Foreign Policy and Global Health Experts on the USG’s Role in Global Health

Overview

The experts with whom we spoke have no doubt about the indispensability of the USG’s global health leadership—both strategically and from a funding standpoint. The issue for them, rather, is how the USG’s role can and should evolve with new learning, changing needs, and the political realities of a) presumably stagnant USG funding levels, and b) what sells global health.

The greatest tension by far is finding the right balance between expenditures that have near-term life-saving impacts and investments in sustainable solutions that have less certain outcomes. While most argue that global health funding should tilt to the latter, they are disinclined to shift current allocations, either because they feel that current allocations are correct, or because augmenting one area would necessarily come at the expense of another—a trade-off many feel reluctant or unqualified to make. Moreover, they recognize that systems-building is a far less evocative fund-raising platform compared with saving lives.

Among left-leaning experts, the approach most commonly advocated for addressing global health needs going forward is greater integration across initiatives (e.g., nutrition, clean water, and child and maternal health) and greater participation and cooperation among key stakeholder groups. This includes the USG exerting its leadership more as a facilitator, organizer, and coordinator, and inserting itself less through mandated interventions. Right-leaning experts are less focused on integration across initiatives, but advocate strongly for greater cooperation among current and potential players, including NGOs and recipient countries. While a more cooperative and/or integrated approach does not explicitly resolve the tension between short-term and long-term solutions, it has the virtue of accommodating both.

Specific expenditures advocated by experts range from continued investment in areas of known success (e.g., infectious disease prevention and treatment) to the build-up of local health care infrastructure and expertise, defining global health more broadly to include nutrition, improved access to clean water, education, and other health determinants. Many emphasize, however, that expenditures must be tied to benchmarks and approved on the basis of their performance. This is a particularly common theme among right-leaning experts.

In terms of the politics of global health funding, there are notable partisan differences in perceptions of the priority Congress assigns to global health funding. Left-leaning experts believe there continues to be strong bipartisan support for global health funding, while right-leaning experts feel that global health is not a high priority for many Republican members of Congress because other issues are seen as a much greater priority as well as some of the cross-pressures that some of the issues funded in global health present, specifically regarding reproductive health.

Aside from their views on Republican receptivity to global health as a priority, other notable differences between left- and right-leaning experts include:

• Different views of PEPFAR: Right-leaning experts who are familiar with PEPFAR typically praise it as a beacon of efficient funding and bipartisan support, and as a model for success. By contrast, experts on the left are more critical of PEPFAR, citing it both for its successes and for what it has taught us about our approach to global health.
• Different opinions on the use of data and benchmarks to determine funding allocations. Right-leaning experts argue that, given the limited amount of federal funding the USG can allocate to global health efforts, Congress should restrict its funding to initiatives that are proven to meet quantifiable benchmarks. By contrast, many left-leaning experts express concern that hewing rigidly to this approach could overlook valuable efforts whose outcomes are harder to measure or that would take years to produce measurable results.

Differences are fewer by area of expertise (global health versus other foreign policy issues) than by partisan leaning. That being said, foreign policy experts are often less confident than global health experts about the efficient use of USG global health expenditures; some simply lack the knowledge to comment, while others are skeptical about the USG’s reliance on for-profit contractors for administering global health programs, or else presume the same inefficiencies they observe in the US health care system. Foreign policy experts also make fewer distinctions between development and global health efforts. While this may reflect their unfamiliarity with specific global health initiatives, it may also stem from a more systems-oriented approach to foreign policy issues. Not surprisingly, they often see other foreign policy issues as being a higher priority than global health.

USG Leadership and Learning from Global Health Efforts

There is no question that the USG does and should continue to play a leadership role in advancing global health. Experts on the center-right and center-left cite two fundamental reasons for why they feel this way:

• It is in our self-interest to promote global health: In a physically-connected world, treating and preventing infectious diseases elsewhere ultimately protects Americans; healthy nations are more stable and less prone to disruption; healthy nations are also better economic partners; and advancing the health of other countries fosters goodwill, enhancing our stature and soft power.
• Supporting global health is part of our national character and a moral obligation given our nation’s wealth and ability to make a difference.

Sealing the case, USG support for global health is readily justified through measurable and viscerally-appealing accomplishments: reductions in child and maternal mortality, a stabilized HIV epidemic, the near-eradication of polio. Global health experts are quick to point out that global health expenditures yield among the highest returns from the USG’s foreign assistance budget.

The grounds for our success in global health are both practical and political. Experts cite a well-organized and thoughtful global health coalition—including private-sector companies and foundations—that have lobbied effectively, contributed technical expertise, and added significantly to the available funding. They also credit the process by which funding is assigned and administered: setting clear targets, simple guidelines, and measurable goals. Some left-leaning experts state specifically that the Millennium Development Goals provided important structure for organizing and promoting USG global health efforts. And finally, right- and left-leaning experts alike credit solid bipartisan support in Congress for providing the requested funding.

Amid our successes, however, we have also seen shortfalls. The most common complaint about global health efforts is insufficient coordination among stakeholders, resulting in wasted or underleveraged resources. In some instances the lack of coordination is the result of ignorance or poor planning. In others it stems from jurisdictional boundaries or deliberate choices that establish arbitrary boundaries for specific health issues and interventions. Left-leaning experts cite PEPFAR as a useful example, viewing it as a victim and perpetrator of each type of inefficiency:

• One left-leaning expert witnessed PEPFAR, the Global Fund, and other donor nations provide funding to cover the same problems in the same countries, and questions whether their efforts are complementary or even coordinated;
• Another notes that the funds given to USAID and the CDC in the early days of PEPFAR were so great that their programs necessarily overlapped, leading to territorial disputes and inefficient management;
• A third comments that not all countries receiving PEPFAR support are able to absorb it; in essence, while the allocated funding may be commensurate to a country’s need, it is not necessarily aligned with that country’s capacity to use the funds effectively.

More complex concerns about insufficient coordination arise from the singular focus of many initiatives. Left-leaning experts again cite PEPFAR as an example. On the one hand, they laud the program for generating unprecedented resources and creating an enormous positive impact through its straight-forward and compelling mission. On the other hand, they criticize PEPFAR’s narrow targeting of HIV/AIDS for ignoring the reality that HIV/AIDS prevention and treatment is connected to a host of other issues. Some point out that the program has broadened its scope as it has matured (e.g., including funds to integrate nutrition into PEPFAR programs), but many contend that taking a more holistic approach from the start would have yielded even greater returns on the program’s investments.

A second lesson mentioned by left-leaning experts relative to recent USG initiatives is a variation on imperfect coordination: the potential for USG funding to crowd out other funders and to create disincentives for recipient countries to take ownership of their health. One left-leaning expert argues that PEPFAR was so effective that other donors retreated from the HIV/AIDS sector, placing even greater burden on USG efforts. Another left-leaning expert characterizes PEPFAR as the de facto Ministry of Health in many countries, relieving them of the responsibility to build their own health infrastructure.

The Ebola crisis of 2014 revealed additional areas that warrant USG attention as a global health leader: lapses in leadership, staffing, and funding at WHO; insufficient investment in disease surveillance by WHO and the CDC; the incapacity of in-country, on-the-ground health systems to monitor and intervene in order to keep an outbreak from becoming a pandemic. While many experts credit USG efforts for ultimately containing the Ebola epidemic, they view the epidemic as a wake-up call to the world to take seriously the potential for global pandemics. Left-leaning experts were more likely to reference problems with WHO and CDC, while those on the right focused more on issues with the US response. Some right-leaning experts point to the Ebola crisis as an example of how insufficient coordination negatively impacted our efforts. Some of these experts believe that our reaction to the crisis was too emotional, and that we responded too quickly without taking the time to organize our own efforts or collaborate with groups that were already in the area. One noted that other countries were developing vaccines before the crisis, and we were not a part of that research. A few volunteered that the US should strengthen its ties to international organizations such as WHO.

The use of data to drive decisions is perhaps the thorniest issue emerging from our experience as a global health leader, eliciting both practical and philosophical concerns. Experts on both sides consistently call for evidence-based decision-making and repeatedly cite the demonstrable return on investment as a key justification for our global health efforts. In line with this, they plea for better data collection and analysis in order to determine if our funding is having the intended effect, or if different allocations are warranted. A more basic concern among many left-leaning experts, however, is the potential for data-driven decision-making to skew efforts away from those that may be vitally important, but harder to measure. This includes initiatives that involve multiple factors with complex interactions, as well as those that would take years to yield quantifiable benefits; “strengthening health systems” is an example of both. Concerns about the use of data reveal a notable partisan divide: For many on the left, a fundamental question is whether our current accounting is circumscribing our approach to global health and ultimately compromising our long-term effectiveness. For those on the right, it is a necessity to use data from these programs to evaluate their effectiveness and determine funding levels.

As these experts consider the future of USG involvement in global health, they also identify emerging issues that could affect the global health burden and the funding needed to address them:

• Both right- and left-leaning experts point to increased global conflict and mass migration creating new vulnerabilities to disease;
• Additionally, left-leaning experts mention climate change and its potential to impact food security, as well as the spread of pathogens and insect-borne diseases.

Left-leaning experts also note that as we realize the easy gains (the “low-hanging fruit”), it will be harder to see the same kinds of impacts going forward. While there are certainly many populations that are still untouched by low-cost interventions, our successes are moving the health burden to more expensive non-communicable diseases. By contrast, several right-leaning experts maintain that going after the “low-hanging fruit” is a useful way to gain support for funding these initiatives, providing lawmakers with success stories that can be used to show their constituents how our support makes a difference.

Top Priorities for USG Involvement in Global Health

Experts’ top priorities for USG involvement in global health are informed by their views on our on-going commitments, our past successes and failures (in mostly siloed efforts), and what they hope and fear for the future. There is widespread agreement that USG priorities should be shifting to sustainable solutions for improved global health, but without losing sight of short-term needs and threats. In terms of goals, this means:

• Consolidating and extending our wins, particularly in HIV/AIDS, malaria, and maternal and child mortality. The proven success of these initiatives—and the fear of backsliding if funds are cut—justify their continued emphasis. Some advocate a rebalancing of funds to acknowledge changes in the current disease burden (e.g., from HIV to maternal and child care) or to focus more on programs with the highest proven returns. Assuming a fixed budget, however, most are satisfied with the current allocations or else reluctant to propose changes, noting that each of these programs is serving a vital need.
• Developing more scalable and systemic approaches. A lot of this involves strengthening systems and taking a more holistic view of health promotion and disease prevention for individuals and communities—to broaden individual and public health capabilities and to leverage the interconnected impacts of our interventions. Left-leaning experts particularly advocate better exploitation of the relationship between education, nutrition, and health—factors that are foundational to good health and that can also address the rise of non-communicable diseases. Right-leaning experts particularly emphasize the importance of better surveillance and measures for averting the risk of pandemics.
• Building more self-reliant and locally sustainable systems. Both right- and left-leaning experts advocate strengthening local health systems in hopes that they can ultimately take over the responsibility for their health needs. This involves developing effective on-the-ground partnerships and expertise with local governments and civic societies, as well as providing education and helping to build the necessary infrastructure. It also means continuing to reduce the disease burden by focusing on communicable diseases that inhibit countries from building a basic level of primary care.

In terms of how the global health community can best address emerging priorities, the common theme is integration—both vertical and horizontal—to create better efficiencies and improve health outcomes. This involves better coordination:

• Across USG programs and initiatives—recognizing that the success of development, education, and global health efforts are interdependent;
• Between the USG and other donors and actors, including the private and nonprofit sectors—to take better advantage of what each does best;
• Between donor and recipient countries—to ensure that aid is targeting the right issues and to help countries take ownership of their health;
• Between donors and local implementers—for better operational efficiency and accountability.

Experts acknowledge that what we should and can do ultimately depends on the circumstances; for example, trying to build self-reliant and locally-sustainable systems is unrealistic in locales where there are no effective governing structures. But they also acknowledge that there will never be the funds to do everything that is important.

Given this reality, a particular concern is that investments with immediate life-saving impacts will always trump longer-term investments in systemic, sustainable solutions. Aside from having to develop new models and new levers to effect systemic change, the goals are less clearly measurable, the management is more complicated, and the time horizon for funding and evaluation is longer and less definite. The trifecta of abstract goals, complex processes, and uncertain payoffs makes this a far harder sell.

The Preferred Approach for the USG as a Global Health Leader

In keeping with the theme of a more integrated approach to global health issues, experts advocate a stronger partnership role for the USG, asking more of others and leading as a facilitator, organizer, and coordinator, as opposed to imposing interventions. As a global health leader, the USG should be helping to identify goals and shortfalls, encourage integrated solutions, and map strategies for developing nations to reduce their disease burden and promote wellness. Experts also expect the USG to leverage America’s technological expertise to find effective and cost-efficient solutions, and to disseminate this knowledge among our partners.

As for specific initiatives and goals, top priorities among these experts include:

• Maintaining momentum in the prevention and treatment of deadly infectious diseases and in reductions in maternal and child mortality;
• Investing in surveillance and rapid response programs to avert pandemics (a particular emphasis of right-leaning experts);
• Addressing structural issues and social determinants of health to help build self-sufficient and sustainable health systems;
• Helping to rebuild the effectiveness and credibility of key international institutions.

Finally, as noted earlier, right-leaning experts are notably more inclined than those on the left to advocate for USG investment in initiatives with clearly measurable goals and proven outcomes.

The Future of USG Global Health Funding

While some anticipate cuts in light of the current economic and political environment, others—particularly left-leaning experts—believe that the bipartisan support of the past will hold and funding will be preserved:

• Right-leaning experts feel that many Americans, as well as some Republican members of Congress, think the US should be spending its money domestically rather than overseas. Those on the right agree it is important for the US to fund global health, but there are a variety of opinions as to what our funding priorities should be: addressing specific diseases through vaccinations and working to eradicate diseases, strengthening health systems, or preventative care. It is clear that, though supportive of US global health funding, these Republican policy experts want the funding tied to actual metrics for measuring success or proof of a return on our investment, as well as more coordination with other countries that are funding global health and with other organizations who are working on the ground. Most of these right-leaning experts see support for global health funding as more of a liability than a benefit for Republican members of Congress because of current levels of all federal spending and the money going overseas rather than here at home.
• By contrast, those on the left believe that Republican support for global health spending is relatively secure, despite the opposition relating to family planning. One left-leaning expert notes that the community around healthy timing and spacing of children has created inroads to the reproductive health barrier.

Among left-leaning experts, the easiest political cases for continued or increased levels of USG investment in global health are emotional: the moral argument that it is part of our national character to save lives and help those in greatest need; and that protecting others from communicable diseases is necessary to protect our own health. Notably, both of these arguments connect more easily to immediate short-term interventions, as opposed to developing longer-term, sustainable solutions.

Right-leaning experts believe that the best political case to make with Republicans would be to tie global health funding to national security. They also feel that preventing disease from spreading to the US is a national security issue. Like the left-leaning experts, there is some sense that investing in global health is the morally correct thing to do.

Other arguments that appeal to Americans’ self-interest are also important, but are less intuitive and more intellectual; while experts on both sides note that healthy nations are less likely to foment conflict or require military intervention, are better economic partners, and are more inclined to hold the US in high regard, connecting these benefits to global health expenditures is more tenuous. That being said, national security arguments may be effective if delivered by respected national security leaders.

The voices deemed most effective for global health funding largely reflect who has been influential in the past, and are mostly overlapping between right- and left-leaning experts:

• Those with strong content knowledge or involvement, e.g., WHO, CDC, and NIH executives; experts at educational institutions; the American College of Pediatricians;
• NGOs and on-the-ground practitioners describing day-to-day issues and solutions, e.g., in-country medical practitioners; individuals from Doctors Without Borders, UNICEF, Save the Children, CARE, Mercy Corps;
• The faith-based community, e.g., Pope Francis, Samaritan’s Purse, Bread for the World, ministers and rabbis;
• Secretaries of State and Defense, and others with national security backgrounds making the case that global health spending is in our own interest, e.g., Colin Powell;
• Private individuals and foundations known for supporting important causes, e.g., Bill Gates, Mark Zuckerberg;
• Celebrities and others with high visibility, e.g., George Clooney, Jennifer Garner, Ben Affleck, Bono, Angelina Jolie, Jon Voigt.

Additionally, right-leaning experts mention:

• Conservative-minded think tanks like the Heritage Foundation, Cato Institute, and others with an economic focus;
• Former Republican elected officials, e.g., former President George H.W. Bush or Sen. Tom Coburn.

Others named by left-leaning experts include:

• President Obama;
• Rare combinations that capture attention and elicit strong bipartisan support, e.g., faith-based organizations joining with the HIV activist community;
• Major companies with investments in developing countries.

Left-leaning experts also note that the global health community has been remarkably effective in a) cultivating key champions among the members of Congress to drive continued support for funding, and b) using trips to bring members close to the issues and making them feel personally invested in advancing solutions.