The U.S. global health regime can hang its hat on many impressive accomplishments over the last decade. Beginning under the George W. Bush administration, the President’s Emergency Plan for AIDS Relief, for example, has funded antiretroviral treatments for over 2.4 million people. Thanks to the U.S. President’s Malaria Initiative, more than 30 million insecticide-treated bed nets have been distributed worldwide. Under the Obama administration, the U.S. Feed the Future initiative has helped reshape the way the global development community thinks about food aid by promoting in-country systems and focusing on agricultural self-sufficiency and sustainability.
But because Washington has frequently fallen short in its efforts to synergize its primarily disease-targeted global health programs, as well as the seven federal departments and four independent agencies responsible for their implementation, delivery gaps and inefficiency were becoming far too commonly associated with American foreign health assistance programming. Even some U.S. aid recipient governments have voiced discontent over rivalry, program duplication, and mismanagement among the various U.S. health agencies on the ground in their countries. A recent report by the Center for Strategic and International Studies assessing PEPFAR in South Africa, for instance, calls poor coordination between the U.S. Agency for International Development and Center for Disease Control and Prevention a “significant shortcoming.”
In May 2009, the Obama administration announced its Global Health Initiative – a $63 billion commitment to refocus efforts on improving the overall health of communities, instead of fighting diseases in isolation, through pursuing coordination and integration within the U.S. global health architecture, as well as strengthening health systems.
“We’re shifting our focus from solving problems, one at a time, to serving people, by considering more fully the circumstances of their lives,” Secretary of State Hillary Clinton said in remarks delivered in August 2010.
On the most basic level, GHI is a set of principles that helps guide and govern how the U.S. government functions and spends money in the 80 countries where the U.S. implements health programs. More profoundly, GHI was developed in the same spirit of country partnership as Feed the Future and the broader USAID FORWARD reform effort (which seeks to transform the way the largest U.S. development agency does business). As such, GHI mandates that the U.S. collaborate more closely with recipient countries to encourage them to assume more leadership and ownership of health programs. All four of GHI’s standard implementation components directly or indirectly support this theme.
Even though these principles will be applied in every country that receives American health assistance, GHI is now focusing its resources on a subset of 29 countries in sub-Saharan Africa (19), Asia (7), Latin America and the Caribbean (2), and Eastern Europe (1). The first batch of eight focus countries (Bangladesh, Ethiopia, Guatemala, Kenya, Malawi, Mali, Nepal, and Rwanda) was announced back in June 2010, with the designation of the second batch of 21 following in November of last year. According to the U.S. government, these countries were selected for additional financial and technical assistance based on a wide range of factors such as: interest in participation; existence of a health information system; health programming in at least three program areas (e.g. HIV/AIDS); and magnitude of health problems. The U.S. also emphasizes that these focus countries were intended to serve as “learning laboratories,” providing lessons for GHI implementation moving forward.
While some prominent members of the development community have criticized the pace of GHI’s implementation, few have questioned its underlying principles and ultimate objectives. And recent progress suggests that the initiative is on a markedly better track today even as political deadlock and budgetary problems in Washington threaten major foreign affairs programs. Specifically, despite being announced over two years ago, in 2011 the Obama administration rolled out an official GHI strategy document and appointed an executive director to lead the initiative. At least 43 countries have completed or are in the process of developing country strategies. There has also been observable headway in the focus countries where GHI implementation has received the most energy and attention. In Kenya, for instance, CSIS found “meaningful work” toward developing a more cohesive model of integrating U.S. programs. The Global Post reported that the initiative has paved the way for new avenues of communication between U.S. government agencies implementing health programs in Rwanda.
Of course, realizing the intended benefits of GHI will continue to be a test for the Obama administration which conceived it or, depending on the 2012 election results, the Republican administration which adopts it. While there are mixed signs about whether or not other donors are trying to replicate the GHI model, the U.S. government provides over half of all public spending on global health so Washington is in an unparalleled position to influence the rest of the donor community. Recipient country governments must also prioritize public health and make concurrent investments if the promise of GHI is to be realized. The following is Devex’s assessment of some of the key issues that will impact GHI in 2012 and beyond.
Organizational leadership and structure
In January 2011, over 18 months after the initiative’s launch, the Obama administration named former Clinton senior advisor Lois Quam as GHI’s executive director. Quam has been charged with facilitating coordination of GHI programs, as well managing the initiative’s transition from the State Department to USAID which will take place in 2012, assuming USAID meets management benchmarks outlined in the Obama administration’s Quadrennial Diplomacy and Development Review. Due to her close relationship with Clinton, Quam’s appointment to an office almost exclusively dedicated to harmonizing U.S. global health efforts served as a much-needed signal that the administration is committed to seeing GHI through.
To the astonishment of some observers, PEPFAR, which claims over four-fifths of the six-year GHI budget from fiscal 2009 to fiscal 2014, will remain under the Office of the Global AIDS Coordinator at the State Department. A Center for Global Development blog post argues, with OGAC already responsible for coordinating PEPFAR’s implementing agencies including USAID, “everybody will be coordinating each other.” This has prompted Congress to step in, requiring a status report on GHI’s transition to USAID, as well as a study to determine the costs of moving OGAC to USAID. The danger here is that if GHI lacks budgetary authority over individual programs, then leaders such as Quam might not have enough influence to compel government agencies to comply with GHI’s principles and protocols.
Many in the global health community have praised GHI for heralding a shift away from vertical programs, those largely focused on specific diseases, toward horizontal programs that emphasize health system strengthening. In late 2009, USAID submitted the first-ever report outlining its priorities in the area to Congress. According to the World Health Organization, key elements of a viable health system include policy, financing, human resources, supply system, service management, information, and monitoring systems. For now, however, it appears that actionable GHI targets remain largely disease-oriented (e.g. achieving a 70 percent reduction in malaria burden), as metrics to assess the robustness of health systems are still being developed.
The delay is not surprising considering that metrics for health system strengthening, coordination and integration are more complicated to develop and track than those for disease-specific initiatives. This is a common cause of concern among development experts such as Jeffrey Sachs, who argues that it is easier to mobilize funding for initiatives where the “donors can see what the programs need.” The absence of effective metrics casts doubt on whether or not GHI has been thoroughly conceptualized and strategized. The gap between Obama’s GHI announcement and the time when the wheels began to turn did not help the matter. With every foreign aid dollar being scrutinized by the U.S. Congress, metrics that prove performance and positive outcomes are more important now than ever.
The bulk of the $63 billion figure touted by the Obama administration is not actually new money. The figure merely marries pre-existing funding streams for global health and ties them under GHI. It is important to note that a small percentage of U.S. global health activities are not included in the GHI budget, such as those under the Millennium Challenge Corp.
Anti-AIDS advocates call attention to the fact that while GHI promises $51 billion (81 percent) for PEPFAR from fiscal 2009 to fiscal 2014, Congress had already authorized $48 billion for the same program from fiscal 2009 to fiscal 2013. More troubling, some analysts are contending that GHI is likely to miss its $63 billion funding target by as much as a third as a result of Washington’s budget tightening. While President Barack Obama’s 2012 GHI budget of $9.8 billion represents a 10 percent increase from the year before, Congress is poised to slash that request by at least $840 million. Before the cuts, GHI was planning to add 13 countries to its roster.The aggressive addition of 21 countries in November goes a long way to prove to Congress and other stakeholders that GHI is on the right path, but it will not necessarily result in Congress sparing global health programming from further cuts.
Balancing the global health portfolio
In line with GHI’s pledge to more holistically address global health challenges, administration officials have promised to pursue a balanced portfolio that ensures program areas beyond those covered by PEPFAR enjoy adequate support. An oft-cited 2009 report by the Institute of Medicine recommended that 52 percent of the U.S. global health budget support HIV/AIDS programs, only slightly below the 57 percent requested for GHI by President Obama in 2012. In fiscal 2007, HIV/AIDS programs had accounted for 62 percent of what is now the GHI budget. The president’s 2012 budget proposes year-on-year funding increases of 67 percent for nutrition and 54 percent for maternal and child health – key areas under GHI that will help diversify and balance the country’s health aid portfolio. But modest realignments in U.S. global health spending will always attract a fair share of critics. Leading voices in the global AIDS community, for example, have warned the Obama administration that with the number of new infections still rising even as antiretroviral drugs prolong the lives of HIV patients, now is not the time to put AIDS on the backburner.
Engagement with multilateral organizations
The GHI strategy document states that strengthening and leveraging multilateral organizations is a key principle of the initiative. With little change from years before, President Obama’s budget for fiscal 2012 allocates 16 percent of the GHI budget to multilateral organizations, the bulk of which goes to the Global Fund to Fight AIDS, Tuberculosis and Malaria. In 2010, President Obama pledged $4 billion from 2011 to 2013 for the Global Fund, a 38 percent increase from the previous three-year commitment, keeping intact the U.S. position as its leading supporter. The Global Fund’s decision to cancel its next funding round due to insufficient resources has sparked calls for the Obama administration to marshal support for the institution in this time of distress. According to a report by a coalition of leading global health advocacy groups, U.S. contributions to the Global Fund have historically mobilized contributions from other funders at a rate of about two to one.
Others have called upon the Obama administration to more closely engage with its multilateral partners in order to harmonize the efforts of the over 40 donors, 26 U.N. agencies, and 20 global and regional funds involved in global health. Many global development practitioners and analysts agree that developing countries would benefit from streamlining programs across the global health enterprise, beyond just the confines of the U.S. aid architecture. The GHI strategy document explains that the U.S. will only explore models for harmonizing various donor efforts at the country level.
Key conclusions for implementing partners
GHI commits to engage and collaborate with both the private sector and civil society. The AIDS, Population, and Health Integrated Assistance Program in Kenya offers some guidance for prospective partners. Demonstrating all that is possible when barriers between individual program areas are broken down, APHIA clinics offered women a wide range of health services including HIV counseling, tuberculosis screening and antenatal and postnatal care. A consortium of U.S. nongovernmental organizations that included PATH, JHPIEGO and World Vision implemented the USAID-funded project.
Many in the global health community have their own suggestions for furthering GHI’s engagement with prospective partners in the private sector and civil society. Global health advocacy groups have called upon the Obama administration to follow the example of the Global Fund in requiring the mandatory participation of civil society in the development of GHI country strategies. Others say that the Obama administration should consider establishing an entity responsible for pursuing private sector partnerships for global health programs, similar to the private investment center for the Feed the Future. These times of austerity will likely force the U.S. government to redouble its efforts to reach out to private sector co-financiers, perhaps opening the door to new public-private partnership opportunities.
As U.S. global health programs move further away from treating diseases in isolation, demand will likely increase for implementing partners, perhaps formed in a consortium, which can offer expertise beyond one or two program areas. On that basis, major tenders under GHI may require bidders to explain their own more rounded approaches to health, willingness to partner, and in-country experience as opposed to global expertise in a single area. One GHI program in Vietnam, for example, is being implemented by a diverse set of partners which includes nongovernmental organizations (Management Sciences for Health, FHI 360), consulting firms (Chemonics International, Abt Associates) and research institutes (Harvard Medical School, Vietnam’s National Institute of Hygiene and Epidemiology). GHI’s focus on country ownership and sustainability will also likely require international bidders to get to know smaller, in-country partners to assist during both bidding and implementation. In view of GHI’s commitment to rebalancing the U.S. global health portfolio, prospective partners with expertise in nutrition, maternal and child health, as well as neglected tropical diseases can expect demand for their services to grow as well.
Lorenzo Piccio contributed to this report.