A Reporter's Guide to U.S. Global Health Policy
Current Issues in U.S. Global Health Policy
U.S. global health policy is driven by many factors, such as infectious disease outbreaks, wars, and humanitarian crises. In addition, decisions about U.S. global health programs are influenced by broader debates about health, foreign policy and development priorities, as well as the larger economic and political context in the U.S. and around the world. While there are many questions and challenges related to how the USG approaches global health, some overarching and timely issues include:
Funding for global health increased substantially over the last decade—collectively, major donor governments provided more than $18 billion in funding for global health in 2010. However, the health needs of low- and middle-income countries continue to be significant and budgetary pressures in the U.S. and other donor countries have made it more difficult to expand aid to meet those needs. Funding falls short of the need identified by health organizations. For example, UNAIDS estimates a resource gap of $7.2 billion annually to address the global HIV/AIDS epidemic.
The U.S. government is the single largest bilateral donor for global health and while global health has been a policy priority and funding has fared relatively well in the national budget, it has begun to flatten and the Obama administration’s Fiscal Year 2013 budget request for the first time requested less global health funding than the previous year. The trend of stagnant or lower funding levels may well continue given the current economic environment and may have implications for U.S. global health programs, as well as the multilateral programs the U.S. supports, and has raised concerns about sustainability and ongoing success of U.S.-supported global health efforts. It has also led to increased attention to the role played by emerging donors, such as China, India and Brazil, and recipient country governments in financing global health.
Bilateral vs. Multilateral Aid
A fundamental decision for countries providing assistance for global health is how much aid to funnel through bilateral channels vs. multilateral institutions. This tension has heightened in recent years with the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), which now accounts for one fifth of international funding 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 funder of the Global Fund.
Proponents of bilateral aid argue that it ensures more control over assistance and greater accountability for funds, though such accountability generally requires a substantial on-the-ground field presence, which may be more feasible for larger donor countries like the U.S. On the other hand, multilateral aid may have certain advantages, including allowing donors to expand their reach and pool funding, and streamlining administrative and reporting processes for recipients (compared to separate reporting to multiple donors), as well as permitting greater ease in aligning funding with their own priorities, compared with bilateral programs.
Most U.S. funding for global health is provided bilaterally, although in recent years, the share allocated to multilateral institutions has increased and strengthening relationships with multilaterals has been a key principle of the Obama Administration’s global health and development policy.
In his FY2013 budget request, President Obama reduced bilateral spending for HIV to increase the USG’s contribution to the Global Fund, in large part to fulfill a multiyear pledge the Administration made to the Global Fund. However, this decision spotlighted the debate about the optimal balance of bilateral and multilateral aid. These discussions will likely continue, particularly as challenging economic times persist and as the Global Fund struggles to attract sufficient funding to maintain, if not expand, the programs it supports. Moreover, with increased emphasis on the importance of country ownership (see below) and concerns about sustainability, some have called for the need for a new global health architecture, including a more centralized financing mechanism.
With the potential for stagnant or even reduced funding levels for global health, major donors – including the U.S. – will likely face difficult choices about how to allocate resources. These choices will have consequences for a variety of global health stakeholders, particularly the people programs are intended to help.
The current U.S. global health portfolio includes programs/activities that address HIV, TB, malaria, maternal and child health, family planning and reproductive health, neglected tropical diseases, and nutrition, as well as broader efforts to strengthen health systems. HIV/AIDS funding through PEPFAR represents the vast majority of the global health budget. Some have argued that U.S. global health funding needs to be “rebalanced” to more accurately reflect:
- The impact of health problems on societies;
- The potential for making improvements with the interventions;
- The work of other donors, so as to avoid duplication of efforts;
- The cost-effectiveness of interventions (for example, is money better spent fighting the leading killers of children, which can be cheaper and easier to treat, or paying for a lifetime of HIV/AIDS medications?).
At the same time, others have noted that individual beneficiaries of health assistance face multiple health needs and such rebalancing could have negative consequences, including affecting recent positive trends in combatting diseases such as HIV and malaria, for example. With the recent prioritization by the U.S. government of efforts related to an “AIDS-free generation,” child survival and the health of women and girls, questions remain about the optimal distribution of resources – among these priority initiatives and among other U.S. health efforts. Additionally, as newer threats to health emerge and the attention on the role of non-communicable diseases grows (e.g. cancer and cardiovascular disease), priorities on the U.S. global health agenda will likely be debated.
Program Integration/Health System Strengthening
Traditionally, most U.S. efforts have been siloed by government agency and/or disease-specific initiative (e.g., PEPFAR and the President’s Malaria Initiative). This is often framed as a question of “vertical” aid (e.g., focused on the services and needs related to a specific disease or condition) or “horizontal” aid (e.g., focused more generally on supporting the health care infrastructure in a country).
Some argue that disease-specific funding can be inefficient, miss opportunities to build stronger infrastructure, and ultimately not achieve optimal health outcomes for people in low and middle-income countries who face much more than one disease threat or health challenge at a time. Others point to evidence that disease-focused programs have not only improved treatment and care for specific diseases/conditions, but also such strengthened overall health care infrastructures (as has been shown for HIV/AIDS efforts under PEPFAR).
With the announcement of the GHI in 2009 as the global health strategy of the USG, the Obama Administration aimed to refocus global health activities by developing and implementing a more comprehensive and integrated approach to its efforts, not only within the U.S. government, but with other stakeholders as well in order to leverage resources, enhance efficiencies and reduce redundancies.
There are numerous barriers to integration, however. One major barrier is that funding streams designated by Congress are typically appropriated by specific health issues, with specific accountability requirements, rather than for global health efforts as a whole, potentially making integration more difficult. In addition, it is often challenging to “retrofit” programs on the ground to achieve integration. Based on a recent KFF analysis of 15 GHI country teams and USG staff, integration has started to occur on the ground across programs, departments and agencies, and funding, however, challenges remain.
The creation of PEPFAR by President George W. Bush in 2003 marked a significant increase in funding and attention to the HIV epidemic. Initially authorized by Congress in 2003 as a 5-year, $15 billion initiative, appropriations from Congress over this period were higher, totaling nearly $19 billion. In 2008, PEPFAR was reauthorized by Congress for an additional 5 years (FY 2009–FY 2013) at up to $48 billion. PEPFAR now accounts for more than 70% of the U.S. global health budget. Many successes have been achieved and lessons learned since PEPFAR’s launch. As PEPFAR looks ahead to its next phase, there are several issues to consider:
- Because of the severe and expansive nature of the HIV epidemic when PEPFAR was started, its response was “emergency” in nature. Nearly a decade later, PEPFAR is moving to a sustained, country-led model. This will include engaging host governments in new ways and integrating a growing focus on health system strengthening.
- Balancing the distributions of funding that pertain to PEPFAR will become more pertinent in the future. These include striking the appropriate funding levels between HIV treatment, prevention, and care; between bilateral HIV programs and the Global Fund; and between HIV and other parts of the U.S. global health portfolio.
- With existing restrictions on how PEPFAR prevention money is spent, there will likely be future discussions of whether the U.S will take a more comprehensive approach to reducing sexual transmission of HIV and support harm reduction among injection drug users as part of its HIV prevention policy.
- The U.S. government recently announced efforts to create an “AIDS-Free Generation” by preventing mother-to-child transmission and promoting voluntary medical male circumcision and the use of treatment as a prevention strategy. However, many questions remain about how this will be achieved and how PEPFAR will be augmented. On World AIDS Day (December 1, 2012), the USG released a “blueprint” which outlines how it plans to carry out this initiative.
- Lastly, PEPFAR is technically due to be reauthorized by October 1, 2013, though funding for the program can continue without a reauthorization. As such, policymakers and other stakeholders are still considering whether and when a reauthorization might be needed.
The overarching idea of country ownership is that each recipient nation sets its own priorities for health and works collaboratively with donor countries. The end goal, which has become particularly relevant in the current economic environment, is the country will have primary funding and governance responsibility of its programs. A 2012 Ministerial Leadership Initiative for Global Health report set forth a plan for achieving country ownership. This plan is based on recipient country accountability and fiscal stewardship as well as civil society input, leading to greater access and equity in health care.
Developing countries have indeed boosted their own contributions to health in recent years. For example, UNAIDS reports that domestic funding to address the global AIDS epidemic grew by 15% between 2010 and 2011 and represents more than 50% of the global response. Yet, many challenges to country ownership remain, including concerns about corruption, the loss of donor control of funding decisions, and the ability of countries to take on financing and delivery of health programs.
The USG has made county ownership a key principle and goal of its global health efforts; PEPFAR in particular has been working with partner countries to develop transition plans. As these transitions take place, the relationship between the two governments will undoubtedly shift as will the way the USG “does business” in country.
The shift toward developing countries taking on more responsibility for leading, implementing, and funding their own initiatives is meant to ensure sustainability for these programs, and will likely affect how the U.S. and other donors interact with recipient countries in the future.
Global Health Diplomacy
The U.S. has a long history of diplomatic engagement on health issues, and both the Presidential Policy Directive on Development and the State Department’s Quadrennial Diplomacy and Development Review (QDDR) identify diplomacy as a key tool in addressing global health challenges. Recently, the U.S. elevated the role of diplomacy with the creation of the “Office of Global Health Diplomacy” at the State Department, but it remains to be seen how the new emphasis on diplomacy will be translated into concrete action, and how it will contribute to U.S. global health efforts going forward. As global health diplomacy becomes more prominent in the context of U.S. global health efforts, there are several challenges to consider including the potential for tensions between foreign policy and global health goals, the skilled diplomacy needed to help transition to greater country ownership of health programs, as well as a constrained fiscal environment.
Women and Girls as a Policy Priority
Many developing world health issues disproportionately affect women and girls. 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, a lack of legal protections and political influence in many developing countries, and gender based violence.
Within the USG there has been new attention to the role that empowering women and girls can play in tackling health and development challenges, particularly by the Obama Administration. Some recent U.S. policy developments related to the health and empowerment of women and girls include:
- A “focus on women, girls, and gender equality,” is one of seven core GHI principles. The principle aims to guide U.S. global health efforts in order to increase access to health services for women and girls and “redress gender imbalances related to health, promote the empowerment of women and girls, and improve health outcomes for individuals, families, and communities.” This principle has already had an impact on the content and planned directions of GHI country strategies, according to Kaiser Family Foundation reports on the subject. However, it is too early to assess its impact on the health of women and girls.
- The Obama Administration has increased attention to family planning and reproductive health as well as maternal and child health efforts through the GHI.
- The elevation of women and girls on the U.S. policy agenda more broadly is also evidenced by the creation of an Office of Global Women’s Issues within the State Department as well as the appointment of an Ambassador-at-Large for Global Women’s Issues; the announcement by Secretary of State Clinton of the first Secretarial policy guidance on promoting gender equality in U.S. foreign policy as well as her championing of women’s issues across the world; and the recently launch of USAID’s a new policy on gender equality and female empowerment.
While women and girls have been a policy priority of the current Administration, given the current budget constraints and changes in policy leadership, the extent to which these issues remain as a high priority is uncertain.
Meeting the Millennium Development Goals and the Post-MDG Agenda
The U.S. was one of the 189 countries to sign the United Nations Millennium Declaration in 2000, adopted by world leaders with the goal of halving extreme poverty by 2015. The eight 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 MDGs are reflected in U.S. global health efforts such as the goal of creating an AIDS-free generation and efforts to reduce child mortality. Ahead of the high-level plenary meeting in September 2010 to renew support for the MDGs, the U.S. government released its strategy for meeting the MDGs— “Celebrate, Innovate & Sustain: Toward 2015 and Beyond.”
According to the 2012 Millennium Development Goals Report, the world is on track to reduce the poverty rate to below the set goal. Significant progress was also cited in clean water, treating and preventing HIV/AIDS, and reducing child deaths. Still, the report notes that progress continues to elude the most poor and vulnerable. The U.N. has already begun formulating a post-MDG strategy that aims to build on the current momentum and facilitate an ongoing development agenda. While health has been identified as a key area for the post-2015 agenda, it remains to be seen how it will be reflected in new goals.U.S. Global Health Policymaking Official International Agencies and Multilateral Organizations