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The Obama administration today released a government-wide strategy on a subject that previously had drawn little high-level attention from Washington – the Millennium Development Goals, or MDGs.

Much like National Security Strategy documents put together by a succession of U.S. administrations, Obama’s MDG strategy serves as more of a framework of principles, rather than giving specific details on how the U.S. government will help developing countries reach the goals by 2015.

Some of the most prominent MDGs are eradicating extreme poverty and hunger, reducing child mortality, and improving maternal health.

“We just think it’s a tremendous opportunity to have the US engage proactively in the MDG dialogue with some fresh ideas,’’ said Ben Hubbard, deputy chief of staff at the U.S. Agency for International Development, in an interview with Science Speaks. “We are 10 years in, and five to go. We looked at the data, and asked ourselves what is needed to get to the finish line and what the U.S. can uniquely contribute.’’

The strategy, which was released today in an invitation-only gathering in Washington with no press coverage, comes two months before the United Nations will hold meetings on MDG progress.

It lists significant achievements as well as miserable failings in countries. (more…)

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Zackie Achmat, the founder of South Africa’s venerable activist group, the Treatment Action Campaign, today made public a memo to the Obama Administration that details the potential negative consequences of a pull-back from US commitments on global AIDS. It comes in the wake of a protest last night in New York, where President Obama appeared at a fundraiser and several activists were arrested.

In this blog post, Achmat says that when former South African President Thabo Mbeki left office, “the ghosts of two million dead receded,” and activists felt they could catch their breath.  “Now, a new sense of foreboding in relation to HIV has returned,” he writes. “After a decade long battle and a two year respite, a new unnecessary battle lies ahead for people living with HIV.”

He acknowledges that Obama inherited a host of vexing problems, from the global recession to two wars. “However, the misguided manner that President Obama’s advisors are seeking short-cuts to solve these incredibly difficult questions of HIV, health and development will rebound not on them but on his Presidency because he will take the decisions to decide who will live and who will die,” he says. “It is my view that the President is ill-advised with ‘quick-fix solutions’ and ‘good public-health’ sound bytes. These solutions are disguised as a broader ‘global strategy for development’ but they are another way of making poor, working and middle class people pay for the crisis. Investment in health, HIV and broader development is not only the right thing to do — new investments in health-care and in HIV result in growth and improved quality of life for the most vulnerable.”

Read the full post and the memo here: http://writingrights.org/2010/05/13/memo-to-the-us-government-we-will-reverse-your-policy-through-activism-locally-and-globally/

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Ruth Messinger, president of American Jewish World Service, an international development and human rights organization, just posted this passionate response to  The New York Times stories about the unfolding crisis in global AIDS funding. Ruth’s article argues that any U.S. foreign aid policy pitting disease against disease is seriously misguided and that now is the time to recommit to foreign aid funding. It also asks readers to tell their Senators to support S. 1524, the Foreign Assistance Revitalization and Accountability Act of 2009 (letter found here). Check it out!

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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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Under new leadership appointed by the White House, the Presidential Advisory Council on HIV/AIDS (PACHA) convened its first session yesterday under the Obama Administration.

Michael Horberg, an HIVMA board member, introduced himself at yesterday's PACHA meeting

Health and Human Services Secretary Kathleen Sebelius announced 24 new members to the Council earlier this week, including Michael Horberg, MD, a member of the HIV Medicine Association’s board of directors.

The council has focused mostly on providing advice and recommendations to the President on domestic AIDS policy, and this year, a key role for the PACHA will be to advise in the development and implementation of the National HIV/AIDS Strategy. But PACHA also has a role in counseling the White House on global AIDS policy. And several of the PACHA appointees have a strong global focus, starting with its chair, Dr. Helene Gayle, the CEO of CARE USA, who also worked on HIV issues at the CDC and the Bill and Melinda Gates Foundation.

In addition to Gayle, other globally-oriented members include Jim Kim, M.D., Ph.D., who is president of Dartmouth College and a co-founder with Paul Farmer of Partners in Health, and Ernest Darkoh, MD, MPH, who is chairman of BroadReach Healthcare and an expert in HIV treatment program implementation and health system strengthening.

Kathleen Sebelius, Helene Gayle, and other newly appointed members of PACHA at the council's first session

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The Obama Administration has finally lifted the curtain, if only for a preview, on its proposed $63 billion six-year Global Health Initiative (GHI), which the President first unveiled almost a year ago with a broad-brush call for a more integrated comprehensive approach to funding global health. 

Amid much anticipation, the White House yesterday released a 21-page “consultation document” on the GHI. You can read the full GHI document here. The Administration is seeking comments and input on the plan by Feb. 22nd. To offer your perspective, send an email to ghi_comments@state.gov.

Perhaps the biggest news in the document—and the element that raises the most questions—relates to funding. Although there aren’t many new details about how the $63 billion would be spent over the six year timeline, the consultation does outline plans to set up a “GHI Strategic Fund Reserve.”

For FY 2011, this new GHI Fund will have $200 million to support a review of country health plans, to scale up “proven cost-effective interventions” for maternal and child health and infectious diseases, and to begin integration interventions, according to GHI document. In addition, in FY 2011 and 2012, the GHI fund will be tapped to help 10 “GHI Plus” countries with 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.

But there’s concern about where that $200 million will come from. White House officials have made it clear that some of that money will come from PEPFAR and other global health programs. What’s not clear is how much of PEPFAR’s budget, for example, will flow into the GHI Fund. Nor is it clear how those PEPFAR/GHI funds will be spent, i.e. will global AIDS money be used to finance nutrition or child health programs or will it be used for AIDS-related services?

If it’s the former, that could be devastating for efforts to combat HIV and TB, which need every penny available in this era of tiny budget increases. PEPFAR is slated to get a $141 million increase under the Obama budget blueprint, a welcome boost but too small to match the scope of the epidemic. If $100 million of that flows to the GHI Fund, that does not leave much to scale up treatment and prevention as the Administration has promised. As for TB, it would only see a $5 million increase over FY 2010 levels under the White House plan, a bump up that leaves little to spare for other causes. Click here to read more about the Obama budget for global health. (more…)

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