This is a joint post with Rachel Silverman.
Announced in May 2009 by President Obama, the Global Health Initiative (GHI) promised a new way for the United States to do business in global health. Fragmented U.S. programs would be united under a single banner; vertical structures would be dismantled in favor of an integrated approach; and narrow, disease-focused programs would transition toward a focus on broader health challenges, such as maternal health, child survival, and health systems’ strengthening.
Flash forward to this past Tuesday, when the GHI blog posted its own death notice – or, at the very least, an admission of defeat in some of its most important, revolutionary ambitions. Released quietly, on the eve of a national holiday, the post announces a radical change in direction. Instead of transitioning GHI leadership to USAID, or even keeping it at the State Department, they’ve decided to scrap the whole concept of GHI leadership entirely. To quote: the administration will “shift our focus from leadership within the U.S. Government to global leadership by the U.S. Government.” Further, the GHI Office in the State Department is going out of business. A new Office of Global Health Diplomacy will rise from its ashes, with the mandate to “champion the priorities and policies of the GHI in the diplomatic arena.”
In other words, the GHI is no longer about changing the way the U.S. does business; it’s now about telling everyone else what they ought to be doing better. Which may be a good thing to do, I suppose, at least theoretically. But any U.S. moral authority in championing “strategic coordination and integration” – a GHI principle! – will be undermined by our complete inability to achieve those objectives in our own backyard. The GHI 2.0: do as I say, not as I do.
The announcement is not entirely shocking; the GHI has been plagued by infighting, leadership questions, and general confusion since its launch (see previous posts on the topic here, here, here, and here). The leadership question has been particularly problematic. The Quadrennial Diplomacy and Development Review (QDDR), released in December 2010, called for transitioning control of the GHI (minus PEPFAR) to USAID by September 2012, contingent upon meeting a set of (arbitrary and ill-defined) benchmarks. But the QDDR created more questions than it answered. What did leadership of the GHI really mean? Would it include budgetary, political, or legal leverage? How could inter-agency coordination and integration be achieved without addressing separate, vertical funding streams and institutions? And what would be done with PEPFAR – about 70 percent of the GHI’s total funding – which was to remain exempt from USAID leadership even while USAID executed 60 percent of its budget?
In January, Nandini Oomman considered these questions, offering four bad options and the pros and cons of each. But the analysis also offered another possibility, which proved prescient. “At this critical juncture, the administration might be wise to consider cutting its losses, eliminating the problematic interagency ‘umbrella,’ and instead implementing a pared-down GHI that honors the original intent while bypassing the organizational constraints.” GHI 2.0, Nandini suggested, could forget about Washington-based interagency cooperation until PEPFAR reauthorization in 2013. In the meantime, the GHI could focus on clearly defining, tracking and evaluating program results in line with its principles. At least in part, the administration seems to have taken her advice.
Nonetheless, the news is deeply disappointing and frustrating on a number of levels. The announcement reflects a breakdown of the inter-agency process. It demonstrates a continued lack of political will to address the hard questions that hamper integration, particularly separate earmarked funding streams and parallel, competing institutions within the U.S. government that had different strategies and relationships with recipient country governments. And in an impressive display of bureaucratic doublespeak, the blog post transforms this failure into a source of self-congratulation: “We continue to recognize the capabilities of our global health agencies. Each has critical leadership responsibilities that must be maintained in the next phase of GHI as we seek greater impact and efficiency from our collective whole-of-government efforts to implement our health programs.” Translation: “We’re all pretty great. Let’s keep doing what we’ve been doing this whole time, because that’s worked out great so far.” This was bad in 2009, when it was the status quo that needed to be fixed. It’s even worse today, because they’ve basically said they’re giving up on it forever.
What’s more, the announcement comes at a time when the pitfalls of agency fragmentation appear painfully obvious. There are too many strategies and too many goals. Each agency has its pet issues and initiatives: OGAC = AIDS-free generation; USAID = 5th Birthday, Saving Mothers, Giving Life, and now family planning; State=nutrition (1,000 days). And all with incredibly ambitious goals and slogans: Achieve an AIDS-free generation! Scale up nutrition! End preventable child deaths! Contraception for everyone! And also strengthen health systems! And sustainability!
Great stuff that could be synergistic if adequately financed, implemented efficiently and rigorously evaluated, yet none of these goals or strategies are fully funded, none are clear on how to leverage national governments and other funders to achieve goals, and in spite of the cornucopia of “strategies,” there doesn’t seem to be much of a big-picture strategy at all (no disease or economic modeling, no fiscal impact assessment, no scenario planning given the budget uncertainties in Congress). Further, the glib statements about “impact” belie the fact that very few (no?) U.S. global health programs have been rigorously evaluated (see our posts here about studies purporting to show the impact of PEPFAR on AIDS-related mortality).
Finally, I worry about the diplomatization of U.S. global health. To start, it seems short-sighted to put so much control into the hands of the State Department, since it will not always be run by someone as friendly or interested in global health as Secretary Clinton. Do we really want country-based ambassadors directing U.S. inter-agency efforts in global health? What are their qualifications to do so, and what has been their track record thus far? If the State Department wants to create an Office of Global Health Diplomacy, fine enough. But ambassadorial leadership and increased diplomacy on their own are unlikely to move the GHI goals forward dramatically.
The bottom line: GHI 1.0 failed on the hard questions, and GHI 2.0 isn’t even trying.