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This is a joint post with Rachel Silverman.

Since the launch of the Obama administration’s $63 billion Global Health Initiative (GHI) in May 2009, we have followed its ups and downs with great enthusiasm (see for example: here, here, here and here), trying to better understand its structure and role within the U.S. government’s complicated global health architecture. One recurring question we have continually raised has focused on leadership: who, exactly, was to be in charge of this massive undertaking? Who would be accountable for meeting the initiative’s eight high-level targets and adhering to its seven guiding principles?

Last December, the State Department’s Quadrennial Diplomacy and Development Review (QDDR) appeared to put those questions to rest. According to the 200+ page document, USAID would assume leadership of the GHI by September 2012, contingent upon fulfilling a set of 10 benchmarks to demonstrate its capacity. But upon closer inspection of the GHI over the last year, the QDDR provision only seems to have generated a new set of questions that are more difficult to resolve. While there are no easy answers, the administration should consider these issues as it thinks through the tough decision of pulling the GHI together under one leader and demonstrating success by meeting its targets:

1)      Who should lead the GHI? Leading the GHI to success will require a high level of technical capacity in health, development, and monitoring and evaluation. Though USAID is still rebuilding itself as the premier development agency (and isn’t quite there yet), we agree that it should lead this initiative. USAID is better-equipped than any alternative USG agency to deliver development assistance for health – which  incorporates nutrition, better access to water, sanitation, education, and investments in research and development – all of which are core areas of USAID’s focus (see an earlier joint post with Connie Veillette). Moreover, leadership of the GHI is a key step towards building up USAID as the United States’ premier development agency. But…

2)      What does leadership of the GHI actually mean? In theory, the leader of the GHI should be equipped to steer the initiative to success through budgetary, policy, and legal leverage. In reality, leadership appears to mean something rather different.

Let’s start by eliminating what GHI leadership is not. GHI leadership does not entail budget authority. It would not grant USAID decision-making authority for other agencies within the GHI’s purview. It is also our understanding that it won’t restructure the current reporting lines within the government, meaning that the heads of other GHI implementing USG agencies will not report to the USAID’s Administrator Raj Shah. So, you might ask, what else is there? Not a whole lot. Essentially, the GHI leadership as we see it holds a vague mandate to “coordinate” the GHI agencies. Except that the QDDR specifically exempts PEPFAR (see pages 84 and 217) – about 70 percent of the GHI’s total funding – from USAID leadership, stating that this program will remain under the Office of the Global AIDS Coordinator (OGAC). And OGAC is already responsible for coordinating USAID and other USG agencies under PEPFAR. So, if USAID coordinates the GHI, you get the picture—everybody will be coordinating each other!

To sum up: as the GHI leader, USAID will coordinate activities representing about 30 percent of the initiative’s total budget, with no authority over funding allocations, decision-making, or the actions of other agency leaders.

If this gives you a headache, you’ve got company. We tried to map out what the USG GH architecture might look like with USAID as the GHI leader, and OGAC as the PEPFAR coordinator; after several attempts to create a diagram, we gave up. In our effort to identify a practical solution for a way forward, we realized that maybe USAID is being set up for failure; not intentionally, but because the GHI was launched without any clear vision about how it could be operationalized under the current U.S. foreign assistance structure. By burdening USAID with eventual responsibility for the GHI’s success but with no authority or leverage to make it happen, the QDDR has inadvertently placed USAID in an impossible situation. Backtrack now and lose face – it will appear as if the State Department thinks USAID is ill-equipped to lead. But grant USAID nominal “leadership” of the GHI with no real authority, and they’re set up for failure.

We know the deadline for the GHI’s transition to USAID is still a year away, but the administration has some difficult decisions to make, and quickly.  The President’s global development legacy is at stake if one of his biggest development initiatives is seen to fail. Here are the options, as we see them, along with their respective trade-offs--constraints, costs, and benefits:

1)      Move PEPFAR to USAID. Perhaps this option makes the most sense programmatically (unified leadership, horizontal integration with reproductive health, etc)., but it’s a non-starter politically. PEPFAR is protected as an independent structure until its authorizing legislation expires in 2013, and there is no political will to challenge that status quo.

2)      Keep the GHI at State. Under this scenario, the State Department would renege on its highly public QDDR plans to move the GHI to USAID, and would maintain control of the initiative under an executive director. State holds some authority over OGAC and could realistically serve as a coordination point between the GHI agencies, as it has done thus far. But there are two good reasons why this scenario doesn’t make sense: 1) global health is not the State Department’s area of technical expertise and the creation of another global health entity in State will be inefficient when plenty of expertise lies elsewhere in the USG. 2) This option could also be a public relations nightmare; the State Department would need to do serious damage control and protect USAID’s reputation. It will need to be clear about its rationale for the decision, emphasizing the structural considerations and why it’s best for the success of the GHI. However, this option will damage the administration’s efforts to build USAID as the premier U.S. development agency.

3)      Remove PEPFAR from the GHI. If USAID is to lead the GHI but not PEPFAR, then PEPFAR, operationally, will cease to be a part of the GHI, especially because it has its own reporting line to Congress. If we continue down this path, the administration should formally remove PEPFAR from the GHI portfolio and eliminate the targets for HIV/AIDS treatment and prevention as GHI targets. Under this “efficiency” scenario, USAID would be able to focus its energy on the remaining GHI programs and goals – those which it actually controls – and could be realistically accountable for the corresponding results. However, this course of action would fundamentally alter the original intent and design of the GHI to build on PEPFAR’s “platform” and would demonstrate the unfortunate reality that funds appropriated in a siloed, vertical structure don’t really lend themselves to policy and program level integration . Forfeiting the opportunity to integrate HIV/AIDS programs with reproductive health efforts, for example, will unfortunately turn the GHI in to a more “business as usual” health program approach to global health.

The Bottom Line: Only USAID has the technical capacity to lead the GHI as a development initiative, and it is the natural choice for leadership of the initiative. But beware: by giving USAID responsibility for success without the mandate to meaningfully steer the initiative, USAID is being set up to fail.

We want to hear what you think. What is the best option for the GHI to succeed, knowing that there are tough trade-offs?