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This is a joint post with Christina Droggitis.

Budget season this year is messy and confusing. While the FY2011 budget remains unsettled, some focus is about to shift to President Obama’s FY2012 budget request.  Secretary Clinton kicks off the FY2012 budget hearings tomorrow with back-to-back sessions in front of House authorizers and appropriators. Here’s what the FY2012 budget could mean for the Global Health Initiative (GHI) and what members of Congress might ask Clinton about U.S. global health spending.

The GHI, introduced in May 2009, promised $63 billion dollars over six years to develop a comprehensive response for global health programming across the U.S. government agencies. The administration also set lofty goals for the initiative. In his recent speech at NIH, USAID Administrator Rajiv Shah specified targets of the GHI goals: saving the lives of over 3 million children, preventing more than 12 million HIV infections, averting 700,000 malaria deaths, ensuring nearly 200,000 pregnant women can safely give birth, preventing 54 million unintended pregnancies, and curing nearly 2.5 million people infected with tuberculosis.

But where does the GHI stand in the current budget environment? Obama’s proposed FY2012 budget includes $9.8 billion for the GHI, a 10% increase from the requested  FY2011 levels and the enacted FY2010 levels (FY2011 is currently funded at FY2010 levels under the CR which expires on March 4).  Seventy-three percent of that amount, or $7.2 billion, is slated for PEPFAR, (this includes money for HIV, TB, and the Global Fund) representing a 4% increase over FY2011 numbers.  (For a full budget breakdown, see the Kaiser Family Foundation’s GHI fact sheet and HIV-specific fact sheet). Despite the proposed FY2012 increase, Congress is unlikely to be able to fund the full FY2012 amount and the program is falling short of the $63 billion by 2014 trajectory (which will also require lowering expectations on the program goals).

Source: KFF GHI FY2012 Fact Sheet

Here are a few questions we would ask Secretary Clinton:

  1. How will the U.S. balance global health and other development priorities?

    The current  budget environment will create competition across the development sphere for funding and attention (see here) How will stated priorities, like the GHI, be balanced within the greater U.S. development budget to make sure that global health and other development programs get their fair share of limited resources?
  2. If PEPFAR funding comes first, how much will be left for other global health priorities?

    The GHI intends to overhaul U.S. global health, but more than half of GHI funding is for PEPFAR programs, which  supports the treatment of 3.2 million men, women, and children. Therefore, the first funding priority, on ethical grounds, will be to continue to support all of the individuals currently on treatment. Will there be enough money left to achieve the GHI’s grand plan to work for prevention and for other broader GHI program areas like TB, malaria, MCH, and FP/RH?
  3. Will budget cuts threaten the whole-of-government approach to global health?

    The GHI is intended to serve as a model of a whole-of-government approach, with global health efforts coordinated across various U.S. government agencies. However, as agencies compete for limited funding, program budgets are going to be fiercely guarded, making the integration of programs like HIV prevention and family planning in to HIV/AIDS programs almost impossible.  One could argue that when you have to do more with less money program delivery has to become more efficient to produce more and better results. If dollars are directly tied to results and performance to increase efficiency, as they should be, USG agencies will not be incentivized to share their dollars or their program results with other agencies they consider less efficient.  We perceive this battle to get fierce, aggravating the tensions between agencies, for e.g. USAID and CDC.
  4. How can the U.S. manage GHI program and funding expectations?

    Beyond the initial consultation document, not much has been released from the GHI as far as progress on implementation two years in (see here). As far as we can tell, a lot of work is underway on-the-ground in six pilot countries, raising expectations of what the U.S. government can provide for global health. If funding is flat-lined for the next few years, the credibility of this government and the U.S. is at stake with partner countries who have been made to believe that the GHI is indeed a new way of doing business to achieve real results with real and not imagined funding.

UPDATE: Secretary Clinton’s hearing with the House appropriators has been postponed.