US Faces Global Health Aid Dilemma - Strategy sought to make best use of spending

Submitted by Ray Offenheiser From the Boston Globe by James F. Smith President George W. Bush scored major advances in his administration's worldwide campaign against AIDS. In fact, some critics say he was so successful that other dire needs in poor countries were squeezed out by the relentess American focus on AIDS.

Balancing the still-critical AIDS crisis against the many other Third World problems is just one of the dilemmas confronting President Obama as he redefines the American role in Third World health and development.

The Obama administration believes it can leverage Bush's successes into an assault against a much broader array of diseases that afflict poor countries.

Deputy Secretary of State Jack Lew, who is leading a State Department review of development strategy, says the same health delivery systems that the United States has built to treat more than 3 million HIV/AIDS patients should also be used to treat mothers and children with common, but deadly, ailments.

"It's not glamorous to treat diarrheal diseases in small children, but we know it saves a lot of lives," he said. "If you've got somebody who's coming into a facility that treats mothers with antiretroviral drugs, you've already got the capacity to treat their children. . . . If the capacity is there, it ought to be relatively easy to expand the scope of services provided."

Bush concentrated US global health spending on AIDS and two other diseases, tuberculosis and malaria. He set up agencies to drive those programs, and poured in funding - $18.8 billion over five years - concentrated in 15 countries where AIDS was especially devastating, mainly in Africa.

Bush's critics complain that he tied more US development aid to national security policy than ever before. In their view, he pushed too much foreign aid money toward Iraq and Afghanistan for short-term geopolitical goals, at the expense of poverty relief and development in other countries that will pay off in better security down the road.

As a candidate, Obama pledged to double US foreign aid and to elevate development to the same level as diplomacy and defense. That raised hopes in the development community of major changes in direction, including a reduced role for the Pentagon.

President Obama last month announced a global health initiative that will increase funding next year by $460 million, to $8.6 billion. He pledged a total of $63 billion over six years, vowing to keep up the AIDS, tuberculosis, and malaria campaigns, "while increasing and enhancing our efforts to combat diseases that claim the lives of 26,000 children each day."

Those amounts would still fall well short of the Institute of Medicine's recommendation last month of an increase to $15 billion a year for global health aid alone.

The budget is just one source of the frustration among those agitating for Obama and Secretary of State Hillary Rodham Clinton to take ambitious steps.

"There's a lot of confusion in Washington at this point," said Raymond C. Offenheiser, president of Boston-based Oxfam America. "We see Secretary Clinton making speeches, and very compelling speeches, about the importance of effective development, of building civilian capacity and supporting rural development in many regions of the world, and the importance of poverty alleviation. The problem is we just haven't seen that translated into specific commitments."

It's amid this high-stakes debate that Dr. Paul Farmer, the Third World health pioneer from Harvard Medical School and cofounder of Boston-based Partners in Health, is being considered for a top administration position. No one is talking publicly, but the speculation is that Farmer may be tapped either to lead the US Agency for International Development or to take a White House role directing all American global aid.

Just about everyone agrees on the need to revitalize USAID, which was created in 1961 as part of President John F. Kennedy's first-year surge in global development programs.

Laurie Garrett, a global health specialist at the Council on Foreign Relations, says USAID has gone from an organization that had more than 4,000 agronomists, hydrologists, and other experts on staff in 1980 to just over half that size. It now relies heavily on contractors to deliver services abroad.

As USAID services were privatized and outsourced, more development programs were shifted to other departments, notably the Pentagon. The security component of foreign aid has risen steadily since Sept. 11, 2001, with the Pentagon now channeling about 22 percent of all US foreign aid - up from 3.54 percent in 1998, Garrett noted in a study published by the council in January.

In 2006, USAID was effectively folded into the State Department. As Offenheiser put it, the Bush administration knocked down the wall between diplomacy and development.

Senator John Kerry, the Massachusetts Democrat who chairs the Foreign Relations Committee, says the US foreign aid program is awash in over 150 policy directives and goals. "When you prioritize everything, nothing is a priority," Kerry said in a speech last month at the Brookings Institution.

"Right now, while 60 percent of our foreign aid goes to 10 countries for political/military, counternarcotics, and HIV/AIDS, the other 40 percent is spread thin in 140-plus countries," Kerry said. "We need a more balanced approach, and a comprehensive development strategy to determine which agency is in charge, what we hope to achieve, and how best to accomplish our goals."

An audit done for Republican Senator Richard Lugar found that in some countries where the president's AIDS relief program is very active, doctors and nurses are being drawn into HIV/AIDS care "at the expense of primary and maternal health, [leading to] the unintended consequence of weakening a country's overall health infrastructure."

Nonprofit groups say the Bush administration's priorities left other needs unattended.

"Africa is covered with HIV/AIDS money, but they're facing a global food crisis and we don't have a strategy for it," Offenheiser said. Kenya is facing a major governance crisis, but most US development assistance there goes to AIDS, he noted. In Rwanda, where less than 3 percent of the population is HIV-positive, two-thirds of US assistance there is for AIDS, Garrett noted in her study.

Lew said the administration recognizes that the scattered US foreign assistance programs need better coordination and longer-term planning. Lew argues that the ambassador in each country should take on more authority directing all US aid programs.

"We're taking the view that even with the current structure, and assuming you didn't change any of the laws, there's an enormous coordination of programs that ought to be happening at country level, where we really ought to see our ambassadors as true chiefs of mission, not just in title, but as CEOs who have the ability to look across all the programs and manage more effectively," Lew said.

However, Maurice Middleberg, a policy analyst at the influential Global Health Council in Washington, argues for an arm's-length relationship between the State Department and global development.

He notes that diplomacy is often crisis-driven and based on geopolitical interests. Those aren't always the same as the need for social and economic development in a country or region.

"There needs to be a loud and clear voice for development," Middleberg said. "I'm not sure the ambassador is the right person."

But most agree that action is needed to make effective use of US money.