US Global Health Initiatives Key Issues Policy Brief April 2010

8/8/2019 US Global Health Initiatives Key Issues Policy Brief April 2010

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THE U.S. GLOBAL HEALTH INITIATIVE: Key Issues

SUMMARY

The recent reease o the Obama Administrations consutationdocument on the Implementation o the Global Health Initiative1,accompanied by the FY 2011 budget request 2, provide themost signicant detai to date on this new initiative. Firstannounced ast year3,4, the Goba Heath Initiative (GHI) wasproposed as a $63 biion, six-year (FY 2009FY 2014) eort todeveop a comprehensive U.S. goba heath strategy, buidingon disease specic initiatives to combat HIV, TB and maaria, as

we as expanding to encompass broader goba heath targets,incuding materna and chid heath (MCH), amiy panningand reproductive heath (FP/RH), nutrition, and negectedtropica diseases (NTDs), and to strengthen underying heathsystems (see Box 1). The GHI consutation document incudesspecic goas and targets, core principes, and an operationapan or impementing each targeted area (see Box 2). The FY2011 budget marks the ha-way point in the Initiatives undingand, i approved by Congress, woud bring cumuative GHIunding to amost $27 biion, or 43%, o the proposed six-yeartota.5 The Administration has soicited pubic comment on

the consutation document and severa other next steps are expected, incuding the announcement o GHI Puscountries, a subset rom among those receiving U.S. goba heath assistance to be seected or more intensied eort.

Even as these deveopments continue to unod, severa signicant and interreated questions and issues remainon the taberethinking a muti-pronged, muti-biion doar investment that invoves a myriad o goba heathchaenges, programs, countries, and stakehoders, is an inherenty compex undertaking, and one which is occurringagainst the backdrop o other broader assessments o U.S. oreign aid and deveopment poicy, as we as moregenera budgetary constraints. Given the compex environment, this poicy brie highights and summarizes someo the more pressing issues and questions on the GHI. They were identied based on review and anaysis o recentreports in the ed as we as pubic comments submitted in response to the GHI consutation document.6,7,8,9,10,11,12,13

BOX 1: GHI Overview1,3,4

Announced by President Obama on May 5, 2009

$63 biion proposed over 6 years, FY 2009-2014 $51 biion or PEPFAR (HIV, TB, Goba Fund) &

Maaria $12 biion or other goba heath priorities

Integrated approach, government-wide strategy

Continued commitment to PEPFAR, sated to recemore than 70% o cumuative unding

Expanded ocus to broader goba heath chaengincuding materna and chid heath, amiy panninreproductive heath, negected tropica diseases

Emphasis on heath system strengthening

Emphasis on moving rom process to outcomes,investing where signicant returns can be achieve

GHI budget incudes: HIV, TB, maaria, GobaFund, materna and chid heath, nutrition, amiypanning/reproductive heath, negected tropicadiseases, avian inuenza and other pubic heaththreats

ApRIL 2

Seven Core Principles

1. Women- and gir-centered approach2. Strategic coordination and

integration3. Strengthen and everage key

mutiateras and other partners4. Country-ownership5. Sustainabiity through heath

systems strengthening6. Improve metrics, monitoring and

evauation7. Promote research and innovation

Four Main ImplementationComponents

1. Do more o what works, promoteproven approaches

2. Buid on and expand existingpatorms

3. Innovate or resuts4. Coaborate or impact/promote

country ownership

Nine Target Areas

1. HIV/AIDS2. Maaria3. Tubercuosis4. Materna Heath5. Chid Heath6. Nutrition7. Famiy Panning/Reproductive Hea8. Negected Tropica Diseases9. Heath Systems Strengthening

BOX 2: GHI Core princiles, Imlementation Comonents, and Target Areas1


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2 | THE U.S. GlOBAl HEAlTH INITIATIVE: Key Issues

Eight distinct but interreated issues were identied. These are briey isted beow, oowed by a more detaieddiscussion that provides background and context on each as we as specic questions moving orward.

1. HOW WILL THE LEADERSHIp AND GOVERNANCE OF THE GHI BE STRUCTURED?

How wi coordination o the U.S. goba heath response be achieved across mutipe agencies, programs, andCongressiona committees? Is a new coordinating structure needed and i so, where is it best ocatedat the WhiteHouse or within a edera agency? Are new Congressiona authorities needed?

2. HOW MUCH FUNDING WILL BE pROVIDED TO THE GHI AND HOW WILL FUNDING BE ALLOCATED WITHIN

THE U.S. GLOBAL HEALTH pORTFOLIO?

Wi the GHI reach $63 biion by FY 2014? Wi urther rebaancing o the portoio occur and i so, how wi undingbe baanced between disease specic programs and broader, horizonta approaches? What criteria wi be used toinorm resource aocation decisions?

3. HOW CAN THE GHIS TARGETS AND IMpACT BE MEASURED?

What kinds o investments and structures are needed at the edera agency and country eves to oster greatermonitoring and evauation? How can new metrics and reporting requirements be impemented without increasingthe burden on countries? What is the potentia roe, and imitations, o existing measurement toos? How can data

gaps and imitations be overcome?

4. HOW CAN THE U.S. BEST pARTNER WITH RECIpIENT COUNTRIES TO pROMOTE COUNTRY OWNERSHIp?

What is the appropriate baance between donor-dened and country-designed priorities? Is there a trade-obetween country-ownership and accountabiity to donors? How wi country-pans be deveoped with host countrygovernments and other stakehoders, incuding civi society?

5. HOW CAN U.S. ENGAGEMENT WITH OTHER INTERNATIONAL ACTORS, INCLUDING MULTILATERALS,

DONOR GOVERNMENTS, AND THE pRIVATE SECTOR, FURTHER SUppORT COORDINATION, LEVERAGE

RESOURCES AND MAXIMIZE SHARED IMpACT?

What shoud the unding baance be between mutiatera and biatera programs? To the extent that U.S.

investments are channeed through mutiatera organizations, how can concerns about accountabiity beaddressed? Are there opportunities or urther assessing or strengthening U.S. engagement in internationa heathtreaties, reguations, and other partnerships and agreements?

6. HOW WILL THE INCREASED EMpHASIS ON WOMEN AND GIRLS BE REALIZED IN U.S. GLOBAL HEALTH

pROGRAMS?

How can a women- and girs-centered approach best be impemented at a country eve? As country pans aredeveoped or augmented, how can the importance o addressing women and girs be meaninguy incorporated?How can the U.S. reinorce and strengthen the goba consensus that has emerged around the importance oaddressing gender, women and girs?

7. HOW WILL THE U.S. DEFINE, IMpLEMENT, AND MEASURE HEALTH SYSTEMS STRENGTHENING?

What targetseither existing or newy deveopedcan be used to hep assess U.S. investments in heath systems?How can heath systems investments be inked to heath outcomes? As the U.S. moves to strengthen heathsystems, adopting a broader, horizonta approach to goba heath, what wi be the impications or disease-specic, vertica approaches?

8. HOW WILL THE GHI BE COORDINATED WITH AND AFFECTED BY BROADER U.S. FOREIGN AID

REFORM EFFORTS?

How wi these dierent eorts aect the U.S. goba heath portoio and the strategy outined in the new GHIconsutation document? What kinds o broader restructuring can be expected? Where can the U.S. goba heathresponse serve as a mode or broader deveopment reorm eorts?


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THE U.S. GlOBAl HEAlTH INITIATIVE: Key Issues |

BACKGROUND AND CONTEXT

1. HOW WILL THE LEADERSHIp AND GOVERNANCE OF THE GHI BE STRUCTURED?

Background and Context:

The U.S. governments response to goba heath has grown signicanty over time, and today, is a more than$10 biion annua eort, that incudes the GHI as we as other U.S. programs and activities.5 This eort spans seven

executive branch departments, numerous departmenta operating units, severa independent agencies, and morethan 15 Congressiona committees14 (see Figure 1). It encompasses mutipe unding streams, programs, and initiativesand operates in more than 80 countries. Yet historicay, the U.S. goba heath architecture has had no ormaizedorganizing mechanism or structure, having argey been buit within separate agencies and around discrete vertica,or disease-specic, initiatives rather than horizonta, or more comprehensive, approaches that seek to address themutipe heath chaenges that oten impact the same popuations and communities simutaneousy. Dierent U.S.agencies operate under dierent egisative authorities and mandates, have distinctive operating cutures, ace uniqueand sometimes competing priorities, and contro varying eves o unding or goba heath. For exampe, most gobaheath unding is appropriated by Congress to oreign assistance agencies (the State Department and USAID), whoin turn contro the buk o reated programming; by contrast, itte unding is provided directy to the Department oHeath and Human Services (HHS), athough its pubic heath expertise is integra to carrying out the U.S. goba heath

eort.

5,14

Within the Congress, mutipe authorizing and appropriating committees have jurisdiction over dierentpieces o the U.S. goba heath portoio, and unding decisions have historicay been tied to earmarks or specicdiseases, conditions, or individua programs, rather than a more comprehensive approach.8,14

This has resuted in a U.S. response that has been characterized as ragmented and stove-piped, inhibiting theopportunity to take advantage o synergies, be more strategic, maximize the U.S investment and, utimatey, do abetter job in reaching the very popuations who are the intended beneciaries o U.S. goba heath assistance.6,7,8,9,10,12,15 As such, a growing consensus has deveoped that better coordination is needed. Yet there is no cear path or doingso, and mutipe recommendations have been promugated over time. As eary as 1997, the Institute o Medicine(IOM) caed or the estabishment o an interagency task orce, recommending it be ed by HHS given its scienticand technica expertise.16 More recenty, the IOM reafrmed its recommendation or a task orce, but situated itseadership within the White House, to give it convening authority and the abiity to make poicy recommendations

directy to the President.7 Othergroups have aso providedrecommendations abouteadership and structure.8,9,11,13A key issue raised by theseorganizations is the importanceo Presidentia eadership, whichwas centra to the success oPEPFAR or exampe.

The GHI itse was an attempt tocreate a coordinated strategy orU.S. goba heath programs, bydeveoping a comprehensivewhoe o government approach1centered on the utimatebeneciary o U.S. goba heathaidthe individua. Strategiccoordination and integrationis a core principe o the GHI,incuding upstream integrationat the agency and program eve,and downstream integration, atthe point o contact or beneciary

Independent Agency

Labor

Peace Corps

State

OGACOE S

AmbassadorsMissions

CD C

HomelandSecurity

USAIDBureaus for: Global Health;

Economic Growth, Agricultureand Trade; Democracy,

Conict and HumanitarianAssistance

Commerce

EP A

GHI

The White House

Defense

USDA

NI H

FD A

HRSA

PEPFAR

H HSOGHAOPH SMC C

PM I

Water forPoor Act

NT D

Avian InuenzaAction Group

Department

Multi-Agency Initiative

Dept. Operating Unit

FIGURE 1: Schematic of the U.S. Governments

Global Health Architecture

K E Y

C

O

N

G

R

E

S

S


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eve. In terms o structure, the GHI was initiayaunched by the White House, under the auspiceso the Nationa Security Counci (NSC) andthe Ofce o Management and Budget (OMB),together with the State Department17, and eachhas continued to pay an integra roe. The WhiteHouse aso convened an interagency task orce

that began meeting ast summer. More recenty, atriecta structure o the State Department, USAID,and HHSthe three main agencies with assetsin U.S. goba heathhas been carrying orwardimpementation. To date, however, no orma orpermanent coordinating structure or the GHIhas been announced and severa questions andoptions remain.

Key Issues:

How wi coordination o the U.S. goba heathresponse be achieved across mutipe agencies,programs, and Congressiona committees?Is a new coordinating structure needed and i so, where is it best ocatedat the White House reporting to thePresident, within a singe agency, or at mutipe agencies?

Shoud there be a singe designated coordinator or the GHI?

Are new Congressiona authorities needed to carry out aspects o the GHI, such as unding authority acrossmutipe unding streams or agencies, or to support new programming needs?

Can better coordination be achieved within Congress, incuding across Congressiona committees andjurisdictions?

TABLE 1: GHI Funding and Budget Projections, FY 2009FY 20145

$ in billions

FY 2009Enacted

FY 2010Enacted

FY 2011Budget

FY09-FY11Subtotal

FY09-FY14Proposed Total

FY09-FY11% o

ProposedTotal

FY12-FY14Amount

Remaining$ % $ % $ % $ % $ %

PEPFAR (HIV, TB,Global Fund) $6.68 79% $6.84 77% $6.99 73% $20.50 76% >$44.1b*

Malaria $0.55 6% $0.73 8% $0.83 9% $2.11 8%


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2. HOW MUCH FUNDING WILL BE pROVIDED TO THE GHI AND HOW WILL FUNDING BE ALLOCATED WITHIN

THE U.S. GLOBAL HEALTH pORTFOLIO?


Internationa deveopment assistance or goba heath provided by the U.S. and other donors has increasedsignicanty in recent years,18,19 athough it sti as short o need, according to recent estimates rom The Taskorce onInnovative International Financing or Health Systems.20 Moreover, the recent economic crisis has ikey exacerbated the

needs o ow- and midde-income countries at the very time that it has strained the budgets o donor governmentsand raised concerns about the abiity to this gap in the uture.20,21,22,23 As the argest donor o heath assistance inthe word, U.S. unding wi pay a critica roe in this equation.

Whie the GHI was proposed as a six-year, $63 biion initiative, it is not yet known what its overa unding eve wibe or how unding wi be aocated within the U.S. goba heath portoio. This is because a unding or U.S. gobaheath programs is considered discretionary spendingthat is, spending that must be appropriated by Congresseach year (vs. mandatory or direct spending, such as or entitement programs, that is determined by statutesother than appropriations acts and is generay automaticay obigated each year). Not ony are overa goba heathunding eves determined this way, but so is much o the unding aocated to individua goba heath programs orareas, historicay through program or issue specic Congressiona earmarks. Funding, thereore, is one o the mostvisibe and expicit markers o poicymaker priorities and oten seen as a major poicy ever in debates about U.S.

goba heath poicy and programming. When announcing the GHI, the Obama Administration indicated an intentionto rebaance the goba heath portoio, moving rom what has argey been a disease specic approach to a broader,popuation-based one. This has raised questions about how such a shit woud impact current disease programs, suchas HIV treatment (where even keeping a those currenty on treatment wi require new resources in the uture), as weas how the positive eects o vertica programs on broader heath systems and capacity woud be accounted or. 9,24 ,25

With FY 2011 marking the ha-waypoint in the GHIs six-year budget, moreinormation about these poicy prioritiesis avaiabe, incuding whether the GHI ison track to reach $63 biion. The FY 2011request, i approved by Congress, woud

bring GHI unding to date to $26.8 biion,or 43% o the proposed six-year tota.Funding over the remaining period(FY 2012FY 2014) woud need to tota$36.2 biion (an average o $12 biionper year) to reach $63 biion, requiring asteeper rate o increase reative to the rstthree years o the GHI (see Tabe 1).5

The $63 biion six-year GHI proposaincuded $51 biion or PEPFAR (HIV, TB, andthe Goba Fund) and maaria combined,

and $12 biion or other goba heathpriorities. I Congress approves the FY 2011budget request, unding or PEPFAR andmaaria woud reach 44% o this tota and

woud need to more than doube to reach $51 biion; unding or other goba heath priorities woud be at 35% andwoud need to amost tripe to reach its unding target (see Tabe 1).5 Congress provided another marker o undingpriorities in the Tom lantos and Henry J. Hyde United States Goba leadership Against HIV/AIDS, Tubercuosis, andMaaria Reauthorization Act o 2008 (lantos-Hyde) or the FY 2009FY 2013 period; to reach the eves authorizedby lantos-Hyde, unding or PEPFAR and maaria combined woud need to more than doube in the next two years(see Tabe 2).26

2 001 2002 200 3 20 04 2 005 2006 200 7 20 08 2 009 2010 201 1*

NTDs

T B

FP/ RH

MCH/Nutrition

Malaria

G F

H I V

FIGURE 3: Distribution of Funding for Programs in the

U.S. Global Health Initiative (GHI), by Sector,FY 2001-FY 2011*

*FY 2011 is Presidents Budget Request to Congress.


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TABLE 2: Funding or PEPFAR & Malaria Compared to Lantos-Hyde Reauthorization Levels, FY 2009 FY 2013 5

$ in billionsFY 2009Enacted

FY 2010Enacted

FY 2011Budget Req

FY09-FY11Subtotal

Lantos-Hyde FY09-FY13

Authorized Diference

PEPFAR: HIV & Goba Fund $6.50 $6.59 $6.74 $19.83 $39 $19.17PEPFAR: TB $0.18 $0.24 $0.25 $0.67 $4 $3.33Maaria $0.55 $0.73 $0.83 $2.11 $5 $2.89

PEPFAR (HIV, TB, Global Fund)& MALARIA TOTAL $7.23 $7.57 $7.82 $22.62 $48 $25.38

Note: Amounts may not sum to totas due to rounding.

looking urther within the goba heath portoio shows that some rebaancing has aready begun to occur. AthoughHIV continues to make up the ions share o the GHI budget, its more recent increases have begun to sow, andunding or other goba heath priorities has risen at a aster rate. The astest increases over the three-year period havebeen or NTDs, oowed by MCH; MCH received the greatest amount o increase and thereore was the biggest drivero growth in the GHIs budget (see Figure 3 and Tabe 3). These trends woud need to continue i the GHIs proposedsix-year budget parameters are to be met. Yet it is not cear how best to make such resource aocation decisionsmoving orward. In addition, whie the Administration has continued to request increased unding or goba heath,in contrast to a proposed reeze on a domestic discretionary spending2, and Congress has historicay demonstrated

strong bi-partisan support, it is not cear how current budgetary pressures wi aect this cacuus in the uture.

Key Issues:

Wi GHI unding reach $63 biion by FY 2014? Wi lantos-Hyde unding eves be reached or HIV, TB, maaria andthe Goba Fund? How wi budgetary pressures on the U.S. government aect unding?

Shoud the U.S. goba heath unding portoio be urther rebaanced? I so, shoud rebaancing appy to existing orto uture resources ony? Can a zero-sum be avoided? Shoud there be a hod harmess approach?

What criteria shoud be used to make resource aocation decisions? Shoud a greater emphasis be paced on ower-costinterventions or on diseases that have received ess attention in recent years? On diseases and conditions that currentyexert the greatest burden or on those which have the potentia to be eiminated? Shoud smaer benets to a arger

number take priority over arger benets to a ew? What is the right baance between targeting ow-hanging ruit andthe more difcut, but equay critica, chaenges? What is the appropriate baance between prevention, care, andtreatment? To what extent shoud the avaiabiity o other donor resources pay a roe in targeting U.S. investments?

How can these dierent criteria best be assessed to guide U.S. poicymakers and program impementers? What is theappropriate roe o cost eectiveness anaysis? Can simuation modeing be used to inorm resource aocation decisions?

TABLE 3. GHI Funding: Amount and Percent Change by Sector, FY 2009-FY 20115

$ in billionsFY 2009Enacted

FY 2010Enacted

FY 2011Budget Req

FY10-FY11($ and % change)

FY09-FY11($ and % change)

HIV/AIDS $5.50 $5.54 $5.74 $0.2 (4%) $0.24 (4%) TB $0.18 $0.24 $0.25 $0.01 (3%) $0.07 (42%)

Maaria $0.55 $0.73 $0.83 $0.1 (14%) $0.29 (53%)Goba Fund $1.00 $1.05 $1.00 $-0.05 (-5%) $0 (0%)MCH $0.44 $0.47 $0.70 $0.23 (48%) $0.26 (59%)Nutrition $0.05 $0.08 $0.20 $0.13 (167%) $0.15 (264%)FP/RH $0.46 $0.53 $0.59 $0.06 (12%) $0.14 (30%)NTDs $0.03 $0.07 $0.16 $0.09 (138%) $0.13 (520%)Other $0.21 $0.12 $0.11 $-0.01 (-11%) $-0.1 (-49%)

PEPFAR Subtota $6.68 $6.84 $6.99 $0.15 (2%) $0.31 (5%)

PEPFAR & Maaria Subtota $7.23 $7.57 $7.82 $0.25 (3%) $0.6 (8%)

Other Goba Heath Priorities Subtota $1.19 $1.26 $1.75 $0.49 (39%) $0.57 (48%)

GLOBAL HEALTH INITIATIVE TOTAL $8.41 $8.83 $9.58 $0.75 (8%) $1.16 (14%)

Note: Amounts may not sum to totas due to rounding.


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3. HOW CAN THE GHIS TARGETS AND IMpACT BE MEASURED?


Reated cosey to the issue o investment choices is that o measurement and assessing progress. A core principe othe GHI is to improve metrics and enhance monitoring and evauation (M&E) o goba heath interventions, to moverom process to outcomes, and be resuts-oriented rather than expenditure- or input-based. An additiona coreprincipe is to promote research and innovation, incuding scaing-up operationa and impementation research. The

GHI incudes specic targets in each o its major heath areas over the ie o the initiative, yet moving in this directionposes numerous chaenges. These incude both measurement chaenges, as we as broader issues reated to theGHI targets. Heath is a compex domain, encompassing mutipe dimensions, components, and eves making themeasurement o investments particuary difcut. For exampe, whie most woud agree that measuring HIV incidence(new inections) is the best outcome measure or assessing HIV prevention interventions, it is one o the most difcutoutcomes to measure and oten cannot be measured directy (instead, proxy measures must sometimes be used)or within a time rame that matches donor budgeting cyces.27 There are aso concerns about the imitations oexisting measurement toos used to assess goba heath interventions, such as cost eectiveness anaysis, which is astandard too used to compare heath interventions, but does not necessariy capture the benets gained in one areadue to a heath intervention in another (e.g., impact o HIV treatment on materna heath24) or the benets o heathinterventions on non-heath measures (e.g., improved schoo attendance).28 In addition, U.S. investments intermingewith the investments o other donors and recipient countries, making it difcut to attribute outcomes directy tothe U.S. or any other singe under. A urther concern is the ack o data and inormation systems, particuary at thecountry eve, or measuring impact. Finay, as the U.S. moves toward a more outcomes-based M&E ramework, it wibe important to consider and address not ony the capacity o recipient countries in this area, but the potentia tocause additiona measurement burden on countries, many o which are aready conronted by mutipe and distinctreporting rameworks.

Beyond these measurement chaenges are considerations and questions about the GHI targets themseves,incuding their reationship to: current goba needs and burden; other goba heath targets, such as the MienniumDeveopment Goas (MDGs),29 commitments made by the G8 30, and lantos-Hyde26; and actua GHI investments overtime. Additionay, whie the GHI approach is intended to be a broad and comprehensive one, promoting synergiesand maximizing impact across interventions, the targets deveoped are specic to each heath area; measuringinteraction and integration wi ikey prove to be more difcut and there may be a need to deveop new measuresand measurement strategies in this area.

There are severa U.S. agencies aready invoved in goba heath operations research, incuding the NationaInstitutes o Heath (NIH), the Centers or Disease Contro and Prevention (CDC), and the U.S. Agency or InternationaDeveopment (USAID), athough goba heath research activities have not aways been coordinated across them.Moving orward, there may be additiona opportunities to coordinate and buid on their existing research networksand expertise in this area.

Key Issues:

What kinds o investments and structures are needed at the edera agency and country eves to oster greaterM&E? What wi it cost to impement M&E? How much is enough or too muchwoud it be better to invest inheath programs, or are the efciency gains enough to oset M&E costs?

How can new metrics be impemented without increasing an aready heavy and compex reporting burden oncountries?

How do the GHI targets track against current goba heath needs and burden, and compare to other goba heathtargets and commitments, such as the MDGs?

What is the potentia roe, and imitations, o existing measurement toos? How can data gaps and imitations beovercome? Where might proxy measures sti be needed and how wi their use be incorporated into an outcomes-based system?


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4. HOW CAN THE U.S. BEST pARTNER WITH RECIpIENT COUNTRIES TO pROMOTE COUNTRY-OWNERSHIp?


In recent years, there has been an increasing ocus by the U.S. and other donors on the need to work with recipientcountries dierenty, in partnership, to promote country-ownership. This is not ony one o the core principes o theGHI, it has aso been emphasized in severa other, arge-scae U.S. heath and deveopment initiatives, incuding theMiennium Chaenge Corporation (MCC), created in 2004 as a new mode or U.S. oreign assistance buit on country

compacts or partnerships31, and, more recenty, in PEPFARs new ve-year strategy32 and the Administrations newGoba Hunger and Food Security Initiative (GHFSI)33. The emphasis on country-ownership and partnership has beenmotivated by severa actors, incuding a growing recognition that in order to move toward onger-term sustainabiityo programs, recipient country governments and other country stakehoders need to be integray engaged indetermining what is best or their needs and popuations, designing and impementing programs, and buiding theirheath systems.34 In addition, there has been increased recognition that donor-unded programs at the country-eveare oten uncoordinated, ragmented, and dupicative, with mutipe donors operating on simiar issues and evenindividua donors operating mutipe programs that may or may not be coordinated with one another.9 In manycountries that receive U.S. goba heath and reated deveopment assistance, or exampe, there are six, seven, or evenmore distinct U.S. programs operating at the same time (see Figure 4).35

The GHI approach, as stated in the

consutation document, incudessupporting partner countries inmanaging, overseeing, and operatingthe unctions o their nationa heathsystems ensuring that investmentsare aigned with nationa prioritiesand supporting partner governmentscommitment and capacity so thatinvestments are maintained in theuture.1 This is urther describedas investing in country-ed pans,beginning with an assessment oexisting pans as we as country heathsystems, nancing gaps, and capacityto impement programs eectivey.This approach wi aso designate asubset o countries, rom among thosereceiving U.S. heath assistance, asGHI-Pus countries, or countries thatprovide signicant opportunities or

impact, evauation, and partnership with governments.1 GHI-Pus countries wi be targeted with a more intensiedeort, incuding additiona unding ($200 miion across GHI-Pus countries in FY 2011), and chosen based on severacriteria, ranging rom partner country interest in participation to the severity o heath probems and chaenges to be

addressed.Moving ahead in this direction, however, wi not be easy. First, country-ownership is not an easiy dened ormeasured concept and there can be a tension, indeed a deicate baance, between donor dened and countrydetermined priorities. This tension may aso arise around the issue o donor accountabiity; that is, as more programownership is vested in countries themseves, it may become more difcut to be accountabe to donors. A urther issueinvoves the need to change the way the U.S. government does business in countries, moving rom what has becomea heavy reiance on contracting with private (oten U.S. based) entities to impement country-programs to workingdirecty with host country governments. Whie both the Administration and Congress have stated their intention toshit in this direction, they have aso acknowedged the chaenges o doing so, incuding the need to boster agencyand ed-eve capacity in some cases.34,36,37,38,39,40

Major U.S. Government Global Health Programsand Related Initiatives, 2010

1 or 2 Programs

3 or 4 Programs

5 or 6 Programs

7, 8, or 9 Programs


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Other areas to consider incude the appropriate roe o civi society (e.g., non-governmenta organizations, communitygroups, indigenous groups, charitabe organizations, aith-based organizations, etc.) in designing and impementingprograms, particuary in countries where civi society has not been previousy engaged; the impications orecipient government poicies, such as those concerning the rights o women, in assessing partnership parameters;and the need to need ensure coordination not ony among U.S. programs but with other donors to minimize theimpementation and reporting burden on countries. Additionay, whie a key goa o the GHI is to oster countryownership to enabe countries to sustain programs over time, many o the countries acing the greatest heath crises

and chaenges are those that have the east capacity or abiity to sustain programs, and may require onger termU.S. investment to achieve such goas. Finay, whie the GHI-Pus eort is designed to target a subset o countries toacceerate impact, it is not yet known whether the additiona resources made avaiabe to them wi be sufcient orthis purpose.

Key Issues:

What is the appropriate baance between donor-dened and country-determined priorities? What is the trade-obetween accountabiity to Congress and other poicy-makers and country-ownership?

How wi country-pans be deveoped with host country governments and other stakehoders? What shoud be theroe o civi society in dening, determining, and owning programs?

What roe shoud the U.S. pay in using its investments to oster poicy change?

Wi the additiona eort provided to GHI-Pus countries be enough to show a dierentia impact?


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5. HOW CAN U.S. ENGAGEMENT WITH OTHER INTERNATIONAL ACTORS, INCLUDING MULTILATERALS,

DONOR GOVERNMENTS, AND THE pRIVATE SECTOR, FURTHER SUppORT COORDINATION, LEVERAGE

RESOURCES, AND MAXIMIZE SHARED IMpACT?


The U.S. governments engagementin goba heath has ong invoved

working with internationa partners andorganizations, incuding participation inthe Internationa Sanitary Conerenceso the 19th Century, as we as hepingto create the Pan American HeathOrganization (PAHO), the WordHeath Organization (WHO), and, morerecenty, the Goba Fund to Fight AIDS,Tubercuosis and Maaria (the GobaFund).14 U.S. invovement in mutiateraheath organizations incudes severadierent kinds o activities, rangingrom signing onto internationa heathtreaties and agreements to organizationamembership, governance, technicaassistance, partnering, and unding. Somemutiatera organizations themsevesserve as nancing vehices to addressgoba heath chaenges, such asthe Goba Fund and the Goba Aiance or Vaccines and Immunisations (GAVI), and U.S. contributions to theseorganizations provide another avenue or the U.S. to expand its reach and impact; the U.S. is the argest donor to boththe Goba Fund41 and GAVI.42

Despite the U.S. governments ong standing and signicant invovement in internationa organizations, the U.S.response to goba heath, as measured by unding and programs, has argey been biateraapproximatey 86% oU.S. unding or goba heath over the ast decade has been channeed biateray5; this has continued with the GHI54(see Figure 5). This is due to severa actors incuding the signicant ed presence o U.S. programs and sta aroundthe word, as we as a U.S. poicy preerence or targeting unding to certain countries and programs, aowing or U.S.dened priorities and accountabiity to Congress. As a resut, some have caed or increased mutiatera engagementgiven the goba nature o heath chaenges, the need to everage U.S. investments with others and sustain programsover time, and concerns about the nancia stabiity o internationa nancing organizations such as the Goba Fund.They have pointed to the emergence o new, innovative nancing vehices or goba heath, such as the InternationaFinancing Faciity (IFF)43, Advance Market Commitment (AMC)44, and UNITAID,45 which may provide additiona avenuesor U.S. impact. However, such vehices, as mutiyear and contingent nancia commitment mechanisms, have posedega and administrative barriers to U.S. invovement.46 Others have highighted potentia opportunities or the U.S.

to re-examine its engagement in internationa treaties and agreements. For exampe, whie the U.S. is a party to manysuch agreements, others have yet to be ratied, such as the WHO Framework Convention on Tobacco Contro(WHO FCTC)47,48 and the U.N. Convention on the Eimination o A Forms o Discrimination against Women (CEDAW).49Other internationa coaitions, such as the Internationa Heath Partnership (IHP+)9,50, a partnership o donors anddeveoping countries to better harmonize donor unding commitments and improve heath systems, may aso providenew opportunities or the U.S. (the U.S. is not currenty one o the 13 donor government members o the IHP). Finay,there has been recent attention to the ack o a mutiatera nancing vehice or MCH, prompting some to point to theneed to assess whether an existing or new mutiatera vehice shoud be pursued or this purpose.71 The outcome osuch a move coud pose new options or the U.S. unding portoio.

FIGURE 5: Distribution of Bilateral & Multilateral

Funding in the U.S. Global Health Initiative(GHI), FY 2009 FY 2011*

Bilateral

86%

Multilateral

14%

*FY 2011 is Presidents Budget Request to Congress.


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THE U.S. GlOBAl HEAlTH INITIATIVE: Key Issues | 1

Most recenty, the Obama Administration has stated an intention to reinvigorate mutiatera engagements andinternationa partnerships on heath and deveopment generay and or the GHI specicay.1,51,52 In act, a coreprincipe o the GHI is strengthening and everaging key mutiatera organizations, goba heath partnerships, andprivate sector eorts, incuding commitment to achieving the Miennium Deveopment Goas, and support or GAVI,the Goba Fund, and other internationa partnerships and mechanisms. For exampe, Secretary Cinton recentystated support or ratiying CEDAW.53

Key Issues:

What is the appropriate unding baance between mutiatera and biatera programs?

To the extent that U.S. investments are channeed through mutiatera organizations, how can heath impacts beattributed to the U.S. specicay? How can concerns about accountabiity be addressed?

Are there opportunities or urther assessing or strengthening U.S. engagement in internationa heath treaties,reguations, and other partnerships and agreements? Are there innovative nancing mechanisms that can beurther expored?

To what extent is the GHIs success predicated on increased engagement with internationa partners?


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6. HOW WILL THE INCREASED EMpHASIS ON WOMEN AND GIRLS BE REALIZED IN U.S. GLOBAL HEALTH

pROGRAMS?


There has been a growing recognition o the need to eevate a ocus on women and girs in U.S. goba heathprograms, particuary in the ast decade. Whie U.S. programs have ong unded interventions that address the heathneeds o women and girs, such as through MCH and FP/RH programs, as we as HIV, TB, and maaria, this approach

has rarey targeted women and girs expicity. Some o the programs that most directy aect women and girs,such as MCH and FP/RH, have received ess unding historicay and even seen decreases at times. 5 The impetus orincreased attention to women, girs, and gender more broady has been twood: both the recognition that womenand girs have had proportionatey ess access to goba heath programs and ace greater disparities, aong with theevidence that interventions that target the heath o women and girs have high returns or the entire amiy unit. Inact, some have said that the goba heath response o the U.S. and others cannot be uy successu uness the heathneeds o women and girs are more expicity addressed.

In aunching the GHI, as we as severa other new U.S. eorts, incuding the creation a new ofce o Goba WomensIssues and the position o Ambassador-at-large or Goba Womens Issues at the State Department,55 the ObamaAdministration has urther heightened attention and ocus on women and girs. The Administration has aso takensteps to enhance its internationa engagement in this area, incuding restoring unding or the United Nations

Popuation Fund (UNFPA),56 and supporting cas or the creation o a new UN specia agency or women. 53 The rstcore principe o the GHI is to impement a women-and girs-centered approach and the consutation documentdiscusses severa genera measures or doing so, incuding supporting systemic ong term changes to remove barriersand increase access or women and girs, enhancing monitoring and evauation o the heath o women and girs,improving the training o heath providers on gender issues, and invoving women and girs in decision-making aboutprogram impementation. The GHI aso incudes severa targets in MCH and FP/RH, areas that directy aect the heatho women and girs.

Whie there is widespread agreement on the importance o women and girs in goba heath programs, thereare imited modes on how to integrate such an approach at the agency or country eve. There are aso potentiachaenges that may arise i host countries have poicies in pace that may inhibit invovement and access o womenand girs, and otherwise restrict their rights. In addition, there remain difcut poitica divisions in the U.S. and

esewhere around some key service areas that are important to addressing the heath o women and girs, particuaryamiy panning and access to sae abortion. Finay, there may be opportunities to urther reinorce the gobaconsensus that has emerged on women and girs with internationa partners, incuding the near term marker o theG8 Summit this June, at which the Canadian government is expected to champion a major new initiative on materna,chid, and newborn heath, caing on donor governments to participate.57 In addition, athough the U.S. has not yetratied CEDAW, Secretary Cinton has indicated support or doing so.53

Key Issues:

How can a women and girs centered approach best be impemented at a country eve?

As country pans are deveoped or augmented, how can the importance o addressing women and girs bemeaninguy incorporated? Are incentives to do so needed and i so, what are appropriate incentives? What shoud

the U.S. roe be in countries that may have poicies that are harmu to women and girs?

How comprehensivey shoud services or women and girs be dened within the goba heath portoio? Shoudnon-heath interventions that target women and girs, such as improved access to education, be accounted or?

How can the U.S. reinorce and strengthen the goba consensus that has emerged around the importance oaddressing gender, women and girs, both to keep it on the agenda and to support other countries in their owneorts to do so?


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7. HOW WILL THE U.S. DEFINE, IMpLEMENT, AND MEASURE HEALTH SYSTEMS STRENGTHENING?


In recent years, the U.S. government, other donors and internationa organizations, and recipient countries haveincreasingy emphasized the necessity o strengthening heath systems or reaching goba heath goas andimproving the heath status o those in ow-and midde-income countries. At the aunch o the GHI in May 2009, thePresident emphasized this goa, stating we wi not be successu in our eorts to end deaths rom AIDS, maaria,

and tubercuosis uness we do more to improve heath systems around the word.3 Simiary, stronger heathsystems are essentia or the onger term U.S. oreign aid goa o shiting rom an emergency response to one osustainabiitya core principe o the GHI is promoting sustainabiity through heath systems strengthening (HSS).Finay, the U.S. has aso noted that strengthening heath systems in deveoping countries is important to U.S. seinterest, particuary in the area o pandemic preparedness and prevention o heath threats.

Athough there is a consensus about the critica need to strengthen heath systems or short and ong term success ogoba heath programs, it is one o the more difcut areas to dene and operationaize. Connecting U.S. investmentsin heath systems and capacity buiding to heath outcomes is oten more difcut to measure than other areas andagreed upon targets are not readiy avaiabe, compicating eorts to demonstrate impact to U.S. poicymakers,particuary those in Congress. The GHI targets or HSS, or exampe, are the ony set or which measures have yet to bedeveoped; rather, the U.S. has indicated that it wi seek to deveop measures working with other donors and partner

countries. In addition, despite recognizing the importance o strengthening heath systems, some have worried that amore horizonta approach coud come at the expense o disease specic vertica approaches and not account or theroe payed by vertica programs in strengthening heath systems.24 Finay, others have drawn attention to existingnetworks or addressing HSS, such as the IHP+, that the U.S. has not yet been directy invoved in.9

Despite these difcuties, there are severa eorts underway to dene and measure HSS that have or coud urtherinorm U.S. eorts. These incude the WHOs heath systems ramework which identies six buiding bocks o heathsystems (service deivery; heath workorce; inormation; medica products, vaccines and technoogies; nancing;and eadership and governance58) and associated measurement tookits or countries,59 in addition to the work o theGoba Fund60 and GAVI61, both o which und and evauate HSS projects, and the work o the IHP+.50

Key Issues:

What targetseither existing or newy deveopedcan be used to hep assess U.S. investments in heath systems?How can heath systems investments be inked to heath outcomes?

What can be earned rom other eorts, incuding those o the Goba Fund and GAVI about design,impementation, and metrics or HSS projects?

How wi the U.S. baance the need to strengthen heath systems, particuary in countries with the eastinrastructure and capacity, with the need to aso respond to more immediate heath chaenges?

As the U.S. moves to strengthen heath systems, adopting a broader, horizonta approach to goba heath, whatwi be the impications or disease-specic vertica approaches? How can the roe o disease-specic verticaapproaches in strengthening heath systems best be recognized, assessed, and accounted or?


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8. HOW WILL THE GHI BE COORDINATED WITH AND AFFECTED BY BROADER U.S. FOREIGN AID REFORM

EFFORTS AND OTHER NEW INITIATIVES?


In recent years, there has been increasing ocus on the need to reorm the U.S. oreign assistance ramework andprograms, incuding reauthorizing the Foreign Assistance Act o 1961, which created the statutory basis or U.S.oreign assistance, but has not been comprehensivey amended since 1985.34,62,63,64 Cas or reorm have gained

momentum,37,38 particuary in the ast year, and severa broad reorm eorts have either been introduced in theCongress or are aready underway in the Administration. These incude: oreign aid reorm egisation introduced inboth the House39 and Senate40; a Presidentia Study Directive (PSD) on Goba Deveopment, signed by the Presidentin August 2009,65,66 that cas or a government-wide interagency review o goba deveopment poicy; and the StateDepartments Quadrennia Dipomacy and Deveopment Review (QDDR),67 announced by Secretary Cinton in Juy2009, which introduced a new process or reviewing and deveoping bueprints or State and USAID dipomatic anddeveopment poicy and structure. In addition to these reorm eorts, the Administration recenty aunched a majornew ood security initiative, the Goba Hunger and Food Security Initiative (GHFSI),33 which is sti being deveoped,and has aso signaed new attention to cimate change eorts, incuding appointing a Specia Envoy or CimateChange at the State Department.68

The preiminary resuts o some o these eorts are expected very soon, and whie none is heath-ocused, goba

heath has reguary been cited by the Administration as a key exampe o its dipomacy and deveopment eortsaround the word and the GHFSI, GHI, and cimate change issues have been taked about in tandem.69,70 Given thatmost goba heath unding and programs is ocated within oreign assistance agencies, what happens with thesebroader initiatives wi amost undoubtedy aect the U.S. goba heath response. In addition, many o the coreprincipes and objectives o the GHI are aso being pursued through these other eorts, such as an enhanced ocuson coordination and integration, country-ownership, and measurement and evauation. At the same time, theseinitiatives are being deveoped or expored whie the GHI itse is sti in ormation and as heath programs and servicescontinue to be deivered on the ground. Thus, it wi be important to monitor their progress and status and assess theirimpications or the U.S. goba heath response.

Key Issues:

How wi these dierent eorts aect the U.S. goba heath portoio and the strategy outined in the new GHIconsutation document? What kinds o broader restructuring o deveopment can be expected?

Where can the U.S. goba heath response serve as a mode or broader deveopment reorm eorts?

Given the mutipe reorm eorts, assessments and initiatives, and uncertainty in their timing, how can the U.S.government best ensure coordination and synergies at the agency, program, and country-eve, as we as withinternationa partners?

How can the goba heath community coordinate with other deveopment stakehoders to best take advantage onew opportunities presented by reorm eorts?

This policy brie was prepared by Jen Kates o the Kaiser Family Foundation. All gures in this brie, and others, can bedownloaded rom Kaiser Slides, http://acts.kf.org/results.aspx?view=slides&topic=76&start=1&num=4, located on the

Foundations global health gateway, http://globalhealth.kf.org/. Kaiser slides are regularly updated with the most recentdata available.


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1 U.S. Government. Implementation o the Global Health Initiative: Consultation Document; February 2010, www.pepar.gov/ghi/index.htm.2 White House. Budget o the United States Government, Fiscal Year 2011; February 2010, www.whitehouse.gov/omb/budget/Overview/.3 White House. Statement by the President on Global Health Initiative; May 5, 2009, www.whitehouse.gov/the_press_ofce/Statement-by-the-President-on-Goba-

Heath-Initiative/.4 White House. Fact Sheet: American Leadership on Global Health; May 5, 2009, www.whitehouse.gov/the_press_ofce/Statement-by-the-President-on-Goba-

Heath-Initiative/.

5 Kaiser Famiy Foundation anaysis o data rom the Ofce o Management and Budget, Agency Congressiona Budget Justications prepared by individuaagencies, Congressiona Appropriations Bis, and White House Statement by the President on Goba Heath Initiative. Aso see: Kaiser Famiy Foundation,The U.S. Global Health Initiative: Overview & Budget Analysis; December 2009.

6 Institute o Medicine. The U.S. Commitment to Global Health: Recommendations or the New Administration; Washington DC: Nationa Academies Press; Decembe2008, www.iom.edu/Activities/Goba/USandGobaHeath.aspx.

7 Institute o Medicine. The U.S. Commitment to Global Health: Recommendations or the Public and Private Sectors; Washington DC: Nationa Academies Press; May2009, www.iom.edu/Activities/Goba/USandGobaHeath.aspx.

8 levine R. Heathy Foreign Poicy: Bringing Coherence to the Goba Heath Agenda in The White House and the World: A Global Development Agenda or the NextU.S. President, Nancy Birdsa, editor. Washington, DC: Center or Goba Deveopment; August 2008, www.cgdev.org/content/pubications/detai/16560.

9 Report o the CSIS Commission on Smart Goba Heath Poicy. A Healthier, Saer, and More Prosperous World. Washington DC: Center or Strategic andInternationa Studies; March 18, 2010, http://smartgobaheath.org/content/report.

10 Morrison JS, Kates J. Five Emerging Key Challenges For US Policy Approaches On Global Health; Apri 21, 2009, http://media.csis.org/gobaheath/commissioners/ve_emerging_chaenges.pd.

11 Morgan l. Whats on the Agenda in Global Health? The Experts List or the Obama Administration; Washington, DC: Center or Goba Deveopment; June 2009,www.cgdev.org/content/pubications/detai/1422228.

12 Saaam-Byther T, Moss K. U.S. Global Health Assistance: Background, Priorities, and Issues or the 111th Congress. Congressiona Research Service. R40740; Juy 27, 2009.13 Comments submitted by the oowing organizations and coaitions were reviewed (comments submitted by individuas were not incuded): The Center or

Goba Deveopment; The Goba Heath Counci; The Goba Heath Initiative Working Group; The Pubic Heath Institute; The Center or Heath and GenderEquity (CHANGE); Joint comments rom Advocates or Youth, CHANGE, Famiy Care Internationa, and The Internationa Womens Heath Coaition; TheFoundation or AIDS Research (amAR); The Goba AIDS Aiance; Joint comments rom Aeras Goba TB Vaccine Foundation and The Goba Aiance or TB DrugDeveopment; IDSA Center or Goba Heath Poicy; Joint Comments rom Maaria No More, Friends o the Goba Fight, Popuation Services Internationa, PathMaaria Vaccine Initiative, Path Maaria Contro and Evauation Partnership in Arica, and Arica Fighting Maaria; and IPAS.

14 Kates J, Fischer J, lie E. The U.S. Governments Global Health Policy Architecture: Structure, Programs, and Funding; Meno Park, CA: Kaiser Famiy Foundation; Apri2009, www.k.org/gobaheath/7881.cm.

15 Emanue EJ. The Goba Heath Initiative. Presentation at the Consortium o Universities or Goba Heath Annua Meeting, Nationa Institutes o Heath,Bethesda, Maryand; September 14, 2009, www.cugh.org/?q=meetings/2009-annua/presentations.

16 Institute o Medicine.Americas Vital Interest in Global Health: Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests.Washington DC: Nationa Academies Press; 1997, www.nap.edu/openbook.php?record_id=5717.

17 The White House. Ofce o the Press Secretary, Press Brieng by Press Secretary Robert Gibbs and Deputy Secretary o State Jack lew; May 5, 2009,www.whitehouse.gov/the_press_ofce/Brieng-by-White-House-Press-Secretary-Robert-Gibbs-5/5/09/.

18 Kates J, lie E, Pearson J. Donor Funding or Health in Low- & Middle- Income Countries, 2001-2007. Meno Park, CA: Kaiser Famiy Foundation; Juy 2009,www.k.org/gobaheath/7679-03.cm.

19 Ravishankar N, Gubbins P, Cooey RJ, leach-Kemon K, Michaud CM, Jamison DT, Murray CJl. Financing o Goba Heath: Tracking Deveopment Assistanceor Heath From 1990 to 2007, The Lancet, Voume 373, Issue 9681, pp. 2113 2124; June 29, 2009, www.theancet.com/journas/ancet/artice/PIIS0140-6736%2809%2960881-3/abstract.

20 Taskorce on Innovative Internationa Financing or Heath Systems. More Money or Health, and More Health or the Money; September 2009,www.internationaheathpartnership.net/pd/IHP%20Update%2013/Taskorce/Johansbourg/Fina%20Taskorce%20Report.pd.

21 Word Heath Organization, www.who.int/topics/nancia_crisis/en/. See in par ticuar, The Financial Crisis and Global Health: Report o a High-level Consultation,Geneva, Switzerland 19 January 2009, www.who.int/topics/nancia_crisis/nanciacrisis_report_200902.pd.

22 Internationa Monetary Fund. The Impact o the Financial Crisis on Low-Income Countries; March 2009, http://im.org/externa/pubs/t/books/2009/goban/goban.pd.

23 Word Bank. Global Economic Prospects 2010: Crisis, Finance, and Growth; January 2010, http://go.wordbank.org/7NIPEVSMO0.24 Waensky RP, Kuritzkes DR. The Impact o The Presidents Emergency Pan or AIDS Reie (PEPAR) beyond HIV and Why It Remains Essentia, Clinical Inectious

Diseases. Voume 50, Issue 2, Page 272275; Jan 2010.25

See or exampe organizationa comments submitted on the GHI consutation document rom amAR, the Goba AIDS Aiance, and the IDSA Center or GobaHeath Poicy.26 The Tom lantos and Henry J. Hyde United States Goba leadership Against HIV/AIDS, Tubercuosis, and Maaria Reauthorization Act o 2008, P.l. 110-293; Ju y

2008.27 See, or exampe: Brookmeyer R, Measuring the HIV/AIDS Epidemic: Approaches and Chaenges, Epidemiologic Reviews, March 4, 2010; WHO, HIV Incidence,

www.who.int/diagnostics_aboratory/inks/hiv_incidence_assay/en/; Diaz T, Methodoogica chaenges o Measuring HIV Specic Impacts For DesignConsiderations or Evauating the Impact o PEPFAR, IOM Workshop, Apri 30 - May 1, 2007.

28 Jamison DT, Breman JG, Measham AR, Aeyne G, Caeson M, Evans DB, Jha P, Mis A, Musgrove P. CostEectiveness Anaysis. Disease Contro Priorities Project,Priorities in Health, ed. , 39-58. New York: Oxord University Press; 2006, www.dcp2.org/pubs/PIH/3/FuText.

29 UN Miennium Deveopment Goas, www.un.org/mienniumgoas/30 G8 Research Group. G8 Commitments on Health, 1975-2009; December 2009, www.g7.utoronto.ca/evauations/g8-commitments-heath-to-2009.htm.31 Miennium Chaenge Corporation, www.mcc.gov/mcc/panda/programs/compacts/index.shtm.32 State Department, Ofce o the Goba AIDS Coordinator. The U.S. Presidents Emergency Plan or AIDS Relie: Five-Year Strategy; December 2009, www.pepar.gov/

strategy/index.htm.33 State Department. Global Hunger and Food Security Initiative: Consultation Document; September 2009, www.state.gov/s/gobaoodsecurity/.

ENDNOTES


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The Henry J. Kaiser Family Foundation

Headquarters: 2400 Sand Hill Road Menlo Park, CA 94025 650.854.9400 Fax: 650.854.4800

Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW Washington, DC 20005 202.347.5270 Fax: 202.347.5274 www.kff.org

This pubication (#8063) is avaiabe on the Kaiser Famiy Foundations website at www.k.org.

ENDNOTES (continued)

34 Hiary Rodham Cinton, Remarks at the Center or Goba Deveopment, Washington, DC, January 6, 2010, www.state.gov/secretary/rm/2010/01/134838.htm.35 Kaiser Famiy Foundation anaysis.36 Jacob lew, Anne Marie Saughter, Aonzo Fugham, Remarks at The US Goba leadership Coaition, October 14, 2009, www.usgc.org/2009/10/14/putting-

smart-power-to-work-diaogue-on-qddr-%E2%80%93-october-14-2009/.37 Herring S, R adeet S, Modernizing U.S. Foreign Assistance or the Twenty-rst Century in The White House and the World: A Global Development Agenda or the

Next U.S. President, Nancy Birdsa, editor. Washington, DC: Center or Goba Deveopment; August 2008, www.cgdev.org/content/pubications/detai/16560.

38 Modernizing Foreign Assistance Network. New Day, New Way: U.S. Foreign Assistance or the 21st Century; June 2008, http://modernizingoreignassistance.net/newdaynewway.htm.

39 H.R. 2139 - Initiating Foreign Assistance Reorm Act o 2009, http://hd.oc.gov/oc.uscongress/egisation.111hr2139.40 S. 1524 - Foreign Assistance Revitaization and Accountabiity Act o 2009, http://hd.oc.gov/oc.uscongress/egisation.111s1524.41 Goba Fund to Fight AIDS, Tubercuosis and Maaria, Pedges and Contributions, as o Apri 6, 2010, www.thegobaund.org/en/pedges/?ang=en.42 Goba Aiance or Vaccines and Immunisations, Donors, as o Apri 6, 2010, www.gaviaiance.org/support/donors/index.php.43 Internationa Finance Faciity or Immunisation, www.i-immunisation.org.44 Advance Market Commitment, www.vaccineamc.org.45 UNITAID, www.unitaid.eu/.46 Hecht R, Pariwaa A, Rao A, Innovative Financing or Global Health: A Moment or Expanded U.S. Engagement, Washington DC: Center or Strategic and

Internationa Studies; March 2010, http://csis.org/pubication/innovative-nancing-goba-heath.47 WHO Framework Convention on Tobacco Contro, www.who.int/ctc/en/48 McGrady B, U.S. Engagement in International Tobacco Control, Washington DC: Center or Strategic and Internationa Studies; June 2009, http://csis.org/

pubication/us-engagement-internationa-tobacco-contro.49 UN Convention on the Eimination o A Forms o Discrimination against Women, www.un.org/womenwatch/daw/cedaw/.50 Internationa Heath Partnership, www.internationaheathpartnership.net/en/home.51 Barrack Obama. Address to the United Nations Genera Assemby. September 23, 2009. New York, NY, www.america.gov/st/texttrans-engish/2009/September/

20090923110705eaias0.3711664.htm52 State Department, Foreign Press Center, Testimony o Assistant Secretary Esther Br immer, U.S. Engagement With Mutiatera Organizations, October 22, 2009,

www.state.gov/p/io/rs/rm/2009/130998.htm.53 Hiary Rodham Cinton, Remarks at the UN Commission on the Status o Women, UN Headquarters, March 12, 2010, www.state.gov/secretary/rm/2010/03/138320.htm54 Kaiser Famiy Foundation anaysis. Mutiatera unding incudes the Goba Fund, GAVI, IAVI, UNAIDS, Goba TB Drug Faciity, and Microbicides. Other U.S.

contributions to mutiatera organizations, such as to the WHO, are not currenty counted as part o the GHI.55 State Department, www.state.gov/s/gwi/56 UNFPA, www.unpa.org/pubic/site/goba/ang/en/pid/1562.57 Stephen Harper, Canadas G8 priorities, Januar y 26, 2010, http://pm.gc.ca/eng/media.asp?id=3093.58 WHO, Everybody Business : Strengthening Health Systems To Improve Health Outcomes : WHOs FrameworkFor Action, Geneva: WHO; 2007, www.who.int/

heathsystems/strategy/en/.59 WHO/Word Bank, www.who.int/heathino/statistics/tookit_hss/en/index.htm.60 www.thegobaund.org/en/perormance/eectiveness/hss/61 www.gaviaiance.org/support/what/hss/index.php62 Epstein SB, Veiette C. Foreign Aid Reorm: Issues or Congress and Policy Options, Congressiona Research Service, Rl34243; January 27, 2009.63 Epstein SB, Weed MC, Foreign Aid Reorm: Studies and Recommendations, Congressiona Research Service, R40102; Juy 28, 2009.64 GAO. Foreign Aid Reorm: Comprehensive Strategy, Interagency Coordination, and Operational Improvements Would Bolster Current Eforts.

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deveopment/.66 Testimony o Dr. Rajiv Shah, Administrator, U.S. Agency or Internationa Deveopment, Regarding the Fisca Year 2011 Budget Requests, Beore the Committee

on Foreign Aairs, United States House o Representatives, March 3, 2010, www.usaid.gov/press/speeches/2010/ty100303.htm.67 State Department, www.state.gov/r/pa/prs/ps/2009/juy/125956.htm.68 State Department, Appointment o Specia Envoy on Cimate Change, Todd Stern, January 26, 2009, www.state.gov/secretary/rm/2009a/01/115409.htm.69

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Documents

US Global Health Initiatives Key Issues Policy Brief April 2010