The U.S. Global Health Initiative is Dead: Long Live the U.S. Global Health Initiative!

Posted on by Laurie Garrett

On the eve of the Independence Day holiday, as the annual mass exodus from Washington commenced and most national reporters turned off their Blackberries and iPhones, the Obama Administration announced closure of its Global Health Initiative office, sparking social media-expressed outrage and confusion. From NGO health teams working in the trenches in Africa to global health pundits in both Washingtons outrage was tempered by concern and consternation. The official statement released to the public at the end of business on July 3rd only aggravated the confusion. And global health advocates remain perplexed at week’s end.

What is going on?

The take-home message is this: Congress has no appetite for increasing spending on foreign assistance or global health programs, and after two years of trying to juggle the relative roles and budgets of health and foreign aid agencies inside the U.S. government the State Department has decided to try Plan B. The overall health targets outlined by the Administration back in 2009 will not change, but how much money everybody has to work with, who actually runs operations on the ground, coordinates various agencies, and negotiates with other donor nations will swiftly transform.

For those of you that haven’t dedicated hours to tracking the U.S. foreign assistance bureaucracy this may seem a dreadful exercise in inside baseball, but I assure you that this matters. We have an American expression that neatly summarizes what is going on – “trying to get the biggest bang for the buck.” This is what happens when cataclysmic global economics meets austerity + dire global health needs, mixed inside an American bureaucratic Cuisinart.

Before 2003 when President George Bush announced his dramatic commitment to tackling HIV in Africa, spawning the multi-billion-dollar PEPFAR (President’s Emergency Program for AIDS Relief) effort, “global health” in Washington-speak was a pretty paltry business, featuring little money that was spread out over more than 47 agencies. For many health initiatives the biggest player was the Department of Defense or the U.S. Agency for International Development. Things were so poorly coordinated that a Minister of Health in a poor country might well spend 20 hours a week taking meetings with one U.S. government employee after another, each offering small pots of money aimed at tackling an incremental problem – sometimes with policy priorities that contradicted those expressed by other American officials.

It was, in short, a full-out mess.

In 2003-2006 PEPFAR grew so swiftly, bypassing all of those other agencies and their rules and regulations, that the program and concern about HIV/AIDS completely overshadowed every other global health priority by 2007, spawning resentment and cross-agency rivalries. From the outside, the American government’s foreign aid effort looked like well-intended chaos – or worse, a contractor-driven boondoggle. By 2007 a legion of organizations engaged in foreign assistance programs, think tank analysis of aid, and Washington lobbying was calling for reform of the entire U.S. foreign assistance apparatus. Chief among these was the Modernizing Foreign Assistance Network, formed by the CEOs of the largest American aid-distributing NGOs and humanitarian relief organizations, and the Gates Foundation-backed ONE Campaign. MFAN wanted foreign assistance elevated to Cabinet level in the U.S. government, as had recently happened for DiFID, seated inside the UK Cabinet with equal stature to Defense and the Home Office. MFAN also wanted radical change inside the foreign assistance establishment, whittling away at the influence of many agencies and elevating the power of USAID.

On one thing all observers agreed: U.S. foreign assistance was run by a woefully out-of-date 1961 statute, leaving aid agencies ill-prepared for 21st Century challenges. By the time Barack Obama was sworn in as President of the United States dozens of policy reports suggesting howforeign assistance might reorganize were circulating in Washington, including one I authored that focused on global health. The health activist community wanted enormous budget increases, especially for HIV/AIDS, Capitol Hill lobbying had become disease-specific and internally competitive, and there was bipartisan agreement that the status quo chaos had to change.

For its first two years the Obama Administration struggled internally to come up with a coherent scheme. Tensions between the National Security Council and State Department repeatedly threatened to sink negotiations, and as the debates dragged on Congress grew impatient. Ultimately two documents were released, forming the Obama Administration foreign policy framework, including foreign assistance and global health. First, the PPD-6, or the Presidential Policy Directive on Global Development, formally created the Global Health Initiative in late 2009. Its mission was defined as: “Taking into account the lessons learned over the last decade, and with an eye to achieving greater and more sustainable impact, the GHI expands our global health effort and impact by improving disease treatment, integrating our interventions and expanding our investments to strengthen health systems, improve maternal child health, address neglected tropical diseases, and foster increased research and development. “

The second, led by Secretary Hillary Clinton’s Office, was the QDDR, or Quadrennial Diplomacy and Development Review, which laid out specifically the Global Health Initiative and balance of power between agencies. A key mantra strung throughout the 2010 QDDR was a call for“whole-of-government” strategies in which the weight of multiple agencies would be thrown at shared missions, carefully coordinated out of the State Department. “Whole-of-government” soon became the dominant catch phrase of the entire Obama Administration, used to describe how the government responded to everything from tornadoes ravaging the Midwest to Taliban attacks on school girls in Afghanistan.

A key Appendix 2 of the QDDR promised that by 2012 ALL leadership of the Global Health Initiative would be transferred to USAID, “to lead a coordinated, inclusive, whole-of-government effort for GHI. The decision to transition the Initiative, with a targeted timeframe at the end of FY 2012, will be based on an assessment of the ten benchmarks…The Secretary of State will make the final determination on transitioning the Initiative, drawing on the assessment and recommendation of the GHI Operations Committee.”

By late 2009 the documents were finished, and some of the seats of power began to fill, though key positions such as head of USAID and the HHS Office of Global Health Affairs weren’t “person’ed” until 2010. Critics charged that the White House had allowed dithering and appointment foot-dragging to waste two years of valuable foreign assistance time. A Global Health Office was set up inside the State Department, run by Lois Quam. Its job was to coordinate the GHI (Global Health Initiative) triumvirate (CDC/USAID/Office of the Global AIDS Coordinator or OGAC, which runs PEPFAR) and facilitate their activities with U.S. Ambassadors in 42 key countries, including most of the sub-Saharan African nations. Everybody was supposed to behave themselves, avoid agency turf battles, and allow the CDC/USAID/OGAC triumvirate, controlled by Quam’s tiny office of 4 inside the State Department, to build and execute the Global Health Initiative.

Lost yet? Acronyms got you down? Hang in there: we’re almost up to date.

That QDDR laid out ten benchmarks Sec. Clinton would use in 2012 to assess GHI’s readiness to become a USAID-controlled program – things like levels of coordination between agencies, use of empirical evidence to guide policy, engagement with local governments in planning health programs, improvements in USAID’s internal operations and structure and the like.

On June 29, 2012 Lois Quam and Christopher Dorval briefed members of Congress. They told the politicians that Sec. Clinton had decided the GHI was not ready to be absorbed inside USAID, as laid out in the QDDR. Instead, “we have made a collective recommendation to close the QDDR benchmark process and shift our focus from leadership within the U.S. Government to global leadership by the U.S. Government. This recommendation has been accepted,” by Congress, the GHI leadership reported publicly on July 3rd.

Quam’s Office of Global Health will soon be shut down. In its place, leading the entire Global Health Initiative will be a new Office of Global Health Diplomacy. In discussions with Quam and Dorval I have learned that this new office is a work-in-progress, many of its key outlines yet to be determined. Secretary Clinton is anxious that it be up and running before the end of this summer, and its leadership appointed as quickly as possible. Though there has been talk of naming an Ambassador of Global Health Diplomacy, such a position would require both statutory and individual confirmation action by Congress, none of which can be expected to move with haste in the current election environment. Clinton long ago announced that she will step down as Secretary of State in January, regardless of the outcome of the Presidential elections. It would seem that she is eager to solidify the new Office and its appointments to ensure they survive her departure.

A key confusion remains: If State elevates health diplomacy, where does that leave Dr. Nils Daulaire and his Office of Global Health Affairsinside the Department of Health and Human Services? From a diplomatic point of view OGHA is pivotal, as Daulaire is the U.S. member of the Executive Board of WHO and sits on numerous multilateral health bodies and negotiations as the voice of America.

“State is the agency that does diplomacy, and this change is lifting up the diplomatic function of the GHI,” Quam told me today.

“We have narrowed State’s focus,” Dorval explained. Since the 2010 completion of the QDDR the global health efforts of the U.S. government have targeted U.S. Embassies, especially in 42 key countries. All the expertise of American government programs and their counterpart NGOs have been funneled into the Embassies, where the U.S. Ambassadors oversee their coordination, and collaboration with local government agencies. “We have done a lot of hard work that you don’t see, under the hood, so to speak,” Dorval continued. “We’ve integrated everything, under the leadership of the Ambassadors, and created a full set of health targets and metrics.”

Quam added that she has been systematically speaking with key Ambassadors, soliciting their input on the design of this new Office of Health Diplomacy. And as she leads the transition, closing her office and designing the new one, there will be no concrete changes on the ground in recipient countries.

Well, almost none. There will be a lot less money.

When the GHI was first announced the White House promised $63.5 billion for global health over 5 years (2009-2013). In reality, the total is likely to fall somewhere south of $40 billion.

“We do need more resources,” Dorval insisted. “But Congress has told us in no uncertain terms that we’ve reached the high water mark,” and funding may even decline in the coming year. So a key job for the new Ambassador of Health Diplomacy (or whatever the leader is titled) will be nudging other donors and rich countries, pushing them to work with the GHI to maximize the impact of ever-smaller amounts of money.

On March 22, 1961 President John F. Kennedy delivered an historic speech to Congress, calling for “foreign aid.” Citing fragmentation of post-Marshall Plan foreign aid operations and the lack of “sustained development” in targeted countries, Kennedy said, “I propose that our separate and often confusing aid programs be integrated into a single Administration.

“The field work in all these operations will be under the direction of a single mission chief in each country reporting to the American Ambassador. This is intended to remove the difficulty which the aided countries and our own field personnel sometimes encounter in finding the proper channel of decision-making. Similarly, central direction and final responsibility in Washington will be fixed in an Administrator of a single agency--reporting directly to the Secretary of State and the President,” Kennedy continued.

It looks like in 2012 we are finally getting to 1961.