First Hundred Days for Global Health

The first hundred days of the new administration should kick start an ambitious agenda in global health alongside long-needed reforms to enhance the efficiency and effectiveness of US action. Building on our earlier work,[1] we suggest seven priority actions within three broad categories:

1. Right size budgets—and use them well—to achieve headline USG global health goals.

The United States is an incredibly generous funder for global health programs, contributing over $12 billion in FY2015.[2] Nonetheless, additional resources—and better use of existing resources—will be required if the US hopes to achieve its headline global health goals.

• Align budgetary requests with agencies’ programmatic goals—and vice versa. Global health agencies rightfully want to see deep impact from their programs—but in so doing too often adopt aspirational goals that are divorced from budget realities. To reach ambitious global goals like an AIDS-Free Generation by 2020 or the end of AIDS of by 2030, or expanded access to voluntary family planning services for an additional 120 million women, the United States and other global funders will need to substantially increase their contributions.[3] The incoming administration should craft a realistic plan to increase global health budgets and/or scale back programmatic goals. By aligning budgetary requests with programmatic goals, the US can set itself up for global health success and hold agencies accountable for succeeding against realistic metrics.
• Set out a value for money agenda for PEPFAR and other global health programs.[4] The incoming administration has an obligation to its own citizens and to the intended beneficiaries to ensure that global health funds are spent efficiently and effectively. Accordingly, the new administration should affirm its commitment to value for money in global health by publishing a value for money agenda within the first 100 days. Drawing from civil society recommendations and expert advice, the agenda should consider ways that the US government can improve the allocative and technical efficiency of its spending; ensure accountability for results among its implementers and recipient governments; and create better incentives for recipient governments to co-finance US contributions with domestic health expenditure.

2. Scale up and consolidate for global health security.

The next US president will face ongoing and emerging global health crises. The Zika outbreak continues, and experts warn that the next pandemic could be right around the corner. The spread of infectious diseases poses a real and serious threat in countries at all levels of development, while growing resistance to antimicrobial drugs threatens to reverse decades of progress against common pathogens. International organizations like the World Health Organization and country leaders must work together to effectively prepare and respond to these threats—but the United States has a leading role to play. We propose the following three actions for the incoming administration:

• Pursue an integrated agenda to strengthen global health security and combat antimicrobial resistance. The best way to protect the health of all Americans is to ensure infectious disease threats are adequately addressed at their source. Fifty countries have volunteered to conduct an external evaluation of their capacity to prevent, detect, and respond to public health threats within the International Health Regulations. In parallel, the United Nations General Assembly recently passed a landmark resolution acknowledging the threat of antimicrobial resistance and committing to a national, regional, and global response. The incoming administration should build on this momentum by integrating these two parallel streams through a single, integrated agenda that addresses global surveillance, infection control, response capacity, and research and development. A top priority is to strengthen the incentives for regular evaluation and performance on International Health Regulations and pandemic response preparedness in low- and middle-income countries. The United States should go beyond its current in-kind support to develop clearer financial and reputational incentives for low- and middle-income countries to conduct rigorous external evaluations of their surveillance and response capacity; self-fund and address gaps in disease response and preparedness; and improve evaluation scores over time. [5]
• Create a $1 billion contingency fund to enable a timely response to the next pandemic. The US response to the Zika outbreak was hamstrung by congressional deadlock on tangentially related policy issues, leading to preventable infections and further spread of the virus throughout the Americas and into US territory. To enable a timely and robust response to the next pandemic, the incoming administration should request that Congress create a $1 billion contingency fund which can be accessed during an infectious disease outbreak or other public health emergency meeting a set of pre-agreed, legislatively specified criteria. Unused portions of the contingency fund should roll over year-to-year, requiring Congress to simply “refill” its budget it future allocative cycles.

3. Organize US efforts to optimize impact for global health.

Far from a unified approach with clear and coordinated goals, US global health programs are spread across eight executive branch departments, four independent or quasi-independent federal agencies, numerous departmental agencies and operating units, and at least four large-scale, multiagency initiatives. As a result, US global health efforts remain ad hoc and uncoordinated, both at the headquarters and field levels, leading to duplication, inefficiency, and the persistence of vertical, siloed programs. The next administration should take the following steps to increase the coherence and impact of US global health programs at the headquarters level while reducing duplication and better supporting integrated health systems at the country level:

• Appoint a global health senior director to the White House National Security Council, along with a global health directorate. To prepare and respond to looming health threats, the United States needs a senior leader who can develop and implement a cohesive strategy for the full range of US global health programs, accounting for existing agency mandates and acting as an honest broker among disparate specialties. The next US president should therefore create a new role in the White House National Security Council—a global health senior director—who is supported by a dedicated directorate. The senior director will coordinate policies and agency actions, elevate global health issues to the President, provide direction on behalf of the President to the agencies, and engage civil society. She or he would work closely with the Office of Management and Budget to ensure that global health funding is also coordinated across all US global health programs, ensuring each funding stream fits within the overarching, whole-of-government global health response.
• Craft and staff a harmonized approach to multilateral global health institutions. To maximize the US government’s leverage in advancing its goals through each multilateral institution, it must represent a cohesive policy and reform strategy through its participation on all their governing boards. A single agency, or the newly appointed White House global health senior director, should coordinate leadership at all the multilateral institutions. 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. Under the leadership of the senior director, the US should also pursue opportunities to leverage its financial contributions into policy reforms, for example by developing performance agreements with incoming global health multilateral leaders and tying replenishments to improvements in efficiency and effectiveness.
• Commit to increase transparency and rigorous evaluation of US government spending and its uses in global health. The US government invests many billion annually in global health and global health security programs, yet it can be challenging to track exactly how that money is being spent—beyond high-level commitments—and what that money is achieving. The incoming administration should commit to transparently and quickly making spending and other relevant data available, and carrying out rigorous evaluation as appropriate. We otherwise 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.

Endnotes