The Global Health Initiative: Hubris has its Limitations
In May 2011, the U. S. government released its Guidance for Global Health Initiative (GHI) Country Strategies. It provides framework on how the field will structure itself to deliver on a key tenet of GHI—a “whole of government approach” aimed at improving national health outcomes.
The targets and outcomes of GHI are:
1. HIV/AIDS, “support the prevention of more than 12 million new HIV infections, provide direct support for more than 4 million on treatment, and support care for more than 12 million people, including 5 million orphans and vulnerable children;
3. Tuberculosis, contribute to the treatment of a minimum of 2.6 million new sputum smear positive TB cases and 57,000 multi-drug resistant (MDR) cases of TB, and contribute to a 50% reduction in TB deaths;
4. Maternal Health, reduce mortality by 30% across assisted countries;
5. Child Health, reduce under-five mortality rates by 35% across assisted countries;
6. Nutrition, reduce child undernutrition by 30%;
7. Family Planning and Reproductive Health, prevent 54 million unintended pregnancies;
8. Neglected Tropical Diseases, reduce the prevalence of 7 NTDs by 50% among 70% of the affected population.
These are a Herculean set of outcomes in the best of healthcare settings. GHI is targeted on approximately “80 countries in which the U. S. Government invests in foreign assistance funding in the health sector”, and is funded at $60 billion over six years. For items 1, 2, 3 and 7, it promises to deliver 110-115 million various health interventions, and for items 4, 5, 6 and 8, at least another 25-30 million more!
From a humanitarian and security perspective, these outcomes and target are supremely representative of the most fundamental values in American society. Reviewing them from an operational perspective, however, they elicit troubling questions. There hasn’t been a health Project Paper funded by USAID over the past 40 years that didn’t contain similar targets for MCH and Child Health. If they had been met at a modest level of 10% over this time period, there would be no need for GHI to pursue them today. In November 2010, it was reported that of the $26.9 billion in Development Assistance for Health, 50% represented funds originating from non-US sources (ODA and NGOs, etc.). (See Financing Global Health 2010, Institute of Health Metrics and Evaluation). How, then, can GHI establish control groups for these targets from which baseline measurements can be taken to demonstrate an outcome that is specifically relative to GHI funding when so many other donors, the private sector, and the countries themselves, are funding the same projects? In the most costly element of GHI, PEPFAR at some $55 billion of its total, the sole metric is numerical on AIDS treatment. That is, the outcome is achieved if the number of those on treatment increases over time. The outcome doesn’t relate to any clinical element of patients’ treatment, e.g., responses to ARV therapy ‘x’ vs ‘y’; the onset of drug resistance and the reasons; co-morbidities and their causes; mortality rates and their causes, etc. Because GHI follows a public health approach of treating as many as possible, as quickly as possible, and as inexpensively as possible, we are driving toward the universal goal of access to ARV treatment for 14.7 million by 2015 in the absence of any clinical knowledge on outcomes.
Most importantly, since the “whole of government approach” is the operating mantra of GHI, can its implementation in 80 countries achieve a better outcome than it has in the District of Columbia—one of the smallest population areas of the U. S. and the institutional citadel of this principle. Yet, it has the highest incidence of HIV/AIDS in the U. S., and nationally, “it has literally become easier to obtain AIDS drugs in some African countries than in many states in this country”. (See; James Driscoll, We can change the reality of AIDS, The Washington Post, 6/25/11).
Is there evidence that foreign aid affects health outcomes? Several authoritative studies take exception to that notion:
- In the World Bank Development Group’s Child Mortality and Public Spending for Health: How Much Does Money Matter, the authors found in 1997 that “the major drivers on reductions in infant mortality are economic and educational: public health investments account for 5% of this decline”;
- In the same paper, the author wrote that in a 1997 examination of cross-national variation in child survival and infant mortality “approximately 95 percent of the variation in under-5 mortality is explained with income, its distribution, female education, and other “cultural” factors”;
- In the World Bank’s 1999/2000 World Development Report, it found that “within Lower Middle-Income Countries, infant mortality rates improved from 61/1000 to 38/1000 between 1980–1997, while ODA declined from 1.5% of GNP to 0.9%”;
- In a 2007 IMF report on Health Aid and Infant Mortality, its authors commented on the importance of understanding the relationship between foreign aid and health outcomes. They said: “despite the vast empirical literature considering the effect of foreign aid on growth, there is little systematic empirical evidence on how overall aid affects health, and none (to our knowledge) on how health aid affects health. This is surprising given the recent attention devoted to promoting health in developing countries”;
- In a 2007 GAO report on USAID’s Maternal and Child Health Activities for Fiscal Years 2004 and 2005, totaling an expenditure of $675 million, it was found that “USAID did not centrally track its expenditures, and was thus unable to determine if the funds were used for MCH activities … or how much was actually spent on child survival”.
- An internal World Bank audit of its health, population and nutrition programs in 2009 revealed that of the $17 billion spent since 1997, “one-third had unsatisfactory outcomes and much of the spending aids the richest 20% of people”.
- Kenya has been held up as one of the signature programs of GHI. In 2010, USAID made a grant of $40 million for Health Financing. Because of a divided government, GHI’s “whole of government” approach had to be applied to “half of government” approach by distributing the grant evenly between its Ministry of Health and Ministry of Medical Services.
In and of themselves, the objectives and targets of GHI are worthy of pursuit from a humanitarian perspective on behalf of the least advantaged in our world. It is hubris, though, to believe that any reductions in the diseases being address can be attributed specifically to its efforts. Recipient countries might find the program more compelling and deserving of emulation if the headquarters of GHI had proven that the concept of a “whole of government approach” is one which works here in the first instance.
Mix a bit of humility in with the evidentiary record and anyone might reasonably reach the same conclusion.