In this Lancet opinion piece, Jennifer Kates, vice president and director of global health and HIV policy for the Kaiser Family Foundation, and Josh Michaud, principal policy analyst at the Foundation, examine the U.S. Global Health Initiative (GHI), which “represents the bulk of the U.S. global health budget and bilateral activities in more than 80 countries.” Kates and Michaud provide a brief overview of the initiative, identify the principles upon which it was founded and say that four years into the GHI, “The picture is one of both successes and challenges.”

While only 55 percent ($35 billion) of GHI’s original $63 billion budget has been appropriated, the initiative “has pushed for stronger coordination” among U.S. Government agencies and has “consolidated services and reduced parallel systems in some countries,” they note. Kates and Michaud discuss a number of challenges GHI faces, “including its leadership structure at the State Department that lacks statutory or budget authority to coordinate across agencies and programs”; the fact that potentially later this year, “GHI coordination function will move to USAID but without PEPFAR,” which represents more than 70 percent of GHI’s budget; and “that Congress typically designates funding streams for specific global health programs individually,” a “structural barrier to integration.” They note that GHI is an attempt to move away from vertical programs and establish an “overarching strategy or coordinating mechanism” for U.S. global health programs; that GHI’s “roll-out coincided with the global economic crisis that has altered fundamentally the fiscal environment in Washington”; and that it “has also been hard to ‘sell’ integration and coordination to policymakers and the public, even if health experts recognize that such an approach is better and more cost effective than a vertical approach.” Kates and Michaud conclude, “The GHI has to some extent been a victim of unfortunate timing, but it has also perhaps underestimated the governance and structural challenges of integration — challenges that fall both to the Administration and Congress. At the same time, the GHI represents a move beyond a polarizing, and unresolvable, dichotomy between vertical and horizontal approaches to global health” (5/26).