DOM INIC C HAVEZ / GLOB AL POS T
Solomon Zewdu M.D., the country director of Ethiopia for Johns Hopkins Bloomberg School of Public Health, listens to a nurse in the children’s ward at Black Lion Hospital in Addis Ababa, Ethiopia, on April 5.
The GHI was designed to take a bunch of unconnected U.S. health programs that focused on AIDS, malaria, tuberculosis and immunizations, among others, 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 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
12 | JULY 13–19, 2011 | BOISEweekly
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, WWW. B O I S E WE E KLY. C O M