The mishandling of Obama's GHI

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.

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.

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.  

This story is presented by The GroundTruth Project.