Major U.S. Policy Issues

First | Prev | Next | Last

By its nature, global health policy can at times be driven by external events, such as infectious disease outbreaks, wars, and humanitarian crises. However, these crisis-driven situations aside, a number of major policy issues are emerging that could affect the future of U.S. global health programs. These include:

Increasing global health funding: While needs in low- and middle-income countries have not diminished in the current economic climate -- and instead have likely increased -- budgetary pressures in the U.S. and other developed countries could make it more difficult to expand aid than in recent years. Funding for global health has increased substantially over the last few years, but still falls short of the need identified by health organizations. For example, UNAIDS estimates that about $6.5 billion in additional resources were required in 2008 to provide HIV/AIDS treatment and prevention to those in need. As the number of people being treated for HIV/AIDS grows, there will be added pressure to maintain funding since the disease as of now requires people to take drugs for the rest of their lives. In addition, the recent change in WHO treatment guidelines recommending that people who are HIV-positive start antiretroviral drug therapy earlier increases the resources required to treat all those in need. Attention focused on the targets in the Millennium Development Goals as the 2015 deadline nears may also create pressure for increased global health funding. The High Level Taskforce on Innovative International Financing for Health Systems -- a group made up of leaders from donor and low-income countries and international institutions -- has recommended that an additional $36-45 billion (.pdf) per year would be required to fund health services in low-income countries in order to meet health-related Millennium Development Goals.

At the 2009 G8 summit in L'Aquila, Italy, leaders reaffirmed existing commitments to provide $60 billion to address infectious diseases and strengthen health systems by 2012, and to "implement further efforts towards universal access to HIV/AIDS prevention, treatment, care and support by 2010." In the coming years, expectations for the U.S. will likely be high, since it is by far the largest single donor in the world in dollar terms, yet not as a share of GDP. A 2009 report from the Institute of Medicine recommended that the U.S. increase its spending for global health assistance to $15 billion per year by 2012. The Bill & Melinda Gates Foundation in 2009 launched the Living Proof Project, which aims to "highlight successes of U.S.-funded global health initiatives" in order to "reframe the current global health conversation."

In a November 2009 Kaiser Family Foundation poll, two-thirds of the U.S. public supports maintaining (32%) or increasing (34%) spending on global health, while a quarter says the country is spending too much.

Setting priorities for new global health funding: There's broad agreement that funding for global health -- from donor governments like the U.S., private philanthropies, and developing countries themselves -- falls well short of the estimated need. And to the extent that continues to be the case, any budgetary increases for global health will require decisions about how to allocate that funding, and debate over those priorities will likely be contentious. The President's Global Health Initiative builds on existing programs to address HIV, TB, and malaria, while calling for an expanded focus on maternal and child health, family planning, neglected tropical diseases, and broader efforts to strengthen health systems. It will likely continue to focus attention on how U.S. global health resources are spent.

Among the key questions are:

• Should more money be provided for general support to strengthen health systems in low-income countries? This is often framed as a question of the extent to which global health aid should be "vertical" (e.g., focused on the gamut of services and needs related to a specific disease) or "horizontal" (e.g., focused more generally on supporting the health care infrastructure in a country). Current U.S. aid is largely vertical. Some argue (.pdf) that disease-specific funding can result in the creation of health programs and services separate from a country's broader health system, and may draw health workers away from other needs. Others suggest (e.g., see here and here) that this is in some sense an artificial distinction, pointing to evidence that HIV/AIDS investments, for example, have strengthened health care infrastructures and contributed to reduced infant mortality and TB incidence.
  
• Should a greater emphasis be placed on lower-cost interventions or diseases that have received less attention in recent years? Some argue that U.S. aid decisions should be guided to a greater extent by the cost-effectiveness of different approaches. There is not, however, universal agreement around how to measure cost-effectiveness (e.g., based on costs per disability adjusted life year saved, or on broader analysis that takes into account effects on economic stability and growth). In a commentary (subscription-only) in the Journal of the American Medical Association, Colleen Denny and Ezekiel Emanuel (now an Office of Management and Budget official) point to proposals to increase PEPFAR funding and write that "by extending funds to simple but more deadly diseases, such as respiratory and diarrheal illnesses, the US government could save more lives -- especially young lives -- at substantially lower cost." A letter to the editor in response argues that U.S. PEPFAR funding supports a broad range of health services and that because HIV/AIDS primarily affects young adults, it "undermines economic development." The authors suggest the "fundamental problem" is the "lack of adequate funding for global health programs generally.) A recent letter to President Obama signed by a number of academic public health leaders makes similar points, proposing a scale-up of HIV treatment and prevention service.
  

Increasing coordination across global health programs: Global health policy in recent years has been characterized by new, often disease-specific initiatives (e.g., PEPFAR and the President's Malaria Initiative). This is in addition to multilateral initiatives such as the Global Fund. This fragmentation may lead to inefficiencies and create added administrative burdens for countries receiving aid, and make it more difficult to ensure that programs operate strategically to strengthen health systems and foster development. Especially in a time of fiscal constraint, there may be a particular focus on ensuring that programs operate efficiently and with minimal duplication of effort and administrative overhead. The President's new Global Health Initiative calls for an "integrated approach to global health" and may drive changes that result in greater coordination across programs. A 2009 Institute of Medicine report also recommended that government programs be made "more flexible to permit funds to support not only specific interventions, but also to more broadly strengthen recipient nations' health systems." At the same time, efforts to coordinate policymaking and programs across multiple agencies and existing bureaucracies can be challenging, and raise issues about how much day-to-day control should rest with departments vs. the White House. In addition, budget appropriations for global health aid have historically targeted specific diseases and programs, and in some cases oversight rests with different Congressional committees. Efforts to coordinate programs across multiple donor countries and multilateral institutions face additional challenges.

Balancing bilateral and multilateral aid: A fundamental decision for countries providing assistance for global health is how much aid to funnel through bilateral channels and how much through multilateral international institutions. This tension has heightened in recent years with the creation of the Global Fund, which now provides about one-quarter of international financing for HIV/AIDS and about two-thirds for malaria and TB. The Global Fund is financed largely through contributions from higher-income governments, and the U.S. is the largest single donor. The creation of PEPFAR led to large increases in U.S. bilateral global health aid -- particularly for HIV/AIDS -- with annual Congressional budget deliberations often focusing on how much new money should go towards bilateral programs vs. the Global Fund. In FY 2008, 88% of the U.S.'s HIV/AIDS assistance was bilateral, higher than all other major donors except the UK.

From the perspective of recipient countries, there are distinct advantages to multilateral aid, in particular that it streamlines application and reporting activities, and generally allows them to more easily align funding with their priorities. However, donor countries ultimately have less control over multilateral assistance. Proponents of bilateral aid in the U.S. argue that it ensures greater accountability for funds, though such accountability requires a large on-the-ground field presence (which is more feasible for bigger countries like the U.S.). The debate over how best to structure U.S. global health assistance will likely continue, particularly as the Global Fund struggles to attract sufficient funding to maintain, if not expand, the programs it supports. The Obama Administration has placed a new emphasis on multilateral institutions and international cooperation, though it remains to be seen whether that will translate into a shift in funding.

Linking global health and foreign policy: Historically, development assistance programs have generally been distinct from -- and in some cases subsidiary to -- diplomatic and military aspects of U.S. foreign policy. A brief from experts at CSIS and the Kaiser Family Foundation finds a "fault line" between public health and foreign policy based on their different "culture, language, rationale and values." A report from the Council on Foreign Relations suggests that the U.S. should "elevate the importance of development as a core aspect of U.S. global engagement, on par with and reinforcing (but distinct from) defense and diplomacy." Secretary of State Hillary Rodham Clinton said in a January 2010 speech that development "is a strategic, economic, and moral imperative -- as central to advancing American interests and solving global problems as diplomacy and defense."

Proponents of a stronger linkage between global health and foreign policy argue that failure to address health issues in lower-income countries could promote instability and undermine U.S. interests. Some have also promoted the idea that an emphasis on "health/medical diplomacy" could improve perceptions abroad of the U.S. and support foreign policy aims, in addition to providing assistance to people in need (examples here and here). This is a variant on the concept of "smart power," which the CSIS Smart Power Initiative describes as the need for the U.S. to "revitalize its ability to inspire and persuade rather than merely rely on its military might."

Others caution that a closer linkage between health aid and foreign policy that makes development assistance subsidiary to diplomacy could lead to decisions about aid allocation (e.g., across countries) that are influenced more by short-term political or national security considerations than by need. A brief (.pdf) from Oxfam America argues that while the goals of diplomacy and development "often coincide, protecting US interests overseas does not always mean fighting poverty." They suggest development and diplomatic activities should be coordinated, but "must occur in a way that does not detract from the US government meeting either its development mission or its diplomatic mission."

There are also efforts underway to review and reform foreign aid (.pdf) more generally, including addressing the fragmentation of assistance across multiple agencies and departments, as well as the role of USAID. A review of 14 studies by the Congressional Research Service found a consensus that "foreign assistance must be reformed to improve its effectiveness." Any changes could have significant implications for global health assistance and the President's Global Health Initiative.

The State Department in 2009 initiated a process called the Quadrennial Diplomacy and Development Review (QDDR), which "will provide the short-, medium-, and long-term blueprint for our diplomatic and development efforts." Along with the QDDR, President Obama has issued a Presidential Study Directive calling for a review of global development policy throughout the government. In addition, there are bills being considered in Congress to reform foreign assistance, including: S.1524, sponsored by Senators John Kerry (D-Mass.) and Richard Lugar (R-Ind.); and H.R. 2139, sponsored by Representatives Howard Berman (D-Calif.) and Mark Kirk (R-Ill.).

Implementing a new strategy for PEPFAR: As the single largest component of U.S. global health aid, the PEPFAR program is central to deliberations over a broad range of policy issues. Six years into the initiative -- and following on its reauthorization by Congress in 2008 -- there are ongoing discussions about how PEPFAR's structure and strategy should change, and it's relationship to President Obama's Global Health Initiative.

A five-year strategy document released by PEPFAR in late 2009 lays out a number of new directions and strategies, including: transitioning from an emergency response to promotion of sustainable country programs over time; moving towards programs that are "country-owned" and "country-driven;" addressing HIV/AIDS within the context of health systems more generally and broader development efforts; linking HIV/AIDS programs to other services and needs for women and children; providing direct support of treatment to 4 million people (double the number for the first five years of the program), as well as increasing the emphasis on prevention; and taking steps to improve the efficiency of programs.

Many of these goals are also central to the GHI.

Meeting the Millennium Development Goals: The U.S. was one of the 189 countries to sign the United Nations Millennium Declaration (.pdf) adopted by world leaders at the U.N. General Assembly meeting in September 2000 with the goal of halving extreme poverty by 2015. The aims in the declaration have become known as the Millennium Development Goals (MDGs), many of which relate to health:

Goal 1: Eradicate Extreme Poverty & Hunger

Goal 2: Achieve Universal Primary Education

Goal 3: Promote Gender Equality And Empower Women

Goal 4: Reduce Child Mortality

Goal 5: Improve Maternal Health

Goal 6: Combat HIV/AIDS, Malaria And Other Diseases

Goal 7: Ensure Environmental Sustainability

Goal 8: Develop A Global Partnership For Development

The latest report from the U.S. government on the country's MDG commitment was released in 2008 during the Bush administration and is available here. It lists the following as key components of the U.S. MDG strategy: "country ownership and good governance; pro-growth economic policy; investing in people; addressing failing and fragile states." The report notes improvements in life expectancy, literacy, infant survival and caloric intake, while indicating that MDG progress has not been uniform, particularly in "fragile states which are most likely to fall short on specific indicators by 2015."

In his first speech at the U.N. General Assembly in 2009, President Obama said, "We will support the Millennium Development Goals, and approach next year's summit with a global plan to make them a reality. And we will set our sights on the eradication of extreme poverty in our time." The U.N. will hold a high-level plenary meeting in September 2010 with the goal of renewing support and funding for the MDGs among all stakeholders.

In January 2010, Secretary of State Hillary Rodham Clinton pledged U.S. support for MDG 5 by improving women's access to reproductive health care. Clinton said, "This goal is, again, critical to and interconnected with every other millennium development goal. But the world has made less progress toward fulfilling that goal than any other."

A 2009 MDG report (.pdf) from the U.N. shows mixed progress, with notable successes in fighting malaria, dramatically reducing measles deaths, and increasing access to antiretroviral treatment for HIV/AIDS tenfold over a five-year time span. The report indicates that most countries have demonstrated poor performance in reducing maternal mortality and increasing access of the rural poor to improved sanitation facilities.

The U.N. report points to progress being threatened by the economic crisis and "possible reductions in aid flows from donor nations." As the 2015 deadline approaches, assessments of progress towards meeting the MDGs could play a major role in debates over the level and allocation of aid from the U.S. and other higher-income countries.

Raising the profile of women and girls in the context of health: Women and girls are disproportionately affected by many global health issues in the developing world. Contributing factors include an increased risk of living in poverty, fewer opportunities for girls to receive an education, a lower likelihood of access to health services and programs, and a lack of legal protections and political influence in many developing countries.

Within the U.S. government there is new attention to the role that empowering women can play in tackling health and development challenges. President Obama created within the State Department an Ambassador-at-Large for Global Women's Issues, who deals with foreign policy topics and activities that relate to women's advancement around the world. The President's Global Health Initiative emphasizes improving maternal and child health and access to family planning and reproductive health. Secretary of State Clinton has also elevated women's rights on the U.S. policy agenda, often meeting with local women's groups on trips overseas and highlighting their causes.

One of President Obama's first acts as president was to repeal what is known as the "Mexico City Policy," which was instituted under the Reagan Administration to ban U.S. funding for international health groups that use their own funds to perform abortions, lobby their governments in favor of abortion rights or provide counseling about terminating pregnancies. Lifting the ban enables Congress to authorize funding, which the 111th Congress has done. In addition, funding for the U.N. Population Fund has been restored, after having been withheld for seven years under the Bush administration over concerns about forced abortions in China.

Looking more broadly, the U.N. in September 2009 approved a plan to bring four existing entities dealing with women's issues into one full-fledged U.N. agency that would be headed by an under-secretary general. It is believed that once it is operational, the agency will bring more political and financial clout to women's issues within the U.N. system.

First | Prev | Next | Last