Posts Tagged ‘GHI’

Ezekiel J. Emanuel, center, White House global health advisor

Ezekiel J. Emanuel, head of the Department of Bioethics at The Clinical Center of the National Institutes of Health and a breast oncologist, is on extended detail as a special advisor for health policy to the director of the White House Office of Management and Budget.

But that doesn’t speak to his impact. He is one of the architects of the Obama administration’s Global Health Initiative, and he has been a lightning rod of criticism for activists who want a much more vigorous global AIDS response from the administration.

Emanuel spoke to John Donnelly on Saturday about how the Obama administration now needs better ideas for making global health programs more efficient, and how he won’t shy away from taking on AIDS activists. “I have two brothers and all we do is disagree,’’ he said.

Q: You haven’t been shy in pushing back on criticism from AIDS activists about the Obama administration’s smaller increases in the global AIDS budgets than under the Bush administration. What really upsets you?

A: We can have disagreements about the right policy, which way we are going forward, but we can’t have a disagreement about the facts – the facts of the budget. A number of advocates are saying we are cutting the PEPFAR budget. The fact is funding for HIV and our work on PEPFAR is going up – in 2009 2010 and 2011. That is matter of fact. You may not like the allocation we have made, or not like the pot we are putting it in, but (saying we are) cutting the budget is wrong.

The second thing is [the notion] that somehow I am `anti-HIV,’ or `anti-work-we-are-doing-on-HIV,’ is absolutely wrong. This development of the [Global Health Initiative (GHI)] is building on everything we have done, using what our work in HIV and malaria has shown us. One of the things that we have shown is that you can take complicated medical interventions, get them working in rural areas — including sophisticated techniques like measuring T cell and viral loads — and monitor people. A lot of what we have put into the GHI is built on the foundation of PEPFAR. We want to broaden it.

And (another thing) is that we have a moral obligation to the people we are trying to help that if we are spending money on things that are not efficient, we have to be more efficient. There is a moral obligation from the community (working in AIDS issues) not to just ask for more money, but to say, `We have this pot of money, how are we going to do the most with it?’

We’re not doing this because we are green-eyeshade, no-morals people. It’s because we want to save lives and spend money most efficiently.

Q: Still, Ambassador Eric Goosby told Science Speaks this week that even with efficiencies, there will be a `mismatch’ between funds and the need.


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Last week, the Kaiser Family Foundation held a forum on the Obama Administration’s Global Health Initiative, sparking fresh debate over this significant shift in U.S. global health policy. In response to the presentations made by top U.S. government officials at that event, Shepherd Smith, a well-known AIDS advocate and program coordinator with considerable knowledge about the history and politics of PEPFAR, wrote this commentary about the Administration’s proposal for a six-year $63 billion GHI.

First and foremost, there is no one in the global HIV/AIDS community–clinicians, advocates, implementers, etc.—who disagrees conceptually with the intent of the Global Health Initiative (GHI).  In fact, the PEPFAR reauthorization legislation, known as the Lantos-Hyde Act, makes foundational the need to deal with a broad range of opportunistic infections, to strengthen healthcare systems, to train more healthcare workers, and to tackle a host of other activities in a more comprehensive manner than just addressing HIV, TB, and malaria. How and where that is done—and at what cost–is the issue at hand.

The announcement of the GHI in May of 2009 shed little detail on what this new $63 billion program might look like, leading many to believe little thought had gone into the initiative.  Nearly a year later, we are beginning to see the outlines of this plan. Clearly, it is a work in progress that needs further discussion and a broader airing. We now know, for example, that the $63  billion is not really new money, but rather the $48 billion authorized over five years in the Lantos-Hyde Act, with a sixth year tacked on at the end.  There is, perhaps, over that six-year period possibly two or three billion dollars of “new” money. So what does that mean for the core PEPFAR program? And how can a new global initiative be successful with so few new dollars?

PEPFAR concentrated on the countries hardest hit by HIV/AIDS, while this new initiative appears designed to be inclusive of all the developing nations in the world.  In order to gain the resources to do this without any significant additional funding, there has to be some deconstruction of the highly successful PEPFAR program. Furthermore, building an entirely new GHI program, which still has not been entirely fleshed out, will take time and some trial-and-error efforts before we get it right.  That takes a lot of energy and a lot of money.  By lessening the emphasis on the core PEPFAR focus to develop a global program with limited funding may well result in the failure of not just one initiative, but both. This then is a high-risk venture.

It would be helpful to publish any risk analysis that has been done on GHI in respect to its impact on PEPFAR if future funding is flat-lined or reduced. For example, the HIV-positive patients now in care under PEPFAR fully expect to be put on antiretroviral therapy once their CD4 count falls below two hundred.  Is this still a realistic expectation? And if not, how is that explained to host countries and to those who will suffer and die if they don’t get access to treatment?

The credibility of the United States is at stake in this significant and sudden program change.  We have made commitments and established excellent working relationships with the countries that have benefited from PEPFAR.  If we don’t meet those commitments, there will be legitimate criticisms of the U.S.  Many of these countries have very limited resources and will now be asked to shift funding and emphasis. They will have to wonder if a subsequent administration will require them to change everything yet again.   

One particular concern is how GHI will interact with the faith community, which delivers 30 % to 70 % of all health care needs in developing countries, according to World Health Organization estimates. The short GHI narrative nearly overlooks the important role the faith community plays, as well as services other NGOs provide. If failures arise in the core PEPFAR program that negate the commitments these faith entities have made to their patients and congregants, then they will naturally shy away from future participation in U.S. government sponsored health programs.  This aspect alone should cause us to be certain the commitments we made under PEPFAR are met–before moving forward with the GHI.  Already, there have been media reports that some clinics in PEPFAR countries are being forced to turn away new patients seeking HIV treatment because of flat funding.  If such scenarios continue, there will be needless suffering that will not cast a positive light on the GHI.

Another concern is the Administration’s statement, in the GHI consultation document, that “the GHI Fund is expected to increase in FY 2012 and beyond.” That may be wishful thinking of the highest order at this particular time in our nation’s history. It’s almost as if those writing this haven’t watched the news in several years. The American people are saying we need to stop or reduce federal spending, and that needs to be factored into the funding equation for this new program. If spending goes down instead of up, there needs to be a contingency plan for the core PEPFAR program, which so much of this seems to be dependent on for success.

The uncertainty now building around both PEPFAR and GHI is not healthy, and it can only be resolved through Congressional hearings that promote a greater understanding of the issues surrounding this significant shift in policy. Without a strong bipartisan political commitment to this initiative (as there was to the reauthorization of PEPFAR), there is serious potential for failure of not just GHI, but PEPFAR as well. The GHI’s success is dependent on an increase in funding, which at this point may or may not happen. Without that guarantee, we may do more harm than good in embarking down this new road.

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At the start of a forum today on the Obama Administration’s Global Health Initiative, Jen Kates, the Kaiser Family Foundation’s director of global health policy and HIV, laid out eight major questions about the proposal—queries that will go a long way toward determining whether the initiative is a success or not.

After a 90-minute discussion, most of those key questions—such as how much funding the GHI will get, how the money will be divvied up, and how its goals will be measured—remained unanswered. But we did learn a few things from the U.S. government panelists who are developing and overseeing the implementation of the GHI, the White House’s controversial initiative calling for a more integrated, comprehensive approach to funding global health.

Amie Batson, the deputy assistant administrator for global health at USAID, had the most news to share. On governance of the GHI, she said a “strategic council” had been established, and it would serve as a forum for pulling together all the government agencies that have expertise in achieving the GHI’s goals. The group has partners from a gamut of federal agencies—from the departments of the Treasury and Defense to NIH and CDC.

At the more operational level, she said, there was a “trifecta” of leaders– USAID Administrator Rajiv Shah, CDC director Thomas Frieden, and Global AIDS Coordinator Eric Goosby—charged with developing and executing the GHI. “They are tasked with defining a shared or joint operational plan,” she said, and each of them has a deputy charged with delivering on that plan.

Batson also said the Administration would release a final GHI plan by early summer. And by the end of this month, officials would announce the first ten “GHI Plus” countries; those countries will then get additional technical, management, and financial resources to implement integrated programs and make investments across health conditions. (The list of GHI Plus countries will be expanded to 20 in later years.)

“We’re now engaging very actively with the countries,” she said. The GHI Plus countries will offer a sort of field test “where we have an intensified learning effort.”

Today’s forum, hosted by the Kaiser Family Foundation and available online here, was the most extensive public discussion yet of the GHI, a $63 billion six-year plan announced by President Obama nearly one year ago.  It has been the subject of much debate because, while the plan includes many lofty and significant goals, some advocates fear it will not be adequately funded and that it may shift focus away from critical programs, such as PEPFAR. Key officials crafting the plan say the U.S. needs to turn its attention to other health problems, such as child and maternal health, but they do not seem to fully grasp or acknowledge the links between specific diseases, such as HIV and TB, and women’s health.

The shift could have serious repercussions on the ground in the developing world. For example, the GHI’s goals on TB represent a significant step back from more aggressive targets laid out in the Lantos-Hyde Act that reauthorized PEPFAR, even though TB claims 1.8 million lives a year.

At today’s forum, Ann Gavaghan, chief of staff in the Office of the U.S. Global AIDS Coordinator, said the GHI should be viewed as an opportunity to build on the stunning successes achieved in fighting global AIDS and other diseases over the last decade, not as a step back from those efforts. “The GHI is not designed to take away from any of those successes but to say let’s recognize what’s been done … and let’s figure out a way to really build those best practices,” she said.

But wide-ranging questions from the audience signaled there is still deep concern about the initiative and how it will be implemented and funded. Several attendees asked about why TB, for example, appeared to be getting short shrift in funding and focus. Gavaghan and Deborah Birx, director of CDC’s Global AIDS Program, both tried to assure advocates that the Administration was committed to combating TB and understood how much of a threat it presents, but neither one specifically addressed the underfunding or weak targets.

Another advocate asked about the apparent contradiction between the Administration’s rhetoric about wanting more international collaboration and its proposed cut to the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. Gavaghan said the White House had made a robust request for the Global Fund and remained fully committed to its success, including active U.S. participation on the organization’s board and in country-level coordination.

Several attendees asked about how the GHI would deal with the severe health care workforce shortage in the developing world, noting that the GHI blueprint issued in February did not offer very many details about that critical piece of health system strengthening.

Batson said that’s because the solution to that problem is country-specific and will have to be dealt with in a focused way in each place. “Many of the governments have put this as No. 1 on their lists, so I think you will see a lot of innovation,” she said.

To learn more about the GHI, read our earlier blog posts here and here analyzing the GHI’s consultation document. In addition, Kaiser has this nice analysis/overview—including the 8 outstanding questions—of the GHI.

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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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Bill Gates and Bill Clinton testify about US global health priorities before the Senate Foreign Relations Committee

Two global health heavyweights—Bill Clinton and Bill Gates—testified before a key Senate committee today, urging lawmakers to provide more U.S. funding to combat scourges such as HIV and tuberculosis.

In opening remarks, Sen. John Kerry, D-Mass., chairman of the Senate Foreign Relations Committee, stressed the importance of funding global health programs and cited the success of PEPFAR, which provides lifesaving HIV treatment to 2.4 million people in the developing world today.  In addition, he noted, the program has helped ensure that more than 300,000 children born to HIV-infected mothers were born free of the virus. 

 “That’s not enough—but it does represent a remarkable achievement,” Kerry said.

Kerry and his two star witnesses generally praised President Obama’s proposed Global Health Initiative, while reitetring that a strong committee to combating HIV and other diseases, such as TB and malaria, remains vital. And both Gates and Clinton expressed concern over decreased funding for the Global Fund to Fight Aids, TB, and Malaria. Gates told the committee he hoped that the “small decrease will be fixed.”

Ex- President Clinton, who now heads the Clinton Foundation, mounted a particularly powerful case for increased HIV treatment scale up. When Sen. Bob Casey, D-Penn., asked Clinton what he would do with another $1 billion or $ 2 billion for maternal and child health, Clinton highlighted two priorities—prevention of mother to child HIV transmission and HIV treatment for kids. Clinton said the rate of death among HIV infected infants is dire, and it is imperative that mortality rates are reduced by providing more treatment to HIV infected-pregnant women to halt vertical transmission. 

President Clinton repeatedly stressed the need for reducing the price of commodities and other health care costs to accommodate more people in need of care in developing countries.  Citing the high costs of many HIV/AIDS drugs, Clinton remarked that since the market won’t bring prices down low enough, it is imperative that institutions take actions to reduce prices down.  He discussed an agreement with Pfizer to provide rifanbutin, the only drug to combat tuberculosis in HIV-infected individuals, at 65 percent off the market price.  This price reduction will save between 200,000 and 300,000 lives. 

Clinton said other health care costs, like laboratory and testing prices, must come down as well to combat the threat of infectious diseases.  In addition to lowering costs, governments and organizations must better train health care professionals, while also providing incentives to Western-educated health care professionals of developing countries to return home after their education, to improve the public health situation abroad.

While Clinton focused on price reductions for treatment, Gates stressed the importance of developing vaccines for prevention.  Gates stressed that “AIDS is the toughest disease for treatment and prevention.” He highlighted HIV prevention initiatives with real potential to help.  He outlined the efficacy data on male circumcision and expressed surprise that that was a real demand for circumcision among adult men once they heard about the evidence that circumcision was protective against HIV infection, but noted that there is real demand citing Kenya and South Africa as examples.  (more…)

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This post is by John Donnelly, a former Boston Globe reporter and regular contributor to Science Speaks. 

Less than two months ago, Secretary of State Hillary Clinton declared an increased US government commitment to international family planning and reproductive health programs, saying, “In the Obama administration, we are convinced of the value of investing in women and girls, and we understand there is a direct line between a woman’s reproductive health and her ability to lead a productive, fulfilling life.”

So what does that mean in terms of programs and funding, and how will it affect the administration’s efforts in fighting HIV/AIDS, the largest bilateral health assistance program overseas?

One way to find out: On Monday, the Aspen Institute will host a panel discussion titled, ”Women and Health: Today’s Evidence, Tomorrow’s Agenda.”

Featured will be two top US officials who will oversee women’s health programs – Susan K. Brems, deputy assistant administrator of the US Agency for International Development, and Michele Moloney-Kitts, assistant US global AIDS coordinator for the President’s Emergency Plan for AIDS Relief. Julio Frenk, Dean of the Harvard School of Public Health and former Minister of Health in Mexico, will also be on the panel, along with Peggy Clark, Aspen’s vice president of policy programs and executive director of the newly formed Global Health & Development program, and Tonya Nyagiro, director of the World Health Organization’s Department of Gender, Women and Health.;

Brems and Moloney-Kitts will likely talk about how USAID, the Global Health Initiative and PEPFAR plan to strengthen health systems to better meet the needs of women’s health, particularly family planning and reproductive health issues. But critics worry that the Administration’s proposed GHI, while including a welcome and needed broader focus, will come at the expense of the robust response envisioned for HIV through the Lantos-Hyde Act, which reauthorized PEPFAR. 

The Aspen program runs Monday from noon to 1:45 p.m. We’ll plan to blog from the meeting.

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This is a guest blog jointly submitted by Jerald C. Sadoff, MD, the President & Chief Executive Officer of the Aeras Global TB Vaccine Foundation and Mel Spigelman, MD, the President & Chief Executive Officer of the Global Alliance for TB Drug Development.

In recent weeks, U.S.-based global health advocates have been scrutinizing and providing public comments on the recently released draft strategy of the President’s Global Health Initiative (GHI), which rightly expands the US government’s global health policy to address several key areas that were neglected in recent years. However, although tuberculosis kills almost two million people each year, the GHI – more accurately, what’s not in the GHI – suggests that TB is just not a priority for the Administration. 

This is puzzling, since TB kills almost 2 million people each year and is the world’s second-leading infectious killer. There is more tuberculosis today than ever before in history, but it is truly a forgotten disease. That’s evident by the low level of funding requested by the GHI– only a $5 million increase for FY11– and the dramatic scaling back of treatment targets for TB patients. Better prevention and treatments are urgently needed, yet will remain far out of reach if the current GHI proposal is not changed.

TB is a disease of poverty, affecting the most vulnerable and marginalized people around the world. It rarely captures headlines or garners celebrity attention. Still, it’s difficult to reconcile the low levels of US government funding dedicated to TB with the significantly higher levels for other diseases that take similar numbers of lives. We don’t question the need to fund those devastating diseases, but we do question the neglect and imbalance in the approach to TB. This disparity is certainly not evidence-based, since TB claims a staggering number of lives. 

The meager funding for tuberculosis vis-à-vis other serious health threats is all the more baffling when you consider the alarming rise in multiple drug-resistant (MDR) and extensively drug-resistant (XDR) TB, which recognizes no borders and threatens the United States. Failure to invest in drugs and vaccines to better control TB will have severe ramifications for our public health system and for US taxpayers. For example, the 1989-1991 outbreak of MDR-TB in New York cost more than $1 billion to contain. The expense of treating newly emergent, extensively resistant strains is even greater –a single case of XDR-TB in the US can cost taxpayers almost $600,000, according to the CDC. Better TB prevention and treatment will benefit people at home and abroad.

The devastation caused by tuberculosis was recognized in 2008 when the US government passed the Lantos-Hyde PEPFAR reauthorization to increase funding and prioritize TB research and control. (To read more about Lantos-Hyde, click here.) Over five years, it aimed to treat 4.5 million drug-sensitive patients and 90,000 drug-resistant patients and authorized $4 billion for TB control. It also set out a long-term strategy of investing in research and development to create new and improved tools, including vaccines and drugs, to prevent and treat the growing TB problem. 

By contrast, the proposed GHI treatment targets and funding levels represent a step backwards. The GHI proposes to treat 2.6 million patients afflicted with drug-sensitive TB and 52,700 patients suffering from drug-resistant tuberculosis around the world – 40% fewer than called for in Lantos-Hyde. The GHI also does not explicitly address R&D, which is crucial to any long-term sustainable response to TB. In particular, this draft strategy omits the significant role played by USAID in funding the development of new technologies to combat tuberculosis – efforts that urgently require greater investment.

New tools are desperately needed. Current TB treatments were developed over 40 years ago and require patients to undergo a lengthy and complex regimen – which is even longer and more difficult to comply with in the case of drug-resistant tuberculosis – and which cannot be administered with certain HIV medications. The existing vaccine – which has limited effectiveness and is not recommended for HIV-positive infants – was invented almost 90 years ago. The most commonly available diagnostic method in developing countries, sputum smear microscopy, was developed over 120 years ago. The GHI should highlight the fact that TB will not be controlled or ultimately eliminated without the development of new tools, such as new drug regimens, new TB vaccines, and improved diagnostics.

By failing to invest adequately in TB, the GHI also undermines its ability to make progress in all priority areas or leverage the cross-cutting global health impact of a comprehensive TB elimination strategy. Consider the following: 

• HIV/AIDS – TB is the leading killer of people living with HIV in developing countries. In 2008, the United Nations identified the integration of TB and HIV control programs as a global health priority. Failing to address TB undermines existing US investments in AIDS treatment; each year, thousands of people whose lives have been preserved by antiretroviral treatment die from undiagnosed and/or untreated TB. 

• Reproductive, maternal, newborn, and child health – TB kills more women each year than all causes of maternal mortality combined and claims the lives of more than 100,000 children every year. In India alone, 300,000 children are orphaned each year because their mothers have died of TB.

• Health systems and health workforce – Combining the more than 9 million cases yearly with the lengthy and complex TB treatment (including drug-resistant TB) places substantial burdens on healthcare systems.

Commitments to funding levels and treatment targets in the GHI must be, at a minimum, restored to the levels contained in the Lantos-Hyde Act, and the development of new tools to address the epidemic must be an expressly defined part of the strategy. The lives of current and future tuberculosis sufferers are worth saving.

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The Center for Global Health Policy has detailed its concerns with the Obama Administration’s proposed Global Health Initiative (GHI), raising particular questions about how U.S. efforts to combat global HIV and tuberculosis would fare under this new approach to global health.

At issue is a “Consultation Document” the State Department released on Feb. 1, with a call for public comments on the proposal due today. The Consultation Document provided some new details about how the Administration plans to implement President Obama’s call for a $63 billion six-year GHI, which envisions a more comprehensive approach to global health aid and a more intensive focus on child and maternal health.

In an official response submitted to the State Department today, the Global Center’s two co-chairs write that the Consultation Document includes many significant and laudable goals. But they said the GHI blueprint falls short in key respects, from scaled-back targets for TB treatment to murky details about funding to inadequate plans for addressing the health care worker shortage.  

Take, for instance, the disconnect between the GHI and Lantos-Hyde (the reauthorized version of PEPFAR). Lantos-Hyde requires the President to formulate a comprehensive 5-year strategy to combat global TB, including the treatment of 4.5 million new TB patients and the diagnosis and treatment of 90,000 new multidrug-resistant (MDR) TB cases, with both targets to be achieved by 2013. The GHI Consultation Document, by contrast, sets a goal of treating 2.6 million new TB cases and 57,200 multi-drug resistant (MDR) cases of TB.

“Despite the enormous death toll resulting from tuberculosis, the burden it places on the health care system, and the growing threat of drug resistant TB, this goal is roughly half of the target set by Congress in Lantos-Hyde, and it extends over a longer time frame, six years under the GHI as compared to five years under Lantos-Hyde,” the Global Center notes in its response to State.

On HIV/AIDS, the Global Center notes that the Consultation Document is short on specifics explaining how the Administration would meet key treatment and prevention goals with the modest funding increases proposed. In addition, there are serious questions about an apparent proposal to direct $100 million of the PEPFAR 2011 budget to the new Global Health Initiative Fund. 

“We welcome an approach that supports systemic strengthening and better integration across health interventions,” the Global Center’s response says. “However, we are concerned that removing $100 million from an already essentially flat PEPFAR budget for 2011, in part to finance technical assistance, will make it impossible for PEPFAR to continue to scale up lifesaving prevention and treatment interventions, particularly in marginalized communities.”  

Here is the Center’s full submission: commentsGHIconsultationfinal

And tell us what you think of the GHI Consultation Document.

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Many details of the Obama Administration’s Global Health Initiative are still murky, and it’s unclear just when we will learn more. In the meantime, the Global Health Council has launched a little Internet information hub about the GHI, with relevant documents, media coverage, and other related info. It’s at least a good starting point to sort out what we know, and what we don’t, about the six-year $63 billion plan. Check it out here.  You can also get another perspective on the GHI–and how it should be framed and funded–here.

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Although Administration officials have said PEPFAR would be the “cornerstone” of its Global Health Initiative, HIV advocates and experts are worried that PEPFAR and the Office of the U.S. Global AIDS Coordinator could actually have less visibility and authority under the GHI.

The Administration has not yet detailed what the GHI’s governance will look like, but there’s apparently some discussion about moving PEPFAR to USAID, instead of keeping at the State Department. Advocates worry this would be disruptive for a program that has been so successful, in part because of its streamlined, singular focus.

The Global Center and other groups sent a letter to Secretary of State Hillary Clinton today asking her to “preserve the autonomy” of PEPFAR by keeping at State and reporting to her.

“Subsuming OGAC and the administration of the PEPFAR program within a new GHI organizational structure could set back the Administration’s global agenda,” the letter states. “OGAC and PEPFAR’s success are a testimony to what streamlined processes and a nimble structure can accomplish.  Its programs are lauded around the world for making a difference while respecting countries’ autonomy.  We must not disrupt or undermine the program’s operation, including its important leadership and coordination role among the agencies that now implement programs, and within countries where continuity of leadership and funding sustains life-saving programs.”

Click here to read the full document. Letter to Sec Clinton re PEPFAR within GHI (2)

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