Global Health Initiative Could Lead the Way for Broader Foreign Assistance Reform, but Questions Remain

The Global Health Initiative (GHI) seeks to bring U.S. global health efforts under a coordinated, integrated, sustainable, women-centered, and country-owned umbrella of global health foreign assistance. The U.S. is expected to spend $63 billion on global health over six years (2009-2014). Given the size of this effort, the GHI reforms may be the testing ground for any future reforms of U.S. foreign assistance.Yesterday, the Kaiser Family Foundation held an event and released a new brief (which draws on the comments we submitted on the GHI consultation draft, see below) on the evolving GHI. Unfortunately, no one made an announcement about the selection of GHI+ countries—the “test sites” for the U.S. government’s new approach to global health foreign assistance—or a new draft of the GHI implementation plan, but it was useful to hear from the GHI focal points at USAID (Amie Batson), CDC (Deborah Birx), and PEPFAR (Ann Gavaghan) their interpretations of GHI principles (which are laid out in the consultation draft). These officials have been charged (by their respective bosses) with the responsibility to make the GHI happen, but there is much to be done that wasn’t discussed at the event.  My colleague Nandini Oomman pointed our readers to the GHI’s consultation document in February. In that blog post, we promised we would post the comments and questions we shared with the GHI team through this virtual consultative process.  Here are highlights of the HIV/AIDS Monitor Team’s Comments to the GHI Team, which we had hoped to hear more about at the event today.The comments and questions raised below are based on the knowledge we have accumulated over the course of three years of research in Mozambique, Uganda and Zambia and analyses of other secondary data:1. USG global health aid architecture and integration (across agencies, budgets, and program areas): How are budgets and responsibilities for targets going to be allocated at the country level to achieve a comprehensive and integrated approach across program areas and agencies?a. The consultation document recognizes that health services should be organized around the needs of the population rather than around funding sources or diseases (pg 4). However, it will take significant changes in the current USG aid architecture to ensure this recognition is more than just rhetorical flourish. Currently USG health assistance is organized around funding streams and diseases, where funding and responsibility for activities and outcomes remain in strict silos.b. Currently, the GHI is little more than a packaging of different health programs that the U.S. will support. Budgets and reporting remain vertical; delinked across program areas and agencies. The consultation draft does not include a clear mandate or a mechanism for sharing responsibilities for targets or for sharing budgets, especially at the country level.c. Recommendations and lingering questions:

 i.      Provide clear examples of how funding will follow need at the country level. If the U.S. is going to be responsive to health issues identified as priorities by countries (on the basis of evidence), will funding allocations by program reduce this flexibility of U.S. aid dollars?ii.      Create mandates and mechanisms for shared responsibility for targets across program areas, and create (performance based) incentives for USG staff and recipients that reinforce this shared responsibility. For example, if a TB and HIV/AIDS program share targets for treating patients who are co-infected, how will funding be allocated for these programs to deliver joint services and be jointly accountable for targets met or not achieved?

2. Goals and ownership:a. The GHI team has not provided a clear rationale for these targets. Were they calculated as a proportion of the total “global health needs” based on the proportion of the U.S.’s contribution to the total estimate of resources required to address stated global health need? Or as an estimate of the country level health needs that aren’t addressed by domestic and/or other donor resources?b. There is a tension between setting global output targets at the outset and then designing country programs and USG portfolios around country needs. If the USG is serious about country ownership it will need to derive targets within each country based on health needs and in dialogue with governments, civil society, and other development partners. The USG could join, rather than duplicate, existing efforts to facilitate coordination in the health sector, such as the IHP+ and SWAps.c. Recommendations:

i.      Define “global health needs” and describe how USG global health targets were set.ii.      Country specific priorities should drive USG programs. Targets for USG programs should be based on country specific needs, identified and prioritized in dialogue with national governments, civil society, and other international donors and organizations. The most meaningful ways to derive global targets would be to add up the US contribution across countries.iii.      Where PEPFAR is a key component of the USG effort in country, build on partnership framework agreements to create one global health initiative agreement between the US and a specific country to avoid multiple USG agreements in any one country.iv.      Commit to release funding and programmatic data: Country ownership would require much more transparency on the part of the USG (the consultation document only mentions transparency of the national government). The USG should commit to release their funding and programmatic data, such as the COPRS data for PEPFAR. This would facilitate greater learning, cooperation and accountability of USG global health programs and set an example of good global health governance.

3. Metrics for Outcome and Impact: a. The GHI document emphasizes that the USG will focus on health outcomes, but the metrics described in the current GHI strategy mostly focus on outputs. While measures like maternal mortality are a good start at changing this focus, the reduction in the maternal mortality ratio can only be measured over a length of time to see real outcomes.b. Many health outcomes are only fully realized in a period of time well over an annual budget cycle. However USG reporting and budgeting is tied to annual cycles and independent evaluations are rare. To shift the USG focus from outputs to outcomes, the GHI will need to establish an assessment approach (which is transparent and integrated with national HIS) that can evaluate progress over 5-10 year periods and distill out the USG contribution to a multiparty effort within each country.c. Recommendations:

i.      Identify country specific priority health outcomes and intermediate indicators that make it possible to draw causal links among USG inputs and health outcomes.ii.      Establish at the outset a mechanism and plan for independent evaluation of the GHI to assess longer term outcomes and impact, in ADDITION to the annual reporting of targets. Further, outcomes and impact should be assessed and reported to demonstrate progress by country, (particularly GHI+ countries), relative to their baseline indicators measured or estimated at the outset of the USG’s partnership with a country.

4. Systems strengthening: How will the USG reduce its reliance on parallel systems created for the implementation of PEPFAR, and instead make sustainable long-term investments in national health systems?a. The consultation document mentions the USG intention to support national efforts and join into existing multilateral frameworks in country, yet the USG has had serious challenges doing this in the past. In many countries and at a global level development partners, national governments and civil societies have been developing joint strategies for strengthening health systems, such as the IHP+ frameworks. How will the GHI support national and other donor efforts rather than starting new, duplicative, and resource intensive parallel health system components such as the MEEP Program in Uganda, or the separate ARV supply chains in Uganda and Zambia?b. USG annual planning and budgeting processes limit the ability to use USG funds for medium and long term systems strengthening efforts, as defined in national strategies. For example, the GHI does not address the disconnect between USG financing and countries’ needs for predictable financing to build a strong health work force.c. Assessment of health systems strengthening outcomes. The GHI vision to develop indicators of health system capacity deserves merit. Moreover, the selection of an outcome indicator is a strong indication that the USG is committed to measuring change in the capacity of the system over time. While maternal mortality ratio (MMR) could serve as a proxy measure of the capacity of the health system to respond at several levels (outreach with antenatal care, recognition of high obstetric risk, referral systems and finally emergency obstetric services) the challenges of measuring MMR are many including the collection of data over a long period of time to assess actual outcomes.d. Recommendations:

i.      Transfer/integrate the parallel and disease specific systems for information, supply chain, and human resources that PEPFAR has created to national systems. Rather than avoiding national systems to achieve USG specific targets, support of and reliance on national systems will strengthen national health systems and avoid the parallel disease specific systems the USG has relied on in the past five years for PEPFAR. For example, transfer successful ARV specific supply chain systems to national actors, with continued USG supported technical assistance, and expand them to cover all health commodities.ii.      Ensure that USG funding is predictable and on plan. PEPFAR partnership frameworks, if they clearly outline planned inputs over a five year period, are a good start toward this end, helping national health system planners and other development partners take account of USG contributions towards national plans, helping to align and harmonize USG health systems funding with others. Many countries now have costed HRH development plans, which include the inputs of many development partners but not the USG, an indication that the USG is not yet on plan.iii.      Invest in the health workforce at-large and not just for USG project specific health workers.iv.      Provide USG mission staff with guidance to develop measurable intermediate indicators (with countries) to assess health systems’ capacity in the short term, and over a period of 3-5 years. For example, while changes in MMR may only be observed over a longer period of time, intermediate outcomes such as coverage of antenatal services, referral rates, obstetric emergency rates, may be assessed in the short term, providing progressive and regular measures of the ability of the health system to respond to a high priority health problem.

Like all those who are interested in making the GHI a success, we submitted these comments to the GHI team in February, and are eagerly awaiting the opportunity to learn more about many of the issues we raised in a newly revised GHI strategy.