorganization of NIH, which mirrors that put forward by House Republicans over the summer and could have serious implications for the agency’s core global health R&D capacities. Beyond appropriations, we also continued to see a plethora of congressional hearings targeting NIH and CDC on the origins of COVID-19, gain-of-function research, China’s influence, and the perception that these agencies are overstepping their mandates. The scrutiny and reform efforts we saw this year are expected to intensify in 2025, as Republicans gain control of both chambers of Congress and the White House.3. AMR captures the world’s attention as the global threat continues to grow.2024 was informally dubbed “the year of AMR,” with AMR elevated on the global agenda at several key moments. In May, a WHA resolution was adopted to accelerate national and global responses to AMR by advancing R&D, strengthening surveillance systems, and forging international partnerships. Later in September, a landmark report found that without further policy interventions, the death toll from AMR is expected to reach 39 million between 2025 and 2050—the equivalent of three deaths per minute.This shocking report set the scene for the United Nations High-Level Meeting on AMR in September, which led to the adoption of a political declaration that set the goal to reduce AMR deaths by 10 percent by 2030 and committed countries to promote the R&D of and equitable access to antimicrobials, vaccines, diagnostics, and other products. Global leaders also adopted an action plan in November, built off of the declaration, to provide actionable objectives and additional check-ins to monitor progress.This political momentum on AMR was also matched by exciting research breakthroughs that made the news this year. Researchers discovered a new compound that could potentially treat a resistant bacterial pathogen that can cause lethal hospital infections. Additionally, Phase 3 trials yielded promising results for both a therapeutic option for patients with serious bacterial infections and limited treatment options, as well as a new antibiotic that could cure uncomplicated gonorrhea infections, which could be approved sometime next year.4. TB reclaims title of deadliest infectious disease, but promising trials offer hope. This past year, TB surpassed COVID-19 to reclaim the spot as the world’s leading infectious disease killer, according to WHO’s Global Tuberculosis Report 2024. While this sobering news underscored major gaps in the tools needed to prevent, diagnose, and treat TB, especially drug-resistant TB, 2024 also brought exciting news on the research front that will hopefully help fill them.In March, a Phase 3 trial launched in South Africa, which is testing a TB vaccine candidate that could eventually become the first vaccine to prevent pulmonary TB in adolescents and adults. The only approved TB vaccine on the market, which was developed more than 100 years ago, is effective at preventing some types of TB in infants, but it offers inconsistent protection in adults against pulmonary TB. Additionally in November, the endTB consortium announced the completion of the first Phase 3 randomized controlled trial to exclusively enroll people with pre-extensively drug-resistant TB, a very hard-to-treat form of TB. Preliminary results demonstrated that a shorter, less toxic treatment strategy achieved high cure rates. Earlier in the year, WHO also recommended three new regimens for multidrug- or rifampicin-resistant TB, offering a much-needed variety of therapeutic alternatives for those with multidrug-resistant TB. 5. A major HIV breakthrough, but work remains on access. In what has been hailed as a breakthrough in HIV prevention, in 2024, exciting results were reported from a series of clinical trials for Gilead’s long-acting HIV prevention drug, lenacapavir, which found that the drug was 100 percent effective in preventing HIV in cisgender women and adolescent girls and 96 percent effective among cisgender men, transgender men and women, and gender nonbinary individuals who have sex with men. Both trials were so successful that they were unblinded early to offer the drug to all participants. Lenacapavir, which is administered via a twice-yearly injection, is currently approved as a treatment for multidrug-resistant HIV, but, if approved as a preventative regimen, the drug could be a game-changer for the HIV pandemic.Advocates applauded Gilead for its historic commitment to inclusion in these trials, while also urging that lenacapavir be made accessible and affordable as soon as possible to those that most need it. In October, Gilead announced a plan to allow generic versions of the drug to be sold in 120 countries, including all those with the highest HIV rates. However, the plan faced criticism for excluding most middle- and high-income countries that account for around 20 percent of new HIV infections. In these countries, the originator drug will only be available at higher prices, making it potentially inaccessible to at-risk populations.In other welcome HIV prevention news, in October, Population Council announced the results of a Phase 1 trial, which suggest that a three-month dapivirine vaginal ring for HIV prevention will be as effective as the currently approved one-month ring. The ring, which is self-inserted into the vagina and slowly releases an antiretroviral drug to prevent infection over three months, was found to deliver the drug at higher levels than the one-month ring. If the longer-acting ring continues to demonstrate success, it could offer a more cost-effective and convenient option for at-risk women. 6. Trump presidency and Republican trifecta portend changes to US leadership in global health.In the November election in the United States, former President Donald Trump won the presidency and Republicans gained control of both the US House of Representatives and the Senate. It was an across-the-board victory that will portend changes to US leadership on global health and medical research. If past is prologue, we’re likely to see President-elect Trump once again propose significant funding cuts to US global health programs and public health agencies like NIH and CDC, as well as withdraw the United States from WHO and other multilateral initiatives, the latter of which could derail efforts to finalize a pandemic accord. Given that the United States is the largest funder of global health programs and global health R&D efforts, these political changes could have a reverberating impact on health around the world.Since winning the presidency, President-elect Trump has also nominated several controversial picks to lead America’s public health agencies. These include Robert F. Kennedy Jr, a noted vaccine skeptic who has expressed a desire to cut the NIH workforce and refocus the agency on chronic diseases over infectious diseases, to lead the Department of Health and Human Services; Dr. Jay Bhattacharya, a health economist who criticized public health measures during the COVID-19 response and a vocal critic of NIH, to lead NIH; and Dr. Dave Weldon, a former Congressman who has questioned vaccine safety, to lead CDC.On the congressional front, with Republicans now in control of both chambers of the US Congress, as discussed, we’ll likely see continued scrutiny and reform efforts targeting NIH and CDC, as well as potential spending cuts to health and foreign assistance programs.7. New policies and innovative research approaches help reach underserved populations.Every person, everywhere, deserves to benefit from the fruits of science, and in this otherwise tumultuous year, there were several successful efforts to advance more inclusive clinical studies. In September, WHO released new guidance on clinical trial best practices outlining practical considerations for trials to include children and pregnant and lactating individuals, populations currently underrepresented in trials, leading to a lack of approved technologies for these groups. This guidance aligned with WHO’s living toolkit to facilitate the inclusion of pregnant and breastfeeding populations in clinical trials that was published earlier in the year. 2024 also brought the launch of two historic trials that aim to diversify research and thereby ensure that future technologies will serve the needs of underserved populations. This summer, a global consortium launched the first-ever Phase 3 clinical trial testing the efficacy and safety of antimalarials in women in their first trimester of pregnancy, which will hopefully not only lead to an urgently needed new treatment option for these women but also set a precedent for the inclusion of pregnant women in future clinical trials. Earlier this year, the US Administration for Strategic Preparedness and Response also announced funding to Walgreens to support a decentralized clinical trial testing COVID-19 vaccines. This unique approach will allow for a more diverse pool of study participants by bringing the study closer to where they live, ultimately ensuring that the resulting data reflects real-world use among a broader swath of the population. In the end, 2024 proved to be a complicated year, marked by both scientific and political steps forward and back. As new innovations and policies emerge in 2025 and beyond, GHTC will continue to work to ensure support for global health R&D remains a political priority and that the gains we have already made on neglected and emerging health challenges are not only sustained but also strengthened to combat an evolving health landscape.For other fascinating global health news delivered to your inbox weekly and to stay abreast of developments in 2025 and beyond, sign up now to receive GHTC’s R&D News Roundup newsletter.

GHTC responded to a request for information (RFI) on House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-WA)'s recently published framework that lays out the current challenges facing the National Institutes of Health (NIH) and makes recommendations for reform with the letter below, raising concerns that some of the recommendations could limit important and lifesaving work and urging that any reforms included in legislation to be thoroughly vetted to protect that work.Dear Chair McMorris Rodgers, As members of the global health advocacy community, thank you for your interest in optimizing the National Institutes of Health (NIH) and for the opportunity to provide input on the  Reforming the National Institutes of Health Framework for Discussion.We are pleased to share thoughts below on several specific proposals. However, given the significance of NIH to the health, security, and well-being of the American people and populations across the globe, it is critical to engage in a process that permits interactive discussion with and between different parties who can shed light on the day-to-day implications of these potential changes. Through this process, we can work together to identify opportunities to strengthen NIH in support of the goals and objectives of members of Congress from both sides of the aisle.    For this reason, we are deeply concerned that changes outlined in the framework have been incorporated into the Fiscal Year 2025 House Labor, Health and Human Services, Education, and Related Agencies (LHHS) appropriations bill even before the deadline for comments on the proposal. Our concern is not that the calls for reform and increased transparency are without merit but rather that any reform included in legislation be thoroughly vetted to ensure that the important and lifesaving work of NIH is allowed to thrive.In the spirit of such a process, the following text provides specific input from the global health research community and advocates on several proposals included in the framework. The community’s apprehension centers on bifurcating the National Institute of Allergy and Infectious Diseases (NIAID); collapsing several institutes and centers, including the Fogarty International Center, into a single institute; and incorporating the Advanced Research Projects Agency for Health (ARPA-H) into an NIH institute. These actions will impose barriers, both administrative and scientific, for global health research and development that will affect NIH’s reputation as the global leader in biomedical sciences, a legacy that enhances the United States’ image on the international stage as a champion of global health innovation and a steward of global health diplomacy. NIAID is the world leader in global health research and development because its basic research expands our fundamental knowledge of antimicrobial resistance, HIV/AIDS, malaria, tuberculosis, and neglected tropical diseases. As COVID-19 variants continue to arise, the complex interactions between immunity and infectious threats have reached the public’s attention as never before. Antimicrobial resistance is another example of how the intertwined nature of infectious diseases and immunity requires constant collaboration between professionals from these fields. We are concerned that NIAID will not cleanly split in two as the LHHS report and House Committee on Energy & Commerce’s proposed framework posit. Rather, the split will disrupt the research helping us defeat the most deadly infectious disease threats—past, present, and future—at home and abroad. We are also concerned that grouping the Fogarty International Center (FIC) with topically unrelated and domestic-facing institutes into the Institute on Health Sciences Research would minimize the key role FIC plays in maintaining the United States’ global health security leadership role and advancing medical progress that benefits the American people and populations across the globe. FIC is a lesser-known but hugely consequential branch of NIH responsible for training a vast network of approximately 8,500 professionals from 132 countries in public health threat response. These trainees have gone on to hold high-ranking academic and government positions and have moved the needle on neglected and emerging infectious diseases, such as HIV/AIDS, COVID-19, Zika, and Ebola.  Rather than embedding FIC in another institute, we believe an important opportunity exists to strengthen this center to play an even more impactful role in advancing the health and security of Americans. We would welcome the opportunity to discuss options such as expanding FIC’s role to encompass strengthening clinical trial capacity and strategic partnerships in countries where capacity gaps pose risks and create tragic missed opportunities for faster medical progress. Finally, we believe that maintaining ARPA-H’s independent status is important for preserving its unique approach to high-risk, high-reward innovation as initially envisioned by Congress, which does not duplicate NIH’s critical role in basic and translational research.  The agency, authorized in 2022, has not been in place long enough to evaluate federal investment in this new model. Its efforts to reverse blindness, dramatically increase the precision of tumor removal, and overcome challenges with broad significance should be given the time they need to succeed or fail. Had Congress abandoned the Defense Advanced Research Projects Agency in its first years of operation, GPS could be a matter of science fiction, not everyday use. ARPA-H has the potential to bring new scientific thought and processes to a field marked by tradition—minimizing its role risks the United States falling behind our geopolitical rivals in health innovation during an age of rapidly evolving technologies. We believe it is in the nation’s interests to put ARPA-H’s muscle toward addressing health threats within and (currently) outside our borders. Again, Chair McMorris Rodgers, we share your commitment to strengthening NIH and believe that thoughtful, bipartisan reforms, supported by thorough discussion and vetting, are key to achieving this goal. We write to advocate for robust funding and a structural, operational, and policy infrastructure that best supports fast-paced scientific, medical, and public health progress. NIH is an asset that serves US interests and contributes in profoundly important ways to the health and well-being of all around the world. We urge that congressional efforts to optimize NIH take place on a bipartisan and bicameral basis and that only changes that have been carefully vetted through a thorough, interactive, and cross-sector process are considered. Thank you for your consideration,Alex LongUS Policy & Advocacy OfficerGlobal Health Technologies Coalition (GHTC)E: along@ghtcoalition.org 

Executive Director of the Global Health Technologies Coalition (GHTC) Dr. Kristie Mikus issued the following statement following the Senate Committee on Appropriations’ passage of the fiscal year 2025 (FY25) State, Foreign Operations, and Related Programs (SFOPS) bill:GHTC applauds the work of Senators Chris Coons (D-DE) and Lindsey Graham (R-SC), Chair and Ranking Member of the Senate Appropriations SFOPS Subcommittee, and Senators Patty Murray (D-WA) and Susan Collins (R-ME), Chair and Ranking Member of the full Senate Committee on Appropriations, for ensuring critical funding for US global health programs under increased fiscal pressure.  We especially thank Senate appropriators for including language in the Senate’s FY25 SFOPS appropriations report recognizing the importance of funding for global health research and development (R&D) and directing the US Agency for International Development (USAID) to examine the feasibility of creating a new dedicated global health R&D budget line.  This language is an important step toward realizing a GHTC-led proposal to create a Supporting Innovative Global Health Technologies (SIGHT) Fund—a flexible, disease-agnostic fund to be housed at USAID that would infuse new funding into R&D efforts to close the biggest gaps in our global health toolkit.R&D partnerships led by USAID have been instrumental in saving and improving millions of lives around the world while at the same time protecting the health of Americans and stimulating jobs here in the United States. US investments in global health R&D have infused $104 billion into the US economy and created more than 600,000 US jobs since 2007.  Appropriating dedicated global health R&D funds at USAID, to be implemented via a program like the SIGHT Fund, would intensify this tremendous impact and offer significant advantages over funding R&D solely through health-area-specific funding streams. It would ensure a strategic focus on innovation by reducing the trade-off between funding the implementation of existing tools and developing new and improved ones, as well as preserve the effectiveness of ongoing programs, enhance accountability, encourage risk-taking and partnerships, and strengthen the global health infrastructure for future challenges.    As the SIGHT Act (H.R. 6424)—legislation that would authorize the creation of a new global health R&D budget line—works its way through Congress in parallel, we are encouraged to see the Senate FY25 SFOPS report lay the groundwork for the incoming president to request—and Congress to appropriate—disease-agnostic funds specifically for global health R&D that are distinct from and do not compete directly with funding for program implementation or any other purpose.  GHTC calls on appropriators and authorizers in the House and Senate to build on this momentum and support USAID's global health R&D mandate by advancing the SIGHT Fund's mission in this and the next Congress. By committing to dedicated R&D funding, Congress can empower USAID to make groundbreaking advances in global health that could save millions of lives and improve health outcomes worldwide.   

How we got hereSince the earliest days of the House Republicans’ current position in the majority, health agencies like the US Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) have been called to testify multiple times before the House Committee on Energy and Commerce (E&C). E&C has used its power as the authorizing committee for domestic health agencies to hold hearings, issue subpoenas, and file reports on what Republican lawmakers perceive as failures of—and a lack of transparency of—public health agencies. More recently, in the committee, there has been a crescendo of opposition to NIH’s status quo—often focused on the work of the National Institute of Allergy and Infectious Diseases (NIAID) and its staff.With that in mind, GHTC and the global health community were prepared for either new legislation or reform plans targeting NIH. Sure enough, E&C, under the leadership of Chair Cathy McMorris Rodgers (R-WA), released a proposal in June to overhaul NIH by restructuring the agency and redirecting the mission of the institutes back to what House Republicans believe should be NIH’s focus. The proposal was outlined in a report and further explained in an op-ed coauthored by E&C Chair Rodgers and Robert Aderholdt (R-AL), Chair of the Labor, Health and Human Services, Education and Related Agencies (LHHS) Appropriations Subcommittee, which oversees NIH funding, signaling Chair Aderholdt’s support of the proposed framework.Later that month, the House’s fiscal year 2025 (FY25) LHHS bill was released, incorporating the newly proposed NIH framework. Rather than go through the typical process of advancing authorizing legislation, House Republicans attempted to put into effect a new NIH structure through the appropriations process. This process signaled House Republicans’ serious intent to reform NIH, even though there is little likelihood that these currently partisan priorities would ever be enacted in the final version of the LHHS bill since the Democrat-controlled Senate and White House must pass it.The frameworkThe proposed framework takes several key Republican talking points and applies them to NIH’s structure, mission, and processes. These broad buckets of change have implications across the entire NIH system, notwithstanding other new rules concerning how many grants a principal investigator can hold and how much overhead research organizations can claim. Here is a quick walk-through:Structure: The framework takes the 27 institutes of NIH and the (currently independent) Advanced Research Projects Agency for Health (ARPA-H) and consolidates them into 15 new institutes. This consolidation reflects a key Republican talking point that health agencies have gotten too large and cumbersome to effectively collaborate internally, which takes them further away from the core missions of the institution.Mission: The framework proposal persistently condemns demographic- and disease-based research and urges a focus on “the whole individual and all populations across the entire lifespan” instead.  Processes: One issue E&C Republicans have been laser focused on is accountability and transparency concerning what and who NIH funds. The framework proposes a heightened degree of oversight on grants and a stricter set of rules for NIH leadership.Of course, proposals to reform and make a more efficient agency are not without merit, but the context in which they were proposed has left some in the advocacy community with many questions. For example, before the pandemic, on the Hill, NIH generally received bipartisan support for its work and typically unquestioned budgetary increases to maintain its status as the global leader in biomedical research. However, since the pandemic, these issues of NIH consolidation, reconsidering demographic-based research, and heightened transparency have been targeted for what is seen by the advocacy community as a political issue, fueled by the fallout from COVID-19.Global health and the frameworkWhen it comes to the global health implications of the proposal, the issues are vast but also technically speculative, solely based on what we know from E&C and House Republicans’ past comments on the future of NIH and their stance on infectious disease research in the wake of the COVID-19 pandemic. The potential implications are as follows:NIAIDOne of the most intriguing developments is the splitting of NIAID, the world’s largest funder of global health research and development (R&D), into the National Institute of Infectious Diseases (NIID) and the National Institute of the Immune System and Arthritis. This fracturing of NIAID is seen as a direct response to the scrutiny that NIAID and its previous director, Dr. Anthony Fauci, have faced for the institute’s infectious disease work. While there may be good arguments for having an institute expressly focused on infectious diseases, this move also has the appearance of utilizing legislative powers and abilities to purposefully single out a critical line of work in global health at NIH, thus making it more susceptible to political pressures and perhaps more vulnerable to cuts in appropriations. This raises natural questions around process—why use this process at this time versus a more vetted and strategic process and why now.Additionally, the schism may disrupt the immunity and infectious disease research conducted at NIAID. Research into pathogens with pandemic potential, neglected diseases, vaccines, antimicrobial resistance, and even long COVID are all issues that intertwine with infectious disease work and work on the immune system. This break in the institute might disrupt or complicate ongoing efforts to combat important disease threats at home and abroad.If this piece of the framework were to be enacted in any way, NIAID advocates would have to take a closer look at the division of resources at the two new institutes to better understand how the work will be distributed and how the research will be financially impacted. From there, advocates will have to work with congressional colleagues to ensure that the infectious disease work at NIID remains independent but is conducted safely through consultation with researchers and advocacy organizations.FICIn the restructuring proposal, the Fogarty International Center (FIC) is lumped together with unrelated and domestic-facing institutes into the National Institute on Health Sciences Research. FIC acts as the global health focal point at NIH and has trained a vast network of around 8,500 professionals from 132 countries in public health threat response, many of whom have gone on to hold high-ranking academic and government positions. By placing FIC with unrelated institutes under the umbrella of “Health Sciences Research,” Congress would minimize its position in global health leadership and would mischaracterize FIC’s core mission and value added to the NIH ecosystem.If these changes were enacted, the onus would be on the advocacy community to make sure FIC is seen as an integral player in the US global health apparatus and to US global health security. In the 2018 President’s Budget Request and the FY25 House LHHS appropriations amendments process, there have been proposals to zero out FIC, leaving advocates understandably on alert for this potential restructuring.ARPA-HAs was alluded to before, in the framework, ARPA-H is moved under NIH’s leadership and merged with other institutes into a new National Institute on Innovation and Advanced Research rather than serving as an independent incubator for next-generation research. If ARPA-H begins operating under NIH’s topline appropriation, this would likely lead to a shrinking budget for ARPA-H—as was seen in the House’s FY25 LHHS bill.These cuts should be a warning sign to any research that exists outside the US-facing work ARPA-H is set to conduct. ARPA-H’s recently built-out Office of International Affairs and potential for global reach will likely be diminished as available resources dry up because of NIH’s primarily domestic mandate and competition for budgets.If the framework were to be enacted and ARPA-H did fall under NIH’s jurisdiction, global health advocates would need to strengthen their messages on ARPA-H's potential for global health research and needed funding. The next-generation innovation the advocacy community hopes to see out of this new agency is only possible if the appropriators sustain past funding levels, even if it rests within a restructured NIH.Going forwardGHTC wants to see a strengthened and streamlined NIH and agrees that improvements can be made to structures and systems, provided that the ultimate goal is to have an empowered, strategically structured, and well-resourced NIH. That way, the institutes can take on the global health R&D demands and challenges of the future that will result in greater innovation for vaccines, therapeutics, and diagnostics.In the wake of the release of this proposal, GHTC is focused on advocating for strengthening NIH’s global health R&D capacity and working with congressional colleagues on a path forward for NIH that reforms what can be improved and doubles down on what is already working. The global health impacts of NIH’s work are expansive, but in the framework, they are less obvious and require a closer look at the current political landscape and how global health-related issues are divided up at NIH.GHTC is hopeful that our colleagues on and off the Hill will work together to strengthen NIH’s global health impact.