How CDC directs 70% of its global funding to local partners

At a time when U.S. global health and development programs are being asked to direct more of their funding to local partners, one agency has already made that the business model for most of its overseas work. In addition to being the United States’ primary public health agency, the Centers for Disease Control and Prevention works in roughly 60 nations around the world. CDC officials are part of country teams for major initiatives such as PEPFAR — the U.S. President’s Emergency Plan for AIDS Relief — and they work in close collaboration with health ministries and nongovernmental organizations. CDC directs about 70% of its global funding to local partners, including national governments and NGOs that help support health care delivery, said Kevin Cain, the acting director of CDC’s Center for Global Health. Cain spoke to Devex about how CDC has managed to hit that mark, how the agency pivoted in response to the COVID-19 pandemic, and what gaps the health crisis has revealed in countries’ health systems. This conversation has been edited for length and clarity. What is it about CDC that enables you to have so much of your global funding go to local partners? “Localization” is a broad call to action for a number of agencies, but 70% is significantly higher than what most of them have been able to achieve. It speaks to the core of what we are as an agency. We help countries build emergency operations centers so that when there is an emergency, they have a way to respond in a coordinated manner. We help them to build laboratory systems around the country that are able to communicate with one another and handle specimens and laboratory testing. We help with surveillance systems or information management to make sure that when there is data coming in from one part of the country, it can actually be compiled and be useful not only at the local level, but at the national level to guide what's done. And finally, a cornerstone of what CDC does is called the Field Epidemiology Training Program, where we develop epidemiology skills in people who are health professionals — that can be doctors, nurses, other public health practitioners — and give them the skills to really use data to drive programs forward. So when I think of what the CDC does, we really do center ourselves around supporting the local institutions that are there — both in terms of how we fund things but also in terms of the work that we do and the people and programs and systems that we try to develop. How do you work through some of the challenges that other agencies and organizations seem to struggle with when it comes to working through local partners — things like compliance reporting, oversight, and the sheer staffing capacity required to work with a large number of organizations? One of the most important ways that we do it is through partnerships on the ground. This is why we place highly skilled doctors, epidemiologists, and also public health professionals who work more on the business side — the management of grants — on the ground and have them work directly with the government. It is complex, but if you invest the time in working with them and building those skills, then you can succeed in not only having something that's technically strong, but something that's also strong from the management standpoint as well. It definitely takes effort, and there are times that it doesn't work as well as we would want it to. But with that kind of investment, we end up building a foundation that can last for longer, and that's really what we're aiming to do. How were these systems and relationships that you had already established in the countries where CDC works able to adapt to the demands of the pandemic? Were you able to use those existing systems, or did you have to build a response from scratch? All of our staff in offices pivoted towards doing what they needed to do. And that included working with countries in these systems to respond directly, but it also included making sure that people with HIV stayed on care. At the beginning of the pandemic, there was a huge concern that the number of people with HIV who were on HIV care would drop because of interruptions with the pandemic. But because of some of the person-centered care that had already been started even pre-pandemic, even in the midst of the pandemic, we were able to see the number of people with HIV on care increase. “We really do center ourselves around supporting the local institutions … in terms of the work that we do and the people and programs and systems that we try to develop.” --— Kevin Cain, acting director, CDC’s Center for Global Health. It didn't increase as rapidly as it had in previous years or within the past year. But I think the fact that it increased is a huge success. And really, our staff worked with governments to do whatever it took — delivering longer durations of treatment, delivering care in communities, delivering treatment at homes. Our CDC staff in-country, yes, they might be usually tied to PEPFAR or something else. But at the end of the day, they are CDC staff that are there to support the health needs that exist in the country, and they pivoted towards that right away and very effectively. And likewise, the country was able to take the systems that it had developed and pivot those toward the response as well. It’s quite amazing that you were able to increase the number of people on HIV treatment during the pandemic, but we also heard some pretty dire things about disruptions to childhood vaccinations and other routine health services. What’s the overall picture of health service disruption that you witnessed? If you think about the routine health care system and how gaps would manifest themselves, I think one of the best examples is immunizations. The number of children who have either zero doses of vaccines or who are undervaccinated for where they should be increased substantially during the course of the pandemic. And unless that's addressed, what that means is that we can expect that we will see increases in outbreaks of measles and other vaccine-preventable diseases over the future. So one of our top priorities is to address that gap. We know it exists, and we know that about two-thirds of the undervaccinated children are in 10 countries around the world. So that helps us to focus our efforts and make sure that we're really going to where the need is the greatest. I mentioned HIV as an example of success. During the coming year, we also expect to see increases [in cases] and really are pushing towards trying to accelerate towards meeting those final goals of PEPFAR and getting all of the people with HIV access to care. You described how, when the pandemic erupted, everyone suddenly refocused and was able to keep their own priorities in mind, but also go all-in on the COVID-19 response. Is that a workable system? Or does the U.S. government need a completely new platform that's specifically built for pandemic prevention and response in anticipation of whatever comes after COVID-19? I think this is a workable system that we can build on. You need to have a system where the people who are there aren't just narrowly able to address one thing, but are able to broadly address whatever comes up. And I think that's what CDC is really good at, and especially in our overseas settings where we're very good at collecting and using information to advance policy and practice. That is something that applies whether it's a case of Ebola that arises or a case of COVID that arises or measles or whatever it is. I think the foundation of having highly skilled individuals with epidemiologic training who are in-country partnering with ministries, engaging with local partners, and aware of the local context is exactly the foundation we need to build on. Then from that, we need to look at the gaps that existed and how to address those gaps.