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President Obama's ambitious Global Health Initiative — announced to a receptive international community in 2009 — is faltering as budget constraints and shaky implementation limit the impact of the multibillion-dollar program.

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The mishandling of Obama's GHI

Obama's ambitious Global Health Initiative struggles to find its way.

WASHINGTON — Two years ago the White House announced the Global Health Initiative — President Barack Obama’s new blueprint for how U.S. aid can improve international health care and save lives in the developing world.

Back in the spring of the new president’s first year in office few were surprised that Obama, a strong supporter of the fight against AIDS as a United States senator, would launch such a bold and well-intentioned plan to bolster global health.

After all, his predecessor, President George W. Bush, had made a global fight against AIDS his signature humanitarian act –– in a presidency largely defined by the attacks of Sept. 11 and the two wars that followed — Obama’s plan was to go many steps further: The Global Health Initiative (GHI) was designed to efficiently expand narrowly defined fights against AIDS and malaria so that U.S.-funded programs could have a much greater impact.

But few expected what would come next: almost no action.

Over the next 18 months, the administration released few details about the program, sending out officials who showed the same power point slides and the same messages over and over. Some audience members said they had memorized parts of the presentations.

“I have not seen anything mishandled as much as GHI.”
~Shepherd Smith, president of Institute for Youth Development

Behind the scenes, senior officials fought turf wars. Dozens of health experts wrote white papers. Amid the maze of cubicles inside USAID and the State Department, bureaucrats held meetings by the score.

It took more than a year for the heads of three responsible U.S. government bodies — the Office of the Global AIDS Coordinator, the U.S. Agency for International Development and the Centers for Disease Control and Prevention — to travel together to the field to see firsthand U.S. global health programs and to begin to explain to curious foreign service officers and health experts what the GHI was all about.

Now two years after Obama announced the creation of the GHI, little success can be shown and the ambitious undertaking may take several years more to fully get off the ground, if ever, because it has run into one of the most difficult budgetary climates in Washington in decades. Some analysts believe that Obama’s vision for a $63 billion, six-year program that would take all U.S. global health programs and make them work together to improve health systems in the developing world now will receive billions of dollars less than anticipated by 2015.

GHI’s stumbling start has become a signature disappointment in the global health community, an example of this administration’s well-intentioned but often slow and deliberative style and its failure to build bi-partisan consensus in Washington particularly around issues that touch the political third rail of “reproductive rights” for women. As some critics point out, Obama’s GHI and Bush’s policy, the President’s Emergency Plan For AIDS Relief, known by its acronym PEPFAR, make for a stark comparison of differing styles of leadership.

Based on interviews with more than two dozen people, including senior U.S. officials in Washington and in countries around the world, concerns about the GHI’s current predicament begin with the length of time it took for the Obama administration to start putting together the program.

“There were probably hundreds of people, working thousands of hours, writing white papers for GHI,” said one senior U.S. official involved in the effort, speaking on condition of anonymity. “People in the field grew very impatient. It took more than a year after the announcement before they went into the field to talk to people.”

The GHI was designed to take a bunch of unconnected U.S. health programs that focused on AIDS, malaria, tuberculosis, and immunizations, to name some, and to weave together the programs so that a family in, say, Rwanda, wouldn’t go to a U.S.-funded clinic that only served AIDS patients, but instead would go to a clinic that provided a whole range of services that included AIDS treatment and prevention.

The GHI aimed to find savings by combining stand-alone programs that fought one disease. It also put a gender lens on all programs, making sure that programs found ways to address the health issues of women and girls.

But from the start, the GHI was difficult to define. What was it? What wasn’t it?

The architects of the GHI acknowledged that the process took time and several said that they needed to think through the consequences of redrawing a whole new global health approach. The old way of doing things, they argued, may have led to quick results against a disease, but it was an inefficient and piecemeal approach to health care.

“When approaching each of those diseases separately, we were a creating some challenges as well, because we were so fragmented in our approach (before GHI),” said Amie Batson, USAID’s deputy assistant administrator for global health. Batson said that the GHI will show that not only is “treat the patient, the woman, more holistically is better (but) it’s also cheaper.”

But there were three major hurdles from the start in trying to build a new architecture for U.S. global health programs.

One was that the money tilts heavily toward the AIDS fight — roughly 70 percent of all global health funding. The AIDS money has lots of Congressionally mandated conditions that prevented spending for uses outside HIV programs.

The second was that the GHI had three chiefs — as opposed to the Bush’s PEPFAR AIDS plan that had one office, one ambassador, and a president’s marching orders to plow through red tape. The three chiefs — the heads of PEPFAR, USAID and CDC — had designs on the funding as well, said several U.S. officials who were directly involved in the early GHI negotiations. Dr. Eric Goosby, the U.S. global AIDS ambassador appointed by Obama, did not want to relinquish control over his budget, and several U.S. officials said in interviews that the political infighting between Goosby’s office and USAID Administrator Rajiv Shah grew particularly intense at times in the 18 months after Obama’s announcement of the GHI.