Reading the Tea Leaves on U.S. Global Health Policy

2016 could be a consequential year for U.S. global health policy. The U.S., along with the rest of the world, enters the post-2015, post-Paris climate conference period of international development just as new and re-emerging crises and security concerns crowd the foreign policy agenda.  Moreover, in the U.S. political context, a new President will be voted in after eight years of the Obama Administration and elections for House and Senate seats will bring in new lawmakers and leadership.

How will the global health policy baton be passed to new leaders in the U.S.?  Could these looming transitions upset what has thus far been durable bipartisan support for U.S. global health programs?  Or do they present opportunities to forge new consensus going forward?  A year ago, we identified key questions on global health facing the last two years of the Obama Administration.  Today, we look at the prospects for the future drawing on the latest in our series of polls of the American public, new research on the opinions of global health and foreign policy leaders, and our recent event featuring an expert panel discussion on the U.S. role in global health.

Bipartisan Consensus on Global Health May Be Tested

Strong bipartisan support for global health has existed for more than 15 years, but whether such support would continue is an open question. Today, in the midst of a highly partisan Presidential campaign season, this question is even more salient.  Indeed, beneath the larger consensus on global health – one that supported the creation of major new initiatives, including the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI), and has protected global health from funding cuts – there are growing signs of partisan divides.  While U.S. global health efforts have been viewed favorably by a majority of Americans and have had the support of Congress for many years, an overall narrative supported by our latest poll and research findings, there is also some evidence of growing divisions by party and ideology, suggesting that global health may now be more vulnerable to the same partisan tide seen in the wider U.S. political system.

Our latest poll finds, for example, that among the American public, most Republicans think the U.S. is already doing enough to improve health in developing countries (68%) while Democrats say the opposite (52%). Republicans are also much more likely than Democrats to say that the U.S. is contributing more than its fair share to address global health (62 % vs 34 %). More Republicans say the U.S. spends too much on improving health in developing countries than say it spends too little (40% vs 13%), while more Democrats say the U.S. spends too little, rather than too much (37% compared to 20%). While these party differences have existed since we began polling on this topic in 2009, they have widened.

When global health and foreign policy experts are interviewed, their responses also differ by political persuasion. Right-leaning experts saw supporting global health funding as more of a political liability than a benefit, while those on the left believe that support for global health spending among members of Congress is relatively secure. Right-leaning experts also felt the U.S. was doing too much overseas and would be better off spending its money domestically, similar to the views of the American public.  Canvassing experts from across the political spectrum found little expectation that U.S. spending would rise in the future; rather, the U.S. faces a “status quo” global health budget at best with differences between the parties on how funding should be allocated within that fixed funding envelope.

Furthermore, global health programs have to battle against political complacency and fatigue, as well as a more crowded development and foreign policy agenda. Whereas global health comprised three of the eight of the now expired Millennium Development Goals, health is the focus of one of the seventeen new Sustainable Development Goals. At the recent climate change summit in Paris, global health was almost completely absent from the discussion despite health being one of the most immediate direct impacts that climate change has on human populations. Notably, global health is just a small part of the State Department’s most recent strategy document, the 2015 Quadrennial Diplomacy and Development Review (QDDR), despite the fact that State is home to PEPFAR and that global health comprises a large share of the US development assistance budget.

But the Glass is Not Empty and Maybe Half Full?

Despite such challenges, the research also contains good news for global health, with areas of strong bipartisan consensus. The fact that the core U.S. global health budget has remained mostly unchanged for the past several years – during a time of fiscal austerity – registers as a clear vote of confidence from policymakers of both parties. In addition, our polling finds that most of the public, including a majority of Democrats, Republicans, and Independents, still believe the U.S. should stay the course on global health spending or spend more than it does currently.  Moreover, the public at large, along with the foreign policy and global health experts, feel that U.S. support for global health remains indispensable from a humanitarian and a national security perspective, and both send the message to keep doing more of what has been working. This means collaborating with partners to build on prior successes such as reducing child mortality and scaling up HIV treatment, and addressing the needs of mothers, and women and girls. Americans of all political leanings place a high – and growing –priority on U.S. government participation in international efforts with others, vs going it alone, to improve health overseas. In 2009, 55% of Americans agreed with the sentiment that the U.S. should participate in such efforts; by the end of 2015 the share had grown to 68%.

Another area of indisputable consensus is around the concept of health security. The public and experts on the left and right agree that one of the most important things the U.S. can do through global health efforts is to protect the lives of Americans by preventing the spread of deadly diseases. In fact, in the wake of Ebola, the American public rated this as the most important reason for the U.S. to be engaged in global health and it was a particular emphasis of experts interviewed on the left and right.

Many of these themes were echoed at our recent event, with panelists underscoring the strong place global health has had on the political agenda, even as they acknowledged that the shifting political context creates some uncertainties.

What does this all mean?

Among the U.S. public, partisan differences have been present for some time so it is not clear if the fissures highlighted in our research will jeopardize a future consensus on global health or are just par for the course in a politically divided time. With each election cycle, prior champions of global health leave and new policymakers enter; by our count only a third (32%) of the current members of Congress were in office when the flagship U.S. global health program, PEPFAR, was first authorized in 2003 and only 45% when it was reauthorized in 2008. Maintaining solid bipartisan support for global health in the future will be dependent on bringing new policymakers into the fold by informing them of the broad public support these programs have and their record of success. The much more crowded foreign policy and global development agenda will present challenges for attention to global health, within the likelihood of an at best fixed budget. Given the current era of financial austerity there is likely to be little appetite for grand new initiatives that carry a price tag, but strong support for doing what has worked remains a core value.