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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.

The mishandling of Obama's GHI

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

Even the outcome of those talks was problematic: Goosby’s office retains control of that 70 percent — at least for now — and while PEPFAR officials are actively looking for ways to expand AIDS programs for other services, different Washington bosses oversee different pots of money.

The third issue was that during the long buildup for the GHI, few administration officials reached out to Congress to keep it informed and build support. The result, according to many observers, was that the bipartisan goodwill built toward the AIDS program began to wither and the support for the GHI has yet to take hold.

“I have not seen anything mishandled as much as GHI — they never defined it for Congress and many now see it as a program that sucks money off other things, including the AIDS program,” said Shepherd Smith, co-founder and president of the Washington D.C.-based Institute for Youth Development, an AIDS program implementer, who was a critical player in helping win Republican support for PEPFAR. “I think this administration has largely killed the enthusiasm for PEPFAR, or for bipartisan support for global health.”

Not everyone is so pessimistic. Other critics of the administration’s handling of the GHI believe it’s still possible for the Obama administration to build a new coalition for global health. They argue that such funding brings the best return of any item in the federal budget: Tens of thousands of lives saved daily, through AIDS drugs or vaccinations or the training of birth attendants in the poorest countries of the world, all for a relatively small sum of money. Federal aid, in total, is 1 percent of the U.S. budget.

Dr. Mark Dybul, the former U.S. global AIDS ambassador under the Bush administration, said the administration needs to reach out in a much more effective way to Republicans on the GHI, especially the social conservatives, or the Christian right. The flash point here involves women’s reproductive rights, and family planning, which is a cornerstone of the GHI effort. Just the words “reproductive rights” translates into abortion for many social conservatives, and Dybul and others said that the Obama administration needs to tread with care and common sense.

“We need to make sure there’s voluntary family planning available for women who want it, but we can’t alienate people who have … problems with that,” Dybul said. “… This is an issue of administrative leadership and management and listening to people.”

Despite his criticism of the leadership on the GHI, Dybul is a strong supporter of its goals and its strategy for delivering health care. Dybul said that the restrictions placed around PEPFAR were at times counterproductive in trying to deliver life-saving health care in the developing world. He particularly wants to see the U.S. government scale up efforts to protect the lives of women during childbirth. An estimated 350,000 women die each year during childbirth — nearly 1,000 a day.

“What GHI is trying to do on this is extraordinary, and we’re so glad they’re able to do it, because we tried and it didn’t work,” Dybul said. “In Ethiopia, I remember the first time I went to a beautiful, pristine, (prevention of mother-to-child HIV transmission) clinic. They were perfectly well-trained, it was well-staffed, there was a great lab. But then you walk through the doors and you’re in a maternity ward that’s a disaster. For a tiny amount of money you can expand that to have one site that’s a maternal-neonatal health clinic that will improve the lives of women and children. I can’t tell you how hard we tried to get our colleagues to use incremental amounts of money to do that. It was impossible.”

Congress is in a far different place today than it was in 2003, at the start of PEPFAR. Mark Green, a former Republican U.S. House member from Wisconsin and the U.S. ambassador to Tanzania from 2007 to 2009, pointed out in a Washington briefing that of the 100 U.S. senators who voted for PEPFAR, only 52 are now in office. Of the 435 members of the House, just 225 are in. And drilling deeper, of the 19 members of Senate Foreign Relations Committee who helped craft the PEPFAR legislation, only three serve today.

“With these elections we’ve turned around and suddenly seen the giants, if you will, the legislative giants of global health have left the stage,” Green said. “And so I think really what we have to do is go back to basics.”

Rep. Keith Ellison, a Minnesota Democrat, agreed and said that the questions asked today in Congress are different from the ones asked eight years ago.

“I think the thing that both sides want to know is, is the dollar spent well? No one should be afraid of scrutiny, and everyone should be able to prove value associated with the American tax dollar,” he said. “I think the important challenge is to encourage people to look program by program for savings, for real value and for impact.”

That’s a key challenge today for the GHI: Can it show savings and impact soon, even though programs are just being rolled out in countries?

Dr. Ezekiel J. “Zeke” Emanuel, who was a former senior global health adviser in the White House, said in an interview that successes have already begun — if on a small scale.

“Look at the neglected tropical disease area. From 2003 to 2008, this collection of seven diseases, which affect 1 billion people around the world, the poorest billion, the U.S. government cumulatively spent $45 million,” Emanuel said.

Last year, he said the funding went to $65 million, and the administration brought together a number of drug companies to talk about these neglected diseases, and three of the companies increased their donations of drugs. “That’s a big success,” he said. “There are going to be millions of kids treated and de-wormed, who won’t have schistosomiasis, who won’t have river blindness, because we had made this a big focus. It wouldn’t have happened without GHI.”

Emanuel, who is head of the Department of Bioethics at The Clinical Center of the National Institutes of Health, said he knows that funding for GHI won’t come so easily. But he remains optimistic.

“You get more improvement for good for what we spend on global health than for anything else in the budget,” he said. “Nonetheless, if we are going to have a tough budget environment, it puts a burden on us, on the global health community, to do more with the resources we have.”

Funding for this project is provided by the Henry J. Kaiser Family Foundation as part of its U.S. Global Health Policy program.

This piece was updated to revise the estimate of funding that the Global Health Initiative will receive.