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Silos within Silos: Unknotting U.S. Global Health Initiatives December 15, 2009

Posted by Guest Blogger in Analysis.
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Each Tuesday BFAD features a guest blogger- these are experts from a variety of backgrounds writing about what they know best.  This week features Dr. Julie Fischer, Director of Stimson’s Global Health Security program.

Silos within Silos:  Unknotting U.S. Global Health Initiatives

by Julie E. Fischer

In May 2009, the White House announced one ambitious new strategy to overhaul government health spending that met with little public fanfare and inspired no town hall protests.  However, the brief statement heralding a comprehensive new Global Health Initiative reverberated among advocates and the expanding community of public and private sector stakeholders.  For many, concerns revolve primarily around funding: how will the Obama Administration balance commitments to HIV/AIDS prevention and treatment currently at the center of the U.S. global health portfolio against a new focus on more fundamental health challenges as budget growth stalls?  For those directly responsible for implementing this new initiative, the question is even more basic: can the new strategy truly integrate U.S. global health efforts fragmented not only by agency and mission, but by disease?

The unfolding humanitarian and development catastrophe of HIV/AIDS during the 1990s forged an unlikely alliance of the left and right, laying the groundwork for the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003.  Congress authorized $15 billion over five years to establish PEPFAR, the largest global health campaign ever focused on a single disease.  PEPFAR set and met ambitious performance targets – providing anti-retroviral treatment to 2 million people, preventing 7 million new infections, and providing care for 10 million patients suffering from AIDS by 2010.  The re-authorization of PEPFAR in 2008 included $48 billion for fiscal years 2009-2013 to expand these efforts within and beyond the original fifteen focus countries.  Encouraged by PEPFAR’s successes, the Bush Administration launched the President’s Malaria Initiative in 2005 and the Neglected Tropical Diseases Initiative in 2008.  High-profile emerging infectious disease outbreaks such as SARS and avian influenza prompted U.S. support for avian and pandemic influenza preparedness in more than 100 countries.

As a result, annual U.S. global health spending more than doubled from FY2004 to FY 2009, when budgets topped $8 billion, or more than $9 billion counting the closely related categories of water, sanitation, and non-emergency food aid.  U.S. government health programs grew concomitantly, without an overarching global health strategy or a single authority to harmonize global health policies and actions.

The Office of the Global AIDS Coordinator (OGAC), reporting directly to the Secretary of State, now manages foreign assistance budgets for HIV/AIDS and coordinates the activities of six PEPFAR implementing agencies.  A separate State Department “action group” under a Special Representative for Avian and Pandemic Influenza transiently coordinated U.S. international pandemic preparedness efforts with guidance from the White House Homeland Security Council.  Its functions have since been absorbed by the understaffed Office of International Health Affairs in the Bureau of Oceans and International Environmental and Scientific Affairs. Several offices under State’s Under Secretary for Arms Control and International Security include public health laboratory capacity-building and disease surveillance in their portfolios.

USAID leads the malaria and tropical disease initiatives with CDC as its technical partner.  Several reorganizations created the Office of Global Health Affairs in the Department of Health and Human Services to manage the health attaché program and serve as a focal point for the international health activities of operational divisions such as CDC, FDA, and NIH.  Each of these divisions, particularly CDC, now conducts technical assistance through a considerable overseas presence in its own right, despite primarily domestic mandates.  The Department of Defense supports medical humanitarian aid, medical civic assistance projects, a network of international disease surveillance and research centers, and military-to-military health systems capacity-building, alone and under the aegis of PEPFAR.

This proliferation of new health programs on top of a patchwork of old ones has unsurprisingly resulted in organizational and communications challenges.

  • Blurring of operational and policy roles – Concerns about balancing civil and military health assistance during complex humanitarian emergencies now extend into non-crisis periods, as the military engages non-governmental organizations in overseas health interventions.  Public health service agencies execute global health diplomacy on the ground.  The State Department not only oversees the massive operational PEPFAR program in Washington and in the field, but directly supports disease surveillance training and capacity-building projects.
  • Uneven distribution of technical expertise, budgetary oversight, and policy roles –The greatly expanded scope of U.S. global health programs has demanded new interagency partnerships, but integrating technical expertise housed in one agency into another’s policy and planning phases remains difficult.  The public health experts charged with implementing programs often have little voice in the foreign assistance processes that produce policy guidance and budgets.
  • Disease-focused intra- and interagency coordination mechanisms – No single agency or authority holds responsibility for planning and implementing the U.S. global health mission. The Office of the Global AIDS Coordinator uniquely holds a strong leadership mandate and authority over budgets, personnel, and policies to harmonize constituent programs, but only for HIV/AIDS activities. USAID coordinates activities around malaria and other specific diseases, and leads U.S. efforts in maternal-child health.  However, each of these programs – and efforts to improve underlying health status by improving access to safe water and adequate nutrition – are organized by disease or issue rather than around desired population health or development outcomes.  New and overlapping health programs create complex relationships within as well as between agencies.  Coordination among these frequently depends on networks of personal relationships rather than more systematic oversight and communications.

The outcomes of disease-siloed interagency coordination include gaps, redundancies, and simple disconnects in the field.  Most notorious is the politically influenced dissociation between family planning and HIV/AIDS prevention services, despite obviously practical overlaps.  U.S. support for disease-specific programs that save some lives but leave most of a population without essential health services does little to free human capital for economic development, or to accomplish either public health or soft diplomacy goals.  The U.S. has taken steps toward integrating programs where eminently sensible from a policy perspective, such as HIV/AIDS and nutrition assistance programs for vulnerable populations.  Even that limited experiment has demonstrated the remarkable discombobulating powers of unaligned budgets, operational methods, and agency cultures.

The White House has called upon expertise distributed among the National Security Council, the Office of Science and Technology Policy, and OMB to lead the development of the new Global Health Initiative and the framework to support it.  Whether this triad or some other leadership configuration based in the State Department will eventually helm a new global health coordinating office remains unclear.

The Obama Global Health Initiative as sketched so far stresses a focus on cost-effective interventions to promote maternal and child health and strengthen partner nation health systems.  Implemented effectively, such a shift in strategy could move PEPFAR from its “emergency” phase to a more sustainable effort and pay off by averting thousands or millions of preventable deaths from more common (and decidedly less charismatic) causes like diarrhea and pneumonia.  However, a progressive integration of disease-specific programs into a more comprehensive approach will be no quick fix.  Such programs necessitate local ownership likely to involve messy transitions, and generally lack the clear performance targets that helped win Congressional support for PEPFAR. Without strong leadership and patience, such a plan could simply add new maternal-child and health systems silos to the existing landscape.



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