Last week, a researcher from the NAS’s Board on Global Health reached out to us to request public comments from the IH Section in order to inform its recommendations for the next U.S. presidential administration on global health:
A project that we are currently conducting aims to provide recommendations to the new administration on what the next phase of U.S. commitment to global health should look like. This project is a consensus study, meaning that we will be convening with a committee of experts in the field to negotiate a set of evidence based recommendations. However, as we progress through this project we are seeking public comments from interested in parties that we will then present to the committee. Given APHA’s work in International Health, we would be interested in receiving public comments from your organization.
We are interested to see if NAS will approach the new administration any differently than it approached the Obama administration in 2009, and whether it will keep politics in mind – or even better, reference specific political challenges – with their recommendations. Frankly, any new approach to U.S. global health policy will risk going the way of the failed Global Health Initiative without strategic and sustained effort to (1) harmonize it with our overall foreign policy approach and (2) overcome considerable political and legislative barriers. Laurie Garrett has a fantastic summary of the latter in the 2013 Existential Challenges to Global Health report:
The first two years of the Obama Administration were wasted with in-fighting and debate over the future of all foreign assistance, culminating in 2010 creation of the Global health Initiative, a State Department-run melding of programs operated by multiple American agencies. In late 2011 Secretary Hillary Clinton…signaled impatience with the GHI effort: it was abandoned entirely in the summer of 2012. In December 2012 Clinton shifted control over global health operations into the hands of US Ambassadors, creating the Office of Global health Diplomacy to oversee all HIV, malaria, TB, health systems, and other health-related programs. Polls show that Americans…are deeply confused about how much of the federal budget is dedicated to such foreign aid, imagining it devours as much as 25 percent of the budget, versus the actual less-than-1 percent. This combination of Administration shuffling of priorities and structure of global health operations, with public confusion regarding their cost to taxpayers, renders the entire mission highly vulnerable to budget slashes.
Section elected and committee leaders offered their thoughts on what should be in our response, which were compiled and integrated into a formal statement (below).
We urge that the new administration adopt a systems-centered approach to global health with a focus on equity. Historically, the global health field and professional community has been dominated by vertical (i.e., disease-centered) approaches to global health improvement. While these approaches may seem more glamorous and marketable, and the gains and progress made by these initiatives cannot be understated, the earthquake in Haiti, the reappearance of polio in conflict zones, and the recent Ebola outbreak in west Africa are cautionary tales of the devastation that an emerging disease or unforeseen catastrophe can have when health systems are poorly equipped to respond. To advance the health of the world’s population, U.S. global health efforts should contribute to elimination of poverty, advancement of education, and ensuring access to health care by the poor. Health systems strengthening, both technically and managerially, and increasing access by incorporating the participation of communities and civil society in systems for social accountability, is more important than battling each new disease as it erupts and will ensure that those systems are prepared to protect the health of their constituencies no matter the disease du jour. We question current strategies for blanket integration of health programs/services and decentralization of governance, and urge that these policies be carefully assessed in each country situation before promoting them. Countries should be empowered for improved decision-making to increase aid effectiveness.
A greater focus is needed on the health needs of mothers, newborns and children (MNCH), especially in first 1,000 days (conception to 2 years). Improving health and development in infants and young children can have impressive impact and have the greatest potential for better population health and productivity in the future. While substantial gains have been made in this area in the last 15 years, this population group remains underprioritized, as demonstrated by the MDGs 4 and 5 which had the lowest level of completion among the MDGs. MNCH is best helped by addressing social determinants of health with pro-poor and health in all-sectors policies and by strengthening primary health care systems to work better with communities, reducing cultural and economic barriers to improve access to preventive and curative care. Improving quality of obstetric and neonatal care in health services should be a priority to reduce mortality.
A serious commitment to a health systems approach must also include work to address the health effects of climate change, which disproportionately affect developing countries and children under five years of age, with both mitigation and adaptation.
If the NAS is committed to advocating for the administration to make global health a pillar of US foreign policy, then it must urge that administration to work to make sure that the rest of its foreign policy reinforce that commitment. That includes advocating for peace and reducing armed conflict wherever possible. We need to stop investing in war and weapons, particularly the catastrophic conflicts in Yemen and Syria (which the US has prolonged by engaging in a poorly organized proxy war with Russia) and the new planned $1 trillion nuclear weapons modernization act. Our country will have no standing as a global health leader if our military continues to engage in arms races, bomb hospitals, and kill civilians in drone strikes.
Finally, the administration needs to make sure that whatever global health policies or initiatives it decides to launch are sustainable in the long term. The White House’s original Global Health Initiative (which, ironically, appears to have been inspired by the last NAS report on global health to the incoming administration) fell on its face and failed embarrassingly, much to the chagrin and frustration of the development community at large. The problems that were intended to be addressed still remain: turf battles between agencies, competing priorities, lack of rigorous evaluations, and (most importantly) lack of overall strategic vision.