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USA/Africa: Supporting Global Health

AfricaFocus Bulletin
Nov 6, 2009 (091106)
(Reposted from sources cited below)

Editor's Note

"Overall, we call for a doubling of U.S. aid to global health from nearly $8 billion a year to $16 billion by 2011. A six-year scale up of a sufficiently resourced initiative would total $95 billion. While this reflects higher levels than the President's original announcement, 40% of this increase is for the total of $14 billion that must be invested in health workforce - which we believe could make or break the effort." - http://www.theglobalhealthinitiative.org

In a statement calling for the U.S. to support a Global Health Initiative, 24 U.S. groups dealing with international health issues applaud President Obama's commitment to support global health and the recognition that this is both a moral obligation and in the U.S. national interest. But they warn that underfunding the initiative because of budget pressures would be a short-sighted mistake.

This AfricaFocus Bulletin contains the summary statement from this report on "The Future of Global Health." The full statement, as well as additional background and press coverage, is available at http://www.theglobalhealthinitiative.org

Another AfricaFocus Bulletin sent out today contains excerpts from the report from M�decins sans Fronti�res (MSF, Doctors without Borders) warning against the current trend to reduce funding for HIV/AIDS. "Recent funding cuts," the report warns, "mean doctors and nurses are being forced to turn HIV patients away from clinics as if we were back in the 1990s before treatment was available."

That report notes: "a dangerous trend is underway in the global health policy arena. Rather than looking for ways to leverage and replicate the success of the AIDS public health revolution to improve global health, there are increasing calls for a diversion of foreign aid away from HIV/AIDS and towards other health priorities. While there is clearly a need to give urgent and additional resources to an array of global health priorities, not least maternal and child health, cutting HIV/AIDS funding is not the answer."

See http://www.africafocus.org/docs09/hiv0911.php for excerpts from the MSF report and links to the full report.

See also the statement by Africa AIDS groups calling on the Global Fund to sustain its commitments. Reference and link at: http://www.africaaction.org/newsroom/release.php?documentid=4576

For previous AfricaFocus Bulletins on health issues, visit http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

The Future of Global Health:

Ingredients for a Bold & Effective U.S. Initiative

October, 2009

http://www.theglobalhealthinitiative.org

"We cannot fix every problem. But we have a responsibility to protect the health of our people, while saving lives, reducing suffering, and supporting the health and dignity of people everywhere. America can make a significant difference in meeting these challenges, and that is why my Administration is committed to act." - President Barack Obama, May 5, 2009

Major accomplishments in global health over the last decade demonstrate that adequately resourced programs, focused on achieving specific results, can improve health outcomes for millions and support economic progress. They also show that distinct public health challenges are closely interconnected and that a comprehensive and integrated strategy is needed to ensure that ambitious health goals are met.

The next step forward in US global health must be defined by significantly expanded investments, a bold vision of what U.S. assistance can accomplish, and building on successful programs to increase effectiveness and self-sufficiency at the country level. Based on these lessons learned, the United States, through a Global Health Initiative, should:

• Double U.S. aid for global health to approximately $16 billion per year in 2011 and challenge other donors to similarly scale up their investments;
• Establish bold U.S. targets for improved health outcomes in each of the six GHI areas and contribute our fair share to reach the healthrelated Millenium Development Goals; and
• Ensure that as we invest in programs to scale up health for all, we build on successful programs and fulfill existing commitments.

The Global Health Initiative

President Obama's Global Health Initiative (GHI) represents an historic opportunity to achieve bold and ambitious targets in the fight against the most daunting global health challenges of our generation. Alongside related efforts to reform U.S. foreign assistance and to coordinate various initiatives that populate the global health landscape, the GHI is an important signal of the intention of the U.S. government to expand its leadership on global health. At a moment of global economic downturn, we recall the Institute of Medicine's statement from earlier this year that global health programs "play a crucial role in the broader mission of U.S. foreign policy to reduce poverty, build stronger economies, promote peace, and enhance the U.S. image in the world today.

Currently the GHI consists only of a limited number of known elements; fundamental aspects such as scope, targets, timelines, and specific costing data have yet to be finalized. The language of a broad and realistic vision of what the U.S. can accomplish, however, is encouraging.

This report strongly supports the President's focus on the six areas identified: HIV; tuberculosis; malaria; reproductive, maternal, newborn and child health; health systems and health workforce; and neglected tropical diseases.

To substantively tackle these areas, success will depend upon key decisions:

• First, funding targets must be sufficient to meet current estimates of the U.S. share of funding required to reach internationally agreed upon goals in the six priority areas of the GHI. The nation's highest scientific body - the National Academies of Sciences, Institute of Medicine - eloquently articulated the U.S. interest in investing significantly more in global health. Initial figures for GHI - $63 billion over six years - will not be sufficient.
• Second, investing in each of these key areas could yield major synergies for people's health - with an exponential benefit in lives saved. Yet an expanded response to certain health priorities at the expense of planned scale up in other areas would miss this opportunity.

To help achieve these key elements of what the GHI can be, a coalition of civil society organizations with expertise in the six GHI priority areas has developed an analysis of the appropriate U.S. program and funding targets that should define the GHI. Our analysis also includes recommendations for policy changes necessary to facilitate the success of the GHI.

Ingredients for A Bold & Effective Initiative

The U.S. government can and should be a leader in global health on a larger scale - moving the world toward realization of the human right to health through smart, aggressive scale up of key health services that improve not only the health of people but also the economies of nations.

This requires continued expansion of what is working and scale up of other priority efforts to levels sufficient to reap the synergies possible - ensuring systems of health that can care for people long term. We cannot address maternal and child health in Southern Africa, for example, without aggressively scaling up AIDS treatment to address the largest cause of deaths of mothers and, often, their nurses and midwives as well. Simultaneously, with smart, integrated and additional programming we can ensure that their communities are stronger because these same women do not die in child birth, their children do not die of pneumonia, and everyone receives core preventative care. As the GHI announcement highlights, a cross-cutting commitment to strengthening country health systems is essential for this to happen - and this will require increased investment in the health workforce to address bottlenecks that have impeded effective health programs for decades.

In order to reflect a bold, innovative new approach to global health a GHI is needed which:

• Supports bold, people-centered, outcome-oriented services reaching toward universal access to health. A focus on a selective set of the cheapest interventions has been the hallmark of weak and ineffective responses that have undermined progress in reaching global health commitments. The GHI should not support rationing of services based on a narrow and restrictive concept of cost effectiveness.
• Supports direct health service delivery as the core of U.S. global health programs. Major scale up in the purchase of commodities and provision of services to people should be central where it is not currently.
• Continues promised growth of HIV/AIDS, TB, and malaria programs and uses these as a platform for expanded services. As the greatest killers of people living in impoverished nations, infectious diseases must continue to be a major priority. U.S.-supported HIV programs have been used to expand community health care coverage; these innovative models for delivering integrated community care should be expanded as best practices. This will require full funding of the Lantos- Hyde Act.
• Sets bold U.S. targets based on global need to urgently scale-up sexual, reproductive, maternal, and child health and neglected disease response. Despite decades of promises to address these priorities, far too little progress has been made, and scandalous rates of preventable sickness, death and disability must spur the U.S. to bold action.
• Strengthens health systems by focusing on recruiting, training, and retaining health workers. None of the U.S. priorities described here will be reached without sufficient midwives, doctors, nurses, and community health workers.

Recommendation 1: Define Bold, Measurable Global Health Initiative Targets to Reach Universal Access to Services

Over the years, nations of the world have worked together to agree on key global health targets including:

1. Reducing the maternal mortality ratio by three quarters;
2. Achieving universal access to reproductive health, including meeting unmet need for voluntary family planning;
3. Reducing the under-five mortality rate by two-thirds;
4. Achieving universal access to HIV treatment, care and prevention;
5. Halving the global burden of TB;
6. Reaching near zero preventable deaths from malaria and 75% fewer cases through universal access to malaria control tools;

Pronouncing that U.S. funding is contributing toward larger goals, however, is not enough. If we pledge to "do our part" we can leverage other nations to reach global goals. The U.S. should set measurable, achievable U.S.-specific targets to ensure accountability and results-based funding. The GHI should be built on a coordinated strategy that supports comprehensive care at the point of delivery, using targets as guideposts rather than limitations.

As explained in this report, based on global and congressional goals, by 2014 the U.S. can ensure:

• Another 35 million births take place in facilities that provide quality care for both normal and complicated births.
• 40 million women receive quality antenatal care, while 35 million women and newborn babies receive quality postnatal care and 10 million more couples would have access to modern family planning.
• Appropriate treatment for 40 million more episodes of child pneumonia.
• HIV/AIDS treatment for 6 million people, and 12 million new HIV cases prevented.
• HIV/AIDS care for 12 million people, including 5 million orphans/ vulnerable children.
• Treatment under DOTS programs for 4.5 million new tuberculosis patients and diagnosis and treatment for 90,000 new multidrug-resistant tuberculosis cases.
• 730 million people provided with long-lasting insecticidal nets, a mortality rate near zero for all preventable malaria deaths, and a 75% reduction in malaria burden in the original 15 PMI countries.
• Treatment and care for millions facing 14 currently-neglected tropical diseases.
• At least 1 million new midwives, doctors, nurses, doctors, and other health personnel trained and retained, to achieve all the goals of the GHI.

Recommendation 2: Include sufficient funding to reach these achievable goals.

These targets are achievable - yet they require sufficient scale to reap synergies of services. With the passage of the Lantos-Hyde Act last year, the U.S. is already on track to spend roughly $54 billion on the GHI priorities in five years ($48b for infectious disease plus $5b for other priorities at current levels). As a six-year effort, the Global Health Initiative will need significantly more room to ramp up real services, especially if scale up of maternal, child, reproductive, and neglected disease programs are to be sufficiently bold. Failure to invest in the health workforce, especially, could undermine all these goals.

This report does not suggest that the U.S. should shoulder the entire burden. However, the U.S. can and should:

• Fully fund AIDS, TB, and malaria programs at the 5-year levels authorized by Congress in the Lantos-Hyde Act last year and fully fund the Global Fund. An extra year of funding must be added for 2014 since care cannot be put on hold for a year.
• Reach the target goals outlined above by increasing spending on Reproductive, Maternal, Newborn, and Child Health, Neglected Tropical Diseases, and health workforce so that our contribution to each reflects a U.S. share toward global goals - for an additional $28 billion.

Overall, we call for a doubling of U.S. aid to global health from nearly $8 billion a year to $16 billion by 2011. A six-year scale up of a sufficiently resourced initiative would total $95 billion. While this reflects higher levels than the President's original announcement, 40% of this increase is for the total of $14 billion that must be invested in health workforce - which we believe could make or break the effort.

                    2009 2010* 2011 2012 2013 2014 6-Year Total 
AIDS (bilateral)    5.03 5.13  7.25 8.2  9.5  10     45.1 b 
TB (bilateral)      0.16 0.23  0.65 1.2  1.3   1.3    4.8 b 
Malaria (bilateral) 0.39 0.59  0.92 1.28 1.76  1.76   6.7 b 
Global Fund         0.9  1.05  2    2.25 2.5   2.75  11.5 b 
Reproductive, 
Maternal, Newborn, 
and Child Health    1.04 1.18 3.71  3.78 3.86  3.72  17.3 b 
Neglected Tropical 

Diseases            0.03 0.07 0.15  0.23 0.33  0.4    1.2 b 
Health Care Workers 0    0    1.55  2.04 2.34  2.75   8.7 b 
Totals              7.5  8.3 16.4  19.0 21.5  22.6  $95   b 

* FY'10 figures reflect an estimate for TB, Malaria, and RMNCH above President's request, midway between House and Senate. AIDS numbers assume House levels and NTD numbers assume the President's request.

Reduce the cost of commodities: The U.S. can reap additional benefits by actively driving down the price of essential medicines and other health commodities by encouraging local generic production, negotiating prices for pooled procurement, and eliminating harmful trade policies that push countries to adopt rules that surpass their obligations at the World Trade Organization.

On Research: The figures above are based on strengthening and expanding health services to people. In addition to the Global Health Initiative, a bold global research agenda must be crafted with commensurate increases for these areas in the NIH, CDC, and USAID budgets.

Recommendation 3: The Global Health Initiative - and foreign aid reform - should build accountability, focus on outcomes, and support country needs and community rights. [It should be / include]

1. People-centered & Comprehensive: While maintaining clear, specific targets and goals for priority health issues, policies that hinder colocation of services must be eliminated. U.S. supported services should be built around the person rather than the funding stream and should actively seek to deliver priority interventions in ways that strengthen primary care. Programmatic goals must be used as guideposts for accountability and not as excuses for failing to provide comprehensive services.

2. Results-driven & Transparent: Funding allocations should be performance-based - ensuring that every organization receiving funds is consistently monitored and evaluated for its success in delivering high-quality services to people. Information on allocations and results should be public and easily accessible via the internet. Programs that are not achieving results should show improvement or have funding withdrawn.

3. Multilateral: Significantly expand funding through effective international efforts. The Global Fund to Fight AIDS, Tuberculosis, and Malaria should receive significantly more funding - at least $2 billion in 2011 to meet the U.S. commitment to fund 1/3 of the need - and should serve as a model for results- based, participatory, transparent funding for health. Similar support to the GAVI Alliance and other U.N. health-focused agencies must also be provided.

4. Support for the Public Sector: While NGOs will play an important role in health, direct U.S. support for building national health systems capable of providing high quality health services must be explicitly authorized.

5. Country-driven, Accountable, and Participatory: Programs should be driven by national strategies where those are bold and aim toward universal access. This must not mean, however, that decisions are made simply between governments. Every U.S. program should be required to assure that affected communities are central to planning, implementation, and monitoring.

6. Equity: The GHI should include a specific strategy and accountability mechanisms to ensure resources reach the most marginalized and vulnerable populations including rural and poor populations as well as youth, women, sexual minorities, sex workers, injecting drug users, and others.

7. Gender Focus: Women and girls often are more at risk of injury, disease, and death and receive poorer treatment because of their gender. Explicit, specific goals and strategies to reduce gender inequity should be included in the GHI.

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