The United States Government has the requisite technical know-how, financial and logistical resources, and bipartisan political support to lead the response to enduring global health challenges such as HIV/AIDS and malaria, and to new crises like Ebola, antibiotic resistance, and the recent Zika outbreak. As we face a growing number of emerging global health threats, it is critical that the United States is prepared to meet these challenges. Today, global health activities are fractured across US agencies and departments, often with competing mandates and without clear lines of accountability. This structure undermines the effectiveness of US efforts to respond to emerging health threats, as well as existing ones. The next administration must work to modernize the US approach to global health and global health security to protect the health of Americans and ensure the long-term sustainability of US-supported health gains.
This memo’s six recommendations are the result of a roundtable discussion on how the next administration and Congress can update and improve on the US global health engagement model. The recommendations build on those by Amanda Glassman and Rachel Silverman in the Center for Global Development’s The White House and the World briefing book[1] and reflect the joint input of representatives from a range of government, civil society, and international organizations, but do not necessarily reflect a consensus and should not be taken to construe any institutional position.
Defining “global health”
Global health is defined in different ways even within the US government. For this memo’s purposes, we offer the following definition. First, global health is defined from a policy perspective, whereby one country’s policies and actions affect those of at least one other country for either good or ill. For instance, the US action plan for controlling antimicrobial resistance has far-reaching impact on the effectiveness of antibiotics in other countries, and vice-versa. Second, global health is defined from an economic perspective, with health systems understood as a key sector situated in the broader economy. We view improving health systems in low- and middle-income countries as a domestic welfare intervention, and consider health systems as a contributor to economic well-being and growth. The extent to which a health system can effectively and efficiently promote health, prevent and treat disease, and prevent catastrophic out-of-pocket spending on health has major implications for both individual health and the health of a country’s economy.
The case for investing in global health and global health security
In the last decade, the World Health Organization has declared four global health emergencies, including two within the last two years (Ebola and Zika). At the same time, the United States and other actors continue their efforts to control and eliminate diseases like HIV/AIDS and tuberculosis, while combatting rising rates of non-communicable diseases and antimicrobial resistance. These health threats cross borders, jeopardizing the health of people in low-, middle- and high-income countries alike. Health policies in one country can affect health outcomes in all others.
To address these issues, the United States helped launch the Global Health Security Agenda (GHSA) to “advance a world safe and secure from infectious disease threats, to bring together nations from all over the world to make new, concrete commitments, and to elevate global health security as a national leaders-level priority.” And in September 2015, the United States committed to goal 3 of the Global Goals for Sustainable Development (SDGs), to “ensure healthy lives and promote well-being for all, including a bold commitment to end the epidemics of AIDS, tuberculosis, malaria and other communicable diseases by 2030.” Now is the time to determine how best to deliver on these commitments.
Within the next decade, the world may achieve elimination of two deadly scourges: polio and a strain of malaria. This is proof of what we can achieve through sustained investments of time, energy, and money. The next administration has an opportunity—and obligation—to see these elimination and eradication efforts through as well as to ensure the United States maintains its standing as a leader in global health.
Recommendation 1: Appoint a global health senior director to the White House National Security Council, along with a global health directorate
The US government must have a clear and coordinated strategy to prepare and respond to looming health threats. This will require a number of US departments and agencies—including the US Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH) in the Department of Health and Human Services (HHS), and the Departments of State and Defense, among others—to work toward a cohesive agenda that harnesses each agency’s distinct comparative advantage. For instance, the NIH has tremendous depth and expertise when it comes to international research and innovation; USAID works to support health care systems that can enhance economic development writ large in low-income countries; and the CDC focuses on population health, disease surveillance and outbreak response.
To lead a coordinated global health policy across US agencies that takes into account the range of existing agency mandates, and the need for an honest broker amongst the disparate specialties that are essential for excellence in the global health response, the next administration should appoint a global health senior director to the White House National Security Council, supported by a dedicated directorate. The senior director would not only orchestrate responses to pandemic threats, as has been suggested by others such as former White House Ebola czar Ron Klain;[2] she or he would be responsible for developing and overseeing implementation of a strategic, holistic vision and strategy for the full range of US global health programs. The senior director would coordinate policies and agency actions, bring pressing issues before the President for decision, provide direction on behalf of the President to the agencies, and engage the public and civil society groups on behalf of the administration.
Importantly, the senior director would work closely with the Office of Management and Budget (OMB) to ensure that global health funding is coordinated across all US global health programs, including vertical programs, such as the President’s Emergency Plans for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI), and cross-cutting programs, such as the Global Health Security Agenda. This will give the senior director leverage to build greater cohesion among the relevant agencies and ensure that each funding stream fits within the overarching, whole-of-government global health response.
Recommendation 2: Strengthen incentives for regular evaluation and performance on International Health Regulations and pandemic response preparedness among US states and low- and middle-income countries
The best way to protect the health of all Americans is to ensure infectious disease threats are adequately addressed at their source. The Ebola epidemic in West Africa underscored not only the need to enhance the global capacity to prevent, detect, and rapidly respond to infectious diseases, but also an urgency to improve the capacity of low- and middle income countries likely to be affected by an outbreak.
To this end, 50 countries so far have volunteered to conduct an external evaluation of their capacity to prevent, detect, and respond to public health threats within the International Health Regulations (IHR). This is welcome news; however, a lack of funding to complete these evaluations and address gaps is proving a serious barrier to progress, and too many countries have not yet committed to an evaluation.
Working through USAID, the CDC, and the World Bank, for example, the United States could develop strong financial and reputational incentives for low- and middle-income countries to: (i) conduct the evaluation; (ii) self-fund and address detected gaps in disease response and preparedness; and (iii) improve evaluation scores over time. By rewarding countries based on progress toward strengthening disease surveillance and preparedness, the United States could more effectively leverage limited resources and ensure results, rather than exclusively focusing on providing in-kind support for labs, surveillance, and related inputs.
To further manage the risk posed by health threats, the US government must replace its ad hoc interagency task forces and emergency budget requests with a global health emergency fund that would allow for faster release of financing to assist countries in need and provide coordinated funding at each stage of pandemic preparedness, response, and recovery. The existing Public Health and Social Services Emergency Fund (PHSSEF) is not sufficient to meet these needs; it lacks adequate funding and its use is restricted to only those health threats that meet the threshold for a public health emergency declaration—which, in turn, inhibits a timely response. As the HHS FY2016 congressional justification for the PHSSEF recognizes, “the lack of dedicated and flexible funding impeded the Department’s ability to respond more quickly to control the spread of Ebola at its source in West Africa.”[3] It is clear that the next administration must invest more permanently in disease outbreak preparedness and response to keep Americans safe.
Recommendation 3: Harmonize the US approach to multilateral global health institutions
The United States is represented by different agencies at each of the major multilateral global health organizations, with limited coordination. For example, the Director of the CDC sits on the executive board of the World Health Assembly, while USAID sits on Gavi’s board, and the US Global AIDS Coordinator sits on the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Although these roles are likely designated based on relevant expertise, this approach is too fractured and creates missed opportunities to advance US goals.
The United States is the largest common donor among these institutions, but funding alone does not translate into influence. To maximize the US government’s leverage in advancing its goals through each multilateral institution, it must bring one cohesive policy and reform strategy to all of the executive boards. A single agency, or the newly appointed White House global health senior director, should manage leadership at all the multilateral institutions. Just as the US Treasury is responsible for managing the US relationship with the International Monetary Fund, the World Bank, and all regional development banks, a single lead could help guarantee greater policy coherence. Short of restructuring US agency representation on multilateral boards, those who currently sit on the various multilateral boards should meet consistently, led by the NSC senior director for global health, to plan a coordinated approach that assures that the full set of US global health policy priorities are pursued in every setting as appropriate. For example, support for disease surveillance by disease-specific programs should meet and be tracked using global health preparedness standards.
Recommendation 4: Create a platform for more consistent knowledge-exchange with international partners
One of the United States’ greatest strengths in global health is its deep technical expertise in medical research, surveillance, workforce training, and quality improvement. For example, the US government now uses its CMS payment system to incentivize quality improvements in hospitals by denying payments or imposing penalties in response to violations of quality standards.[4] This experience with pay-for-performance, payment bundling and risk sharing innovations could be useful in other countries and settings as they contemplate their own insurance and coverage expansions and reforms. The NIH’s expertise in biomedical laboratory design could also be exported to countries building or upgrading their research institutions, as we recently saw in India.
To a limited extent, the HHS Office of Global Affairs (OGA) and the NIH are able to facilitate exchange of US know-how with other countries. Yet there are currently only a few opportunities for domestically-focused American researchers, scientists, and policy experts to work with their counterparts in other countries to exchange best practices and share technical expertise that can in turn advance global health priorities.
One promising approach is the Medical and Nursing Education Partnership Initiative (MEPI/NEPI), supported by the NIH and PEPFAR, to strengthen academic and clinical training of physicians and nurses in sub-Saharan African. This initiative could ultimately be expanded to share the expertise of the other US “gold standard” departments and agencies such as the HHS, CDC, and the Food and Drug Administration (FDA). In the short term, a rigorous evaluation of this program would help determine its impact and identify strategies to further expand its coverage and improve its effectiveness.
At the same time, the United States can benefit more from clinical research abroad. For example, adequate sample sizes to measure treatment effectiveness for some rare diseases can only be achieved through multi-country studies. These kinds of partnerships can be win-win; clinical trial costs and time to recruit patients can be reduced; affected communities can see greater access to health care and benefit from treatment; jobs and expertise in clinical trials can be disseminated to low- and middle-income countries; and new diagnostics and treatment can be made available for all. There are currently several technologies under development in low- and middle-income countries with potential to directly help Americans.
Recommendation 5: Conduct a whole-of-economy evaluation of the United States’ contributions to global health
US global health engagement has largely ignored the importance of the health sector as a source of economic activity. As a result, the United States has missed opportunities to explore mutually beneficial trade and investment activities. To avoid these missed opportunities moving forward, the US government should help facilitate an independent whole-of-economy evaluation, in partnership with a prominent medical journal, of US efforts to improve health globally and to identify areas where further action can generate benefits for all.
US contributions to global health go beyond government agencies, programs, and funding. In the last two decades, we’ve seen increasing investments in global health from foundations, the private sector, and academia. Stakeholders across the public, private, and non-profit sectors—including universities, teaching hospitals, insurers, pharmaceutical and biotechnology companies, device manufacturers, non-governmental and humanitarian organizations, specialized civil engineering companies, management consulting firms, and many others—are deeply engaged in global health and in the health systems of low- and middle-income countries. For instance, two of the largest medical device companies in the world, General Electric and Medtronic, are based in the United States and now have sizeable and growing investments and sales in emerging markets.
A whole-of-economy evaluation would help to formally recognize the full range of US contributions to global health as an economic sector. It would also identify opportunities for trade, investment, and economic growth that can, in turn, preserve and/or enhance US global health security investments. Finally, the evaluation could help determine the comparative advantages of players across the private, public, and non-profit sectors so we know which actors are best positioned for which roles in the face of new health challenges.
Recommendation 6: Increase transparency of US government spending and its uses in global health
The US government invests about $10 billion annually in global health and global health security programs,[5] yet it can be challenging to track exactly how that money is being spent—beyond high-level commitments—and what that money is achieving. This is particularly true in the context of emergency supplemental budgets. As we have seen with Ebola, tracking spending of US dollars has proved near impossible; USAID’s fact sheets, the Offices of the Inspectors General reports, and ForeignAssistance.gov all provide some level of information around commitments, expenditure and progress, but ultimately provide an incomplete—and sometimes mismatched—record.
Some US agencies and programs have taken steps toward more data transparency. For instance, PEPFAR has created local data hubs, PEPFAR Dashboards, which now include procurement transaction data from the USAID Supply Chain Management System and data on key program elements at the site level. Making this data open should lead to greater accountability and better evidence-based decision making, which can ultimately improve performance.
Overall, however, US government agencies must do a better a job of transparently and quickly making spending and other relevant data available. In the absence of this reporting, we lose the opportunity to determine what United States programs have accomplished and where the next US dollar for global health assistance would have the greatest impact.
[1] Glassman, A. and Silverman, R. 2015. Restructuring Global Health Programs. Center for Global Development: The White House and the World. /publication/ft/restructuring-us-global-health-programs-respond-new-challenges-and-missed-opportunities
[2] Klain, R. 2016. Confronting the Pandemic Threat. Democracy Journal. http://democracyjournal.org/magazine/40/confronting-the-pandemic-threat/
[3] US Department of Health and Human Services. 2016. Public Health and Social Services Emergency Fund: Justification of Estimates for Appropriations Committees. http://www.hhs.gov/sites/default/files/budget/fy2016/fy2016-public-health-social-services-emergency-budget-justification.pdf
[4] Bauhoff, S. 2015. Improving Health Care Quality: What Can We Learn from the US Experience? Center for Global Development: Global Health Policy Blog. /blog/improving-health-care-quality-what-can-we-learn-us-experience
[5] Valentine, A., Wexler, A., and Kates, J. 2016. The U.S. Global Health Budget: Analysis of the Fiscal Year 2017 Budget Request. The Henry J. Kaiser Family Foundation Issue Brief. http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-fiscal-year-2017-budget-request/
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