The State Department’s New Global Health Security and Diplomacy Bureau: Out-of-the-Box Thinking to Streamline Key Functions

On August 1, 2023, the US Secretary of State Antony Blinken launched the new Bureau of Global Health Security and Diplomacy at the Acheson Auditorium in the State Department. The event marked less than a year of planning since the first announcement, including the congressional notification process, to reorganize three units—the Office of International Health and Biodefense within the Bureau of Oceans and International Environmental and Scientific Affairs, the Coordinator for Global COVID-19 Response and Health Security, and the Office of the US Global AIDS Coordinator—into a single unit. Reorganizing government is unglamorous and rife with political hazards, but it has the potential to build a faster and better performing government, in this case for global health security and diplomacy.

Inertial forces maintain the status quo of fragmentation, making “reorgs” time-consuming and challenging to implement. Government tends to grow siloes that can stifle “cooperation, coordination, collaboration, and communication,” which US Global AIDS Coordinator and Ambassador John Nkengasong labeled the “four Cs”. With those siloes come the administrative turfs competing for limited headcount, budget, and authority for which large bureaucracies are notorious. Siloes stifle resource and information sharing, resulting in clumsy government performance. When reorgs are designed and implemented poorly, reorgs can frighten employees in siloed units that will be consolidated.

But we would argue that organization and design of government is a hugely important yet underutilized tool for improving the performance and efficiency of government functions, in this case, for global health security and diplomacy. Organizational design is arguably even more important and more challenging in the context of international cooperation, development, and relations, amidst a large and growing number of stakeholders, with relational dynamics “internally” (that is, domestically, including the multiple ministries of finance, foreign affairs, and health) or “externally” (that is, internationally with the counterpart country).

Similar to the need for redesigning WHO’s organizational architecture, there is a need to revisit and redesign the organization chart of various global health organizations, including in the US government’s global health work. As we noted before:

“The organigram is one of the most important management tools available for ensuring agility and nimbleness, because the siloes created by a chart can hinder the sharing and coordination of resources that might otherwise be possible under a less “boxy” chart. Having fewer boxes can potentially minimize silos and the fragmentation that hinder resource sharing and coordination.”

Thus, the launch of the new and consolidated Bureau in a short period of time indicates creative out-of-the-box thinking and committed leadership in the administration working with Congress to move at “warp speed” by government standards (as noted by Secretary Blinken) and streamline key global health security and diplomacy functions.

Any reorganization has risks. Undoubtedly, some may be concerned that the new Bureau might affect PEPFAR’s performance due to a muddling down of the statutory authority, encompassing the “budget, targets, presidential backing, and a broad mandate” of the PEPFAR coordinator. Without a doubt, the State Department should glean lessons from the ways in which statutory authorities have bolstered PEPFAR’s success as well as monitor and evaluate how the reorg and the changes in statutory authorities may affect PEPFAR’s performance.

But there are reasons to be optimistic. Given PEPFAR’s maturity and stability, as well as PEPFAR’s successes globally as a pioneer in breaking siloes in global health in the US interagency world, the new Bureau has the potential to share best practices and lessons internally in the State Department, domestically in the United States, and internationally. Learning requires evaluation, and evaluation of the impacts of these organizational changes should be designed and established soon.

As part of the evaluation, our first wish is that those who took the initiative to establish the Bureau to document and widely share the insights gained from their reorganization efforts. By doing so, other departments and agencies within the US government and executive branch involved in international development functions can learn from these experiences and feel empowered to contemplate reorganizations as a valuable tool in every skilled administrator's toolkit. CDC, for example, is eagerly awaiting a reorganization, requiring a skilled administrator to design and execute such reforms. The State Department’s reorganization is a critical step forward that will offer lessons in how to streamline government to deliver better and faster.

Our second wish is about reorganization in global health organizations more generally. While global health agencies and their funders spend considerable resources on strategy design and refresh and replenishment, the execution of such strategy frequently encounters failure. One commonality we have observed across many global health organizations which are not able to turn strategy into tangible results or health outcomes is the failure to align the strategy with the organization's design and staffing.

Other policy initiatives are raising the need for rethinking organization, including for MDB reform and the Future of Global Health Initiatives, which is tackling the challenges of a fragmented global health architecture. Indeed, there is a need to gather and bring to bear the lessons from organizational behavior and management applied to the design of global health agencies, government ministries and departments of health, and implementers of global health programs.

What are lessons to global health agencies that are relevant or not from the ways that other industries including tech, manufacturing, and consumer packaged goods sectors have reoriented their organization designs? What are lessons about the managerial span of control, task complexity and workforce specialization, economies of scale and scope, and incentive and mechanism design that can help to improve the performance of global health agencies?

Thanks to colleagues attending the new Bureau launch for their helpful conversation and insights.