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Posts Tagged ‘Budget’

The Center for Strategic and International Studies yesterday unveiled  a new “must-read” report for global health advocates, “Smart Global Health Policy.” While a panel at the Congressionally-chartered Institute of Medicine, made up primarily of scientists, issued recommendations on US global health policy last year, the CSIS panel is the first to involve high-level business leaders and sitting members of Congress.

The report drew on observations made during a study trip to Kenya, but it is unclear if consultation in developing countries went beyond that, for instance to include global representatives of affected communities and of developing country civil society, such as those on the boards of UNITAID and the Global Fund.

The report and the webcast of the launch event are available online.  Here are a few highlights:

The report makes a strong case that it is in the interest of the United States to continue and increase  our investment in global health and that the issue should matter to all Americans. It calls for keeping funding for AIDS, TB and malaria on a “consistent trajectory,” doubling spending on maternal and child health to $2 billion a year, forging a collaborative response to emerging heath threats, establishing strong coordination of global health policy across US agencies, and increasing support for multilateral efforts.

In 2009 there was a massive drop off in the expansion of treatment by US programs, and the report notes that AIDS advocates are “particularly anxious” at the slowing growth rate, a stalling that could also impact health systems.  The report suggests that funding is a concern for treatment advocates, yet, in fact, HIV prevention advocates have also been quite alarmed at the essentially flatline funding picture.

Despite World TB Day (March 24) being just a few days away, no mention is made in the report of immediate tuberculosis funding concerns, lowered TB targets in the 6-year Global Health Initiative or USAID’s role in responding to TB.  Instead, the report includes TB within a much longer timeframe, stating that “we can accomplish great things in the next 15 years:  We can cut the rate of new HIV infections by two thirds, end the threat of drug-resistant tuberculosis, and eliminate malaria deaths.”

In terms of overall funding, the report calls for less spending in the near term than either the IOM panel or the Global Health Initiative coalition did; instead, the CSIS document endorses the President’s proposed funding of $63 billion by 2014.  While the IOM called for specific increased funding levels on AIDS, TB and malaria consistent with Lantos-Hyde, the CSIS report does not delve into specific funding levels, with the exception of maternal and child health.  Instead, taking the long view, it calls for $25 billion in annual spending by 2025.

One exciting aspect of the CSIS report is that it endorses innovative financing as a means of raising funds for global health.  The report does not touch on the concept of innovative taxation for health, recently championed by maternal health advocates at Family Care International and many other groups. However, it identifies some specific mechanisms, such as borrowing the money needed through an international finance facility, and it urges the US National Security Council to review the most promising ideas on innovative financing and develop a US position.

Admiral William J. Fallon kicked off the launch event, stating that global health is a “bipartisan enterprise… which can unite US citizens in collective action.”  He stated the importance of maintaining forward momentum, noting that “we do not want to coast or slide backward.”  Helene Gayle said that global health efforts are showcasing the American spirit of generosity and said “we need forward momentum even in a period of constrained resources.”

Jack Lew, the top State Department official developing the US Global Health Initiative, spoke about the Administration’s goals in developing the new strategy. He said that the Administration’s aim was to “challenge a way of doing business by moving beyond a primary focus on disease treatment.”  He said the goal was “not to do harm to existing programs.”

Advocates for effective HIV prevention have felt stymied in recent weeks by the lack of specific HIV/AIDS guidances from the Administration to the field and have noted that Kenya’s Partnership Framework with the US even appears to rule out family planning integration.  Family planning came up at the event when Dr. Michael Merson, of Duke University, criticized the Canadian government’s rejection of the inclusion of family planning as a part of its maternal health initiative.

But Lew’s presentation did not delve into details — and there was no opportunity at the event for questions from the floor.  He stated that program integration was crucial to meet the needs of women, and he commented on the importance of having family planning and HIV/AIDS services in one location.

The report is particularly noteworthy for the very strong focus on measurement for accountability in delivering services. Business leaders at the event decried the reporting burden on health programs and, along with Dr. Merson, called for a common set of impact indicators.

Rajeev Venkayya, Director of Global Health Delivery at the Bill and Gates Melinda Foundation, said that measurement matters because it allows us to maximize efficiency and stretch dollars while identifying what works and what doesn’t.  In addition, measurement allows us to hold accountable institutions, organizations, and even individuals, which in turn allows for greater project improvement.  Exxon Mobil Chairman and CEO Rex Tillerson agreed, and cited a Lancet article which said that evaluation must be a top priority for global health.

Robert Rubin, former US Treasury Secretary and former head of Citigroup and Goldman Sachs, told the audience that global health leaders “face wrenching choices” as a result of US fiscal problems.  He asked two members of Congress, Rep. Keith Ellison and Senator Jeanne Shaheen, whether global health is an issue that can “break through the mire” on Capitol Hill.

Senator Shaheen said that the issue can succeed, but it is crucial to explain to Americans that international affairs spending is only a tiny fraction of the US budget, much less than people realize.   She said it was cheaper to spend on global health than on war, noting Bill Clinton’s recent statement about the appreciation of PEPFAR expressed by Muslim residents of Tanzania.  She also said the current committee structure in Congress is an impediment and endorsed the recommendation included in the report for a consultative body that would work across committees.

Congressman Ellison also voiced strong support for greater US action on global health, stating that “infectious diseases know no borders.”  He said that while in Kenya, he made good progress in persuading Kenyan leaders of the necessity of stepping up their own contributions.  He suggested that by reducing US spending on outmoded weapons systems the US could improve its budget outlook and make global health spending easier.

Gayle Smith, the NSC official leading the development of the US Global health Initiative, was the concluding speaker at the event. She said global health was a bipartisan issue and that in fact President Obama specifically directed that the achievements of the previous Republican Administration be recognized.  She praised the CSIS report, and said that its ideas were remarkably congruent with those of the Administration.

She said the Administration’s commitment to fighting global HIV/AIDS was “absolute” and, she added, “this will grow over the life of the initiative.” She said the Administration’s plans for the Global Health Initiative “include an ambitions set of targets in terms of outcomes.”

She did not respond to concerns submitted to the Administration by the Global Center, TAG, the Global Health Council, and the GHI Working Group that the Administration’s targets regarding tuberculosis contradict a directive from Congress approved in 2008 as a part of Lantos-Hyde.  In fact, it was surprising that the event unfolded without  reference  to the consultative process which numerous NGOs have engaged in regarding the US Global Health Initiative or to the detailed analyses these groups have submitted to the Administration.

There were a range of reactions from health NGOs to the event.  Eric Friedman at Physicians for Human Rights noted the “surprisingly little attention in the report to human resources for health and health systems, and no mention of including civil society in the development of country compacts.” He praised the report for “proposing that the Administration develop a long-term, 15-year framework for making progress in and committing the United States to improving global health, a good idea so long as it does not set the stage for underambition, and is flexible to respond to changes in the years ahead. ” He also would have liked to see “a recommendation that the United States should deliberately integrate a right to health approach throughout U.S. global health programs, including the consistent focus on equality, accountability, and participation that this entails.”

Matt Kavanagh at Health GAP praised what he heard from the report, which included an emphasis on keeping up the fight against HIV/AIDS, especially important for the health of African women. But he noted with concern that “some of the Administration comments that seemed to favor prioritizing ‘cheap’ interventions that do not work in the long term, such as single dose nevirapine instead of treatment for HIV positive mothers, an approach abandoned long ago as ineffective in wealthy nations.”

The American Medical Students Association’s Farheen A. Qurashi said that the report “takes a bold, but necessary, approach to U.S. global health planning by insisting upon a 15-year comprehensive plan.”  She said, “Unfortunately, the Commission’s report does not appear to specify the need for scaling-up of PEPFAR investments versus the dangers of flat-funding, and instead uses language that suggests that a continuation of current levels of funding without annual growth is sufficient.”

On health systems, she said that “though integration and health systems strengthening is mentioned in general terms, and the need for training and retention of health care workers is noted, there is no detailed analysis of the measures, funding, and support necessary to establish and retain adequate numbers of health professionals and other health care workers.”

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Just as HIV experts are beginning to see new hope in beating the AIDS epidemic, a funding crisis threatens to throw us back a decade or more in the effort to combat this deadly virus. Dr. Peter Mugyenyi and other HIV experts delivered this forceful message to U.S. lawmakers today at a hearing before the House Foreign Affairs Subcommittee on Africa and Global Health.

Dr. Mugyenyi, director of Uganda’s Joint Clinical Research Center, was one of several witnesses who urged Congress to keep its promise on global AIDS by fully funding PEPFAR, instead of approving the near flat budget proposed by the White House for FY 2011.

Dr. Peter Mugyenyi testifies before a House Foreign Affairs subcommittee

Dr. Mugyenyi said that already, last year’s flat-funding has rippled across his home country of Uganda, forcing him and other health care providers to turn away sick patients who were promised treatment. Dr. Mugyenyi described having to turn away as many as 15 to 20 patients a day, including pregnant and breastfeeding women.

“Recently, an HIV-infected woman who was breastfeeding her HIV-negative child because she could not afford formula milk came to our clinic, having been turned away from three other clinics in Kampala because they had no slots. She knew that every day she breast fed her baby without being on treatment greatly increased the chances of her child getting infected, but she had no alternative,” he said.

The situation, he said, jeopardizes the incredible gains PEPFAR has achieved in its first five years. “PEPFAR has saved millions of lives in Africa,” he said. “These people—and their mothers, husbands, wives and children—got a chance to live” because of PEPFAR. The program has “helped ease the carnage that I and my fellow health care providers used to witness on a daily basis.”

Dr. Mugyenyi pointed to recent studies showing that treatment with antiretroviral drugs can also help prevent new infections. Research released at CROI last month documented a 90 percent reduction in HIV transmission among so-called “discordant couples,” in which one partner is HIV-infected and the other is not.

“This gives credence to recent modeling by the World Health Organization that shows some of the first good news on prevention in several years: that we could truly end the AIDS crisis within a generation,” he said. “However, a funding crisis threatens to reverse these highly positive changes and we could miss the opportunity to defeat the epidemic.”

Rep. Donald Payne, D-N.Y., chairman of the subcommittee, said he was “deeply concerned about the reports that the fight against HIV/AIDS is faltering and that continued rapid roll out of AIDS treatment is endangered in Africa. We must make sure we don’t start a decline.”

The panelists and lawmakers alike commended President Obama’s proposed Global Health Initiative, with its call to spend $63 billion over six years and its promise of an integrated approach to foreign health assistance. But experts testified that the GHI would only work if it was adequately funded

And so far, said Joanne Carter, executive director of the RESULTS Educational Fund, there’s a gap between rhetoric and reality on US global health funding. The White House’s budget request for FY 2011 “essentially flat funds our global AIDS programs,” she said, noting it’s more than $2 billion short of what was promised in the Lantos-Hyde Act that reauthorized PEPFAR.

The White House budget also calls for a $50 million cut to the US contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. And she noted that the GHI’s treatment targets for TB were significantly lower than mandated in Lantos-Hyde.

PEPFAR has been “nothing short of transformative,” Carter said. “We’ve made remarkable progress, and we can’t stop now.” (more…)

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Although some details are still murky, a first-blush analysis of  Obama Administration’s fiscal year 2011 budget doesn’t look good for US efforts to combat the HIV and tuberculosis epidemics. From treatment to prevention, these global health threats could get short-changed under the White House plan.

Let’s start with PEPFAR, the President’s Emergency Plan for AIDS Relief. For the second year in a row, the Administration has called for a single-digit increase for this program, about 2.6 percent, or $141 million. That small increase comes despite lofty campaign promises, congressional mandates, plus a pledge that PEPFAR would serve as the “cornerstone” of the Administration’s new Global Health Initiative (more on the GHI later).

The White House’s PEPFAR budget is not adequate to preserve vital momentum in HIV treatment scale-up, nor is it enough to fund important new HIV prevention innovations in the developing world.

The numbers for TB are even more disheartening. The Administration only requested a $5 million increase over 2010 funding, a paltry amount for a disease that last year killed more than 1.8 million people, including 500,000 women. Moreover, the Centers for Disease Control’s TB program, with its critical clinical trials network, would be cut by more than $1 million, further undermining US capacity to evaluate new diagnostic, treatment and prevention tools for TB. This comes in the face of evidence that drug-resistant TB is a growing threat and if left unchecked, could spiral into a broader global health catastrophe.

Here’s a more detailed analysis of all global health funding from the Global Health Council:  GHC FY11 CBJ GH Funding Chart (Draft). The Kaiser Family Foundation also has this helpful breakdown. The Global Center, the GHC, and other groups will continue to analyze the budget as more details come out.

One bright spot in the Administration’s request was in biomedical research at the National Institutes of Health, which would see a $1 billion boost under today’s plan, including $98 million for HIV/AIDS research at NIH, a significant increase at a time of constrained resources.

There’s no question the U.S. faces tough choices amid spiraling deficits and a difficult economy, but underfunding much needed global health programs, which account for a fraction of the federal budget, is not the answer to America’s fiscal woes. Investment in these programs will reap immense dividends down the line–in financial, diplomatic, and public health arenas alike.

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Lawmakers have finalized the fiscal year 2010 budget for foreign assistance, setting funding for key programs to fight global HIV and TB and reaching a landmark deal to revise the needle-exchange ban.

The agreement—expected to pass the House before the end of this week and the Senate before the end of next week—includes some modest increases for bilateral HIV and TB, as well as for the Global Fund to Fight AIDS, Tuberculosis and Malaria. But the funding levels still fall far short of what’s needed to combat these twin epidemics and of what was authorized in the Lantos-Hyde Act passed by Congress last summer.

The deal, for example, would allocate $5.359 billion for global AIDS, $1.05 billion for the Global Fund, and $225 million for TB. It also includes a slight boost for NIH. The gloal AIDS figure does not include bilateral HIV/AIDS funds for USAID or the CDC’s Global AIDS Program; with those pots of money tallied, the total US bilateral AIDS funding for 2010 stands at $5.828 billion. (See chart below for more details on how this comparies to last year, etc.)

The real headline, though, is this: Key congressional negotiators agreed to ease the ban on federal funding for needle exchange programs. This is a long-overdue move that will remove an unnecessary and harmful barrier to effective HIV prevention efforts. It’s also a big surprise.

Earlier this year, the House approved lifting the ban, but included so many restrictions as to make federal funding for such programs essentially unfeasible (i.e., not near any schools, parks, arcades, etc.). The Senate voted to keep the ban in place.

The new agreement revises the ban so it would only prohibit the use of federal funds for needle exchange programs in a location “that local public health or law enforcement agencies determine to be inappropriate.”

Here’s the chart, which lays out the approved spending levels for FY2009, the funding levels authorized in the PEPFAR II, the President’s request for FY2010, and last night’s Congressional agreement.

Dollars in millions

  FY09 PEPFAR II Obama FY 10 Final
Global AIDS $5.159bil $6.5bil $5.259bil $5.359bil
Global Fund $600 $2bil $600 $1.05 bil
Tuberculosis $163 $650 $173 $225
NIH $30.566 N/A $30.758 $31.008

 

Notes:  The reauthorization bill did not contain specified year by year funding levels with the exception of the Global Fund which was authorized at $2 billion.   The amounts listed under PEPFAR II for bilateral Global AIDS and TB are extrapolated from the overall five-year funding levels authorized in the bill. In addition, as noted above, the global AIDS figure does not include money directed to USAID or CDC for their bilateral HIV programs.

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Dr. Kenneth Mayer, co-chair of the Center’s Scientific Advisory Committee and a professor of medicine at Brown University, talked about the benefits of using PEPFAR as a platform on which to build broader health systems in this NPR story that aired this morning.

NPR’s Brenda Wilson takes a look at President Obama’s global health plan, with its new focus on maternal and child health. The hook for the story was a visit to the Capitol by some health officials from Afghanistan, but it pivots to a broader debate over the future of US global health spending and delves into the fear among HIV/AIDS experts that Obama’s new plan will short-change funding to combat the deadly AIDS epidemic at a critical moment.

Dr. Mayer makes the point that PEPFAR has created a strong foundation that the government can use to broaden its global health efforts; we should not walk away from that in favor of the latest new idea, he says.

“The scaling-up process of PPEFAR is something that can be built upon and certainly shouldn’t be seen as ‘that’s the old model, and now we’re going to start from scratch with a new model’,” Dr. Mayer tells Wilson. “I don’t think we have the time to do that. I don’t think we have the resources to do that.”

Click here to hear the full story.

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Editor’s Note: We will be blogging today about the House Appropriations subcommittee meeting, filing an update on funding levels for global health programs. So check back to see what happens!
Rep. Nita Lowey, center, held Neighborhood Office Hours to hear concerns of constituents. Dr. Germaine Jacquette, left, a member of IDSA and RESULTS from White Plains NY, and Inge Auerbacher, right, a TB advocate and Holocaust survivor, attended and shared concerns about global TB and HIV funding.

Rep. Nita Lowey, center, held Neighborhood Office Hours to hear concerns of constituents. Dr. Germaine Jacquette, left, a member of IDSA and RESULTS from White Plains NY, and Inge Auerbacher, right, a TB advocate and Holocaust survivor, attended and shared concerns about global TB and HIV funding.

At last week’s HIV/AIDS Implementers’ Meeting in Namibia, participants expressed deep concern about the commitment among donor nations to maintaining the momentum in the global fight against HIV/AIDS.

This week, attention will turn to the House of Representatives, where a key spending panel will divvy up the foreign aid spending pie—and the global health community will get the first real indication of how much Congress is willing to spend in FY 2010 on global AIDS as well as tuberculosis.

(more…)

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If today’s hearing was any indication, Dr. Eric Goosby is headed for an easy confirmation to be U.S. Global AIDS Coordinator. Dr. Goobsy’s time in the hot seat, before the Senate Foreign Relations Committee, lasted all of 30 minutes this afternoon, and he wasn’t thrown any hardballs.

In his opening remarks, Dr. Goosby talked about working in the HIV/AIDS field from the early days “where death was a daily event, to times of hope” where treatment has saved millions of lives. If confirmed, he said he would be guided by a set of key principles, from an intensified focus on HIV prevention to strengthening health systems. The latter is of course a key concern for the new administration and vital to PEPFAR’s success in winning hearts and minds in Washington these days.

Dr. Goosby also said that PEPFAR has demonstrated what happens “when we dare to think big” and promised to continue that visionary streak if confirmed.

Sen. Russ Feingold, D-Wis., who chaired the session, asked several questions about health-system strengthening, including how Dr. Goosby would leverage PEPFAR to bolster local health infrastructure. Dr. Goosby said PEPFAR should be “used as a platform to extend medical services” to cover a wider net of diseases and broader population.

In response to a question about health care worker training from Sen. Richard Lugar, R-Ind., Dr. Goosby acknowledged the challenges in recruiting and retaining new health professionals. But he said PEPFAR’s efforts should focus on partnering with developing-country academic institutions. “We need to create the capability on the continent and not export it,” Dr. Goosby said.

If anyone expected fireworks, they were likely disappointed. There was little mention of funding—a vital concern among global AIDS advocates at the moment, as Congress considers the Obama administration’s modest proposal to increase PEPFAR’s budget by $100 million in FY 2010.

Feingold wrapped up the hearing after only one round of questions from the two senators in attendance—himself and Lugar—and said he looked forward to “prompt consideration” of Dr. Goosby’s nomination.

IDSA's VP for Global Health Christine Lubinski greets Dr. Eric Goosby after his confirmation hearing

IDSA's VP for Global Health Christine Lubinski greets Dr. Eric Goosby after his confirmation hearing

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