You Ask, We Answer: What Would US Global Health Reform Really Look Like?

As we gear up for the 2016 election, we’re thinking critically about how the next US president can increase the impact and efficiency of America’s taxpayer-funded global health investments. The US lacks a government-wide strategy on global health engagement, and it shows — most recently in the slow and messy response to the Ebola crisis. But we think it doesn’t have to be this way. The next administration has a real opportunity to change things for the better, particularly if it takes up the three recommendations for restructuring global health programs we’ve proposed in the new edition of The White House and the World.

But do you agree? Over the last few weeks, many of you have shared helpful feedback, including questions about the practical implications of our some of our proposals. Here we attempt to clarify our ‘asks’ for the next US president and respond to a few frequently raised points.

Our first recommendation, building on lessons learned from the failure to launch of Obama’s Global Health Initiative (GHI), is to appoint a White House global health coordinator who has the mandate, political support, and budget authority to meaningfully guide policy and enforce interagency collaboration.

As we note in the brief, and as others have emphasized in their responses to us, money is power. The global health coordinator would need to have real control over the purse strings to exercise meaningful policy leadership. That budget authority would also be the essential difference between our proposed coordinator and the current National Security Council Director for Global Health. Why is this an important distinction? The best and latest example is the appointment of Ebola Czar Rob Klain earlier this year—an entirely political move. Without budget authority, Klain had little leverage to align the Ebola response across US agencies. And the appointment of Klain in the first place came only because there was no ‘natural’ leader who could already enforce meaningful and strategic interagency coordination to mount a US response to Ebola or any other global health crisis.

We also know budget authority is a key enabler for meaningful leadership. Already, we’ve seen how similar budget and oversight authority has empowered the US Global AIDS and Malaria coordinators to mount robust, effective responses to their respective disease areas. Importantly, giving final budget authority to a single global health coordinator would not necessarily mean dismantling vertical funding or programs like PEPFAR and the PMI, which have been effective in part because of their vertical focus. Instead, it would offer the coordinator leverage to ensure those vertical funding streams fit within an overarching, coordinated, and strategic whole-of-government global health response.

Even more, as we heard from one global health colleague, perhaps the ultimate wish list should go a step further: the establishment of a Global Health agency or bureau that consolidates all global health personnel and funding under a single roof (and leader!). However, doing so would require Congressional buy-in—a long shot in today’s political climate.

Our second recommendation is to harmonize the approach to multilateral organizations to ensure consistency of priorities and objectives. American leadership can strengthen the multilateral global health institutions. Yet the USG is missing an opportunity to leverage its contributions and influence if it fails to clearly articulate its overarching strategic priorities and speak with a single voice in multilateral settings (think WHO reform, for example). This recommendation has received a warm welcome from some who see the costs of our fragmented approach, while others have expressed skepticism about whether the problem is substantial enough to merit action.

Our final recommendation is to establish an office of Global Health Knowledge Exchange, Trade, and Economics within the HHS that would be responsible for sharing US healthcare know-how with policymakers and businesses in developing countries. Here, readers have emphasized it will be important to ensure the mandate is clear, feasible, and non-duplicative. We see this office as a way to share the types of expertise that fall outside the traditional ‘aid’ banner — for example, how to organize a hospital, raise capital for private health facilities, or determine premium payments in private insurance markets. These will be important areas of collaboration as countries develop more sophisticated health systems, and this office would offer an opportunity to move beyond donor-recipient dynamics toward mutually beneficial partnerships.

We hope you will continue to share your thoughts, either by email or in the comments below. Have we got the issues right? Are there important considerations we’ve left off the list? And with presidential leadership, might we be able to get Congress on board? 


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.