Secretary Clinton on the Global Health Initiative: More on the WHAT and the WHO, but Not the HOW

Secretary Hilary R. Clinton spoke yesterday at SAIS on the objectives of the Global Health Initiative (GHI).  The webcast of the event provided a forum for an interesting and interested set of tweeters (I participated) to point out what we heard and did not hear during the talk. My overall impression, echoed by several others (see here and here for two round ups of the discussion) was that while it was encouraging to hear Secretary Clinton reiterate the administration’s commitment to global health and its vision to transform the way in which global health is designed, delivered and managed, we did NOT hear anything new about the GHI:  for example, no specifics on HOW the U.S. will “do” the GHI and apply all its commendable principles, metrics for success, and global leadership?The Missing “HOW” of the GHIWhile I recognize that we’re still in the early stages of this very complex initiative, I believe that the administration could and should strive to communicate more clearly with the global health community about the implementation of the GHI. HOW exactly is the GHI being rolled out? Even colleagues who work on the ground in GHI countries are perplexed about the roll out.  It’s been well over a year since President Obama announced the GHI and stakeholders need to hear HOW the initiative is progressing. This communication is important for a few reasons:Building stakeholder confidence with up-to-date evidence and information:Stakeholders across the world are worried about the success of the GHI, even though they agree with the goals and embrace the policy shifts toward sustainable, country-led global health delivery. But, the lack of public information has led to a growing lack of confidence in HOW exactly these goals, objectives and principles will be achieved. A couple of examples:

• Financing plan and structure: As various groups battle for health funding, the administration needs to be very clear about its financing plan and structure by providing details about how they intend to overcome what Secretary Clinton pointedly referred to as “the pitfalls and obstacles” that threaten the GHI.  For example, Congressional stove-piping can undermine the integration goal of the GHI (see here for issues we raised a while ago on the topic). HOW is the administration working here in DC and at the country level to overcome this potential obstacle? We need to learn more about what and how the GHI is doing to mitigate risks that might derail it’s goals and principles.
• Monitoring, Metrics and Evaluation: Ongoing discussions about the Monitoring, Metrics and Evaluation (MME) principle of the GHI indicate that this is a priority area. The GHI draft strategy document (the final version has yet to be released) described a strong commitment to monitoring programs, developing outcome measures, and investing in countries’ health information systems to promote the collection and ownership of good quality data.  Secretary Clinton repeated all these important features in her remarks, BUT again, provided no specifics on HOW the MME principle is being applied.

Building stakeholder knowledge about the GHI for greater accountability at all levels

• Global-level leadership: The White House, the State Department, USAID, OGAC, CDC and others are all working to roll out the GHI and promote it as a development success story. But, who is really accountable? Will the GHI go down in history with no USG leader’s name attached to it, except Secretary Clinton? While an interagency process is laudable from an operations perspective (although that suggests even more bureaucratic delays!), from a management and accountability perspective, we need to know where the buck stops. Who is calling the shots in DC? Or is consensus-building slowing down implementation?  Secretary Clinton mentioned that the interagency team leaders are running the GHI “under the guidance of Deputy Secretary Jack Lew.” (Although, Lew may leave the State Department in the near future to run the OMB.) This was one of the clearest articulations about GHI leadership, but that still doesn’t tell us about WHO is calling the shots and HOW final decisions are being made in this process-heavy endeavor.
• Country-level leadership: While country leaders may eventually become true partners (something we called for in 2007 in this HIV/AIDS Monitor report) in the GHI, it is critically important that citizens in the GHI countries are also well-informed and can hold their governments and NGOs more accountable for their financial commitments to health—whether it is with U.S. funding or domestic monies.  The current lack of transparency is undermining the GHI’s goal to transform the “global health system” by pushing governments to “step up” and demonstrate these commitments.  The U.S. and other donors can push governments, but an equally, if not stronger force from well-informed citizens has to pull.  This was the topic of discussion at a CGD HIV/AIDS Monitor event on country ownership in June 2010, during which country-based panelists strongly suggested that information about the GHI—funding and program objectives, and progress—be made publicly available to ensure a chain of accountability: from beneficiaries to implementers (of both GHI- and government-supported programs) to governments to donors.

Following through with pragmatic, but innovative thinking and actions to match ambitious goals about  transforming development

• Another GHI goal that Secretary Clinton raised, and one that I commend the administration for—trying to “embed a deep commitment to health” in countries—is at risk unless we can follow how the next phase of global health leadership is working towards this goal.  Debates continue about whether aid is effective and transformative (here,  here, and here are a few places where you can follow these conversations), and this administration needs to demonstrate HOW exactly it is overcoming many well documented challenges of the aid business to incentivize developing country leaders to commit to health priorities.

My wish list of actions for the GHI team: Share information for greater learning and accountabilityIn the spirit of publish what you fund, I’m pleased to hear that we may have a  USG GHI website very soon. This is very good news, but I sincerely hope that the website is an effective public relations/diplomacy tool AND a learning platform.  Here’s what I would like to see.When the web site goes up: I hope that the new site will include:

• An organization chart for the GHI team that tells us who is in charge of what.
• GHI Metrics and examples of HOW the MME plan is being rolled out.  “We are rolling out the metrics, right guys?” Secretary Clinton added some humor to the event by checking with “the guys” (presumably Goosby, Shah and Frieden seated in the first row) when asked about the metrics of the GHI.  But on a serious note, stakeholders and commenters on the GHI are worried, and in the absence of information, the GHI metrics have become a bit mysterious!

As the GHI progresses: One of the goals of selecting GHI+ countries is to create development learning labs and document the process and outcomes. It would be terrific and useful if we could actually see a page for every GHI+ country and easily track key provisions of this visionary plan. For example, have funds been used effectively to integrate AIDS family planning and maternal and child health services? How are countries “owning” (or failing to own) their respective programs? Different countries present different challenges and learning opportunities for the GHI, and present an enormous opportunity for many different stakeholders to learn across different contexts.Try new ideas for transformative global health and development and share what you learnThere is a growing discussion among development thinkers about incentivizing country governments to get development results, but not many ideas about how to do it. One idea is Cash On Delivery (COD) Aid, developed by my CGD colleagues, Nancy Birdsall, Bill Savedoff and Ayah Mahgoub. They  propose that donors pay governments (almost like a bonus) for results---actual development outcomes that can be measured and audited---that the country achieves with the existing (aid and domestic) resources.  This is certainly one way to try to “embed a deep commitment” to global health and development, because countries, not donors, have to figure out how to design, implement and monitor their programs in order to succeed. The GHI could build pilots for COD Aid for specific health outcomes OR try other innovations to incentivize countries to produce results AND share this learning from GHI+ countries to demonstrate how development can begin to be transformative. This could be an exciting and innovative feature of the GHI.Ultimately, the HOW of the GHI matters, especially when its goals and objectives are about changing the way in which development is done to produce long term and sustainable results. While health outcomes and impact measures will take time to achieve and to document, the GHI team must share its learning about implementation and interim measures towards expected impact, so that we can stop wondering if the GHI will ever realize its goals or not.