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This is a joint post with Connie Veillette.  It is cross-posted on the Global Health Policy blog.

The QDDR pre-release consultation document says the Global Health Initiative will eventually be managed by USAID.  For a number of reasons, it makes complete sense for USAID to lead the GHI.

  • Health is a core development mission.   Consider that the FY2010 budget for health programs totals $7.8 billion, or more than 20% of the entire foreign assistance budget.  We use development assistance dollars for global health as part of a broader development mission.  President Obama’s Global Development Policy identifies the GHI as a key development initiative, so our premier development agency should surely be given the charge to lead the administration’s largest development initiative.
  • Health is more than just health.  Health is about treating and preventing disease and improving health systems but it is also much more.  It’s about improved nutrition and equitable access to food, clean water and sanitation, education, and investments in research and technology.  These are sectors in which USAID has long worked, and they need to be integrated into a strategy that supports the GHI.
  • The GHI needs one leader, not three, for better decision-making and results (see related blog posts here and here). The administration points to the GHI as a new way of doing business and as a leading edge of aid reform efforts, but the current inter-agency consensus style leadership doesn’t seem to be working efficiently.  While all U.S.G. staff at HQ and in-country are working fast and furiously, the lack of a leader at the top seems to be slowing decision-making at the highest levels.  Some visible expressions of this lack of efficiency include the absence, a full year and seven months since the GHI was announced, of a final strategy, country strategies, or even a GHI website.   For this new and ambitious approach to take off, the U.S. needs one leader that is able to tap the strengths of different government agencies that make unique contributions to the GHI.

But, the QDDR states that USAID will begin to manage the GHI once it “builds capacity and achieves defined benchmarks.”  But how (and who) will decide when USAID has the appropriate level of capacity and what are the benchmarks? We hope that the full QDDR document—set to come out later this month—is transparent about how and when these decisions will be made.  Otherwise, it looks like a State Department tactic to keep the GHI firmly entrenched at State.

While the QDDR draft does not explicitly mention where PEPFAR will be anchored, we hear that this largest component of the GHI will remain at the State Department.  This raises a key question about the proposed GHI governance structure and therefore its oversight. Who will really lead the GHI and make the necessary decisions for this U.S. initiative to deliver? We need some clear and honest thinking from the administration on how this bisected structure will evolve if the GHI is to be successful.

Bottom line: We think that a strengthened and empowered USAID should lead the GHI, but we welcome greater transparency and a rationale for the timing and the seeming conditionality of capacity and benchmarks raised by the QDDR draft.