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Amanda Glassman and Nandini Oomman, here at CGD, have released two separate notes (here and here) on the Global Health Initiative (GHI).  Amanda and Nandini, who both have deep backgrounds in global health issues, are critical of the GHI and cautious about its future.  Both see health assistance, in all its many forms, as a fundamental development activity.  Both knock the dysfunction of the current bureaucratic structure and lines of authority and both would like to see a greater role for USAID’s leadership even as they caution about future bumps in the road.

The President’s Global Health Initiative (GHI) was proposed in May 2009 to integrate the far larger PEPFAR program with more traditional health activities – maternal and child health, family planning, nutrition, and building health system capacity.  The plan would require a whole of government approach with the Departments of State and Health and Human Services, the Centers for Disease Control (CDC), and the U.S. Agency for International Development (USAID) managing some portions.

But the GHI was left leaderless as drafters of the Quadrennial Diplomacy and Development Review (QDDR) wrestled with this and other issues.  The QDDR, released in December 2010, punted on making a decision on what agency would be in charge.  It called for transitioning the initiative to USAID by September 2012, but only on the condition it meet certain benchmarks that appear to have been inserted at the insistence of one of the whole of government partners that objected to USAID leadership.  Given that the benchmarks seem arbitrary and difficult to measure make it all the more problematic to claim progress. At the beginning of 2011, Lois Quam was appointed as the GHI executive director by Secretary Clinton, and tasked with recommending who would lead the GHI.  Here we are nearly three years into the initiative and critical issues relating to design, authority and funding are still waiting to be decided.

With the Appropriations Committee weighing in by requiring a status report by mid-February on transitioning GHI to USAID, it is no understatement that the GHI is at an important juncture.  Declining budgets for foreign assistance will also require new thinking on where the U.S. provides assistance and for what purpose.  “The President’s global development legacy is at stake if one of his biggest development initiatives is seen to fail,” writes Nandini.  With so much at stake, Amanda offers that there’s still time to “reshape GHI as a model for effective global health aid in a period of austerity, as well as a model for other aid sectors.”

But to do so will require a major rethink of GHI and whole of government.  As Nandini points out, even if USAID is given the nominal lead, with PEPFAR remaining at State, it will have little real authority since PEPFAR constitutes up to 70% of GHI funding.  In a whole of government framework, USAID will indeed have difficulty getting the cooperation of other agencies if it does not have control over the entire funding.  Ostensibly that is why the House Foreign Operations Subcommittee had initially appropriated all health funds directly to USAID in one health account.  While this language did not make it into the final legislation, another provision was inserted calling for a report within 6 months on transitioning the State Department’s Office of the Global AIDS Coordinator to USAID.

Indeed, if GHI was created to integrate health programs under the development umbrella, there may be merit in transitioning OGAC to USAID, as both Nandini and Amanda discuss.  However, the PEPFAR legislation, due for reauthorization in 2013, would need to be changed.  Some argue that USAID is not ready for GHI leadership and that AIDS patients would suffer as a result.  This overlooks the fact that USAID currently implements more than half of the PEPFAR program now, and such a transition would not eliminate the expertise that resides currently at OGAC or CDC.  After all, in a whole of government framework, agencies are supposed to bring their expertise to bear on any given problem, but it doesn’t work unless there is a designated lead agency.  The problem with whole of government is that each agency often thinks it should be the lead and the resulting inter-agency duels distract from the mission.  It should be noted that there was similar jockeying for control of Feed the Future prior to USAID being designated the lead agency.

The Secretary of State will ultimately decide the future of GHI and she faces tough choices.

  • Transition leadership to USAID but not the authority to effectively manage the programs and inter-agency coordination, and the initiative could fail.
  • Put GHI at State and then have to explain how a development agency that doesn’t do health could ever be the “world’s premier development agency” as the QDDR vowed.
  • Transfer it to CDC and benefit from its established relationships with health ministries, but at the expense of having expertise in related development areas like water and sanitation, urban planning, education, and food security and agriculture.
  • Dramatically reduce the scope and ambitions of the GHI by abandoning the inter-agency umbrella and reverting to the pre-GHI institutional status quo, albeit with a greater focus on GHI principles and measurement of results.

If the administration wants to salvage GHI and the whole of government framework, there needs to be one agency clearly in charge that has the authority to allocate resources and coordinate the activities of multiple actors both here and in the field.

Perhaps it is time for a recast GHI 2.0.