Global Public Health: An Agenda for the 111th CongressFebruary 11, 2009 By Gib Clarke
This is an exciting time to be working global public health, with more attention and money going to the field in the last decade than perhaps ever before. In the past, the struggle has been to direct more money and attention to these issues, but recent efforts have focused more on maximizing funds’ impact—by strengthening health systems, focusing on prevention, and finishing so-called “unfinished agendas” in maternal health, child mortality, and family planning. In my remarks at a recent panel on foreign policy challenges facing the 111th Congress, I focused on four issues: infectious diseases, neglected health issues, funding, and capacity building.
Spotlight on Infectious Diseases
No issue has dominated the global agenda in recent years as much as infectious disease. Three of the biggest challenges in this area are HIV/AIDS, tuberculosis (TB), and malaria. Every year brings 2.7 million HIV infections, 9 million TB infections, and nearly 300 million cases of malaria.
The recent response to these diseases has been significant, even incredible. The single biggest initiative, the President’s Emergency Plan for HIV/AIDS Relief (PEPFAR), was authorized in 2008 for $48 billion over five years. The Global Fund to Fight AIDS, Tuberculosis, and Malaria has allocated more than $10 billion in its campaign against these three diseases. The Presidential Malaria Initiative spent $30 million in 2006, a sum that will grow to $500 million in 2010. And the Global Alliance for Vaccines and Immunization will commit nearly $4 billion by 2015. These sums are unprecedented, and have improved delivery of drugs, bednets, and health services. Much more progress is needed, but the achievements of recent years are truly impressive.
Neglected Health Concerns: Child Survival, Maternal Health, Family Planning
Great strides have been made in child survival. Annual child deaths dropped from 20 million in 1960 to 10 million today, but everyone agrees this is still 10 million too many. Infant and under-five mortality is usually caused by illnesses we know how to prevent and treat—pneumonia, diarrheal disease, and malaria, with under-nutrition often a contributing factor. Proven interventions include vitamin A supplements, use of insecticide-treated malaria bednets, safe drinking water, measles immunization, and early and exclusive breastfeeding.
Similarly, there has been significant progress in reducing the number of women dying in pregnancy or as a result of childbirth, otherwise known as maternal mortality. But this progress has stalled, almost to a stop. Maternal mortality claimed the lives of 536,000 women in 2005, only 40,000 fewer than in 1990 – a decline of less than 1 percent. Successful interventions for maternal health are well-known, and include access to health care before and after delivery and the presence of a skilled birth attendant during delivery.
Family planning is a third, oft-cited “unfinished agenda.” Nearly all developed countries, and indeed many developing countries, have completed or made much progress along the demographic transition—that is, the shift from large families with short life expectancies to small families with longer lives. In some countries, especially in sub-Saharan Africa and Southeast Asia, however, this transition has stalled. Continued population growth may make challenges such as food security, poverty, and conflict more difficult to overcome.
There are sharp differences between Presidents Bush and Obama on this issue. President Obama recently reversed the Mexico City Policy and reinstated $34 million in annual funding to the UN Population Fund. He will likely be pressed to do much more: Five former directors of the U.S. Agency for International Development’s (USAID) Office of Population and Reproductive Health recently issued a report recommending an increase in family planning funding from $457 million in FY2008 to 1.2 billion in FY2010.
Funding: Coordination and Flexibility
The massive sums of money going to global health require improved coordination. The number of actors is striking: Within the U.S. government alone, they include USAID, PEPFAR, the National Institutes of Health, the Centers for Disease Control, and the Millennium Challenge Corporation. Add in foreign governments, large foundations like Gates and Packard, the United Nations, the World Health Organization, and the Global Fund, and the situation is even more complex. Aligning regional and topical priorities will continue to be critical. Hopefully, the likely rewriting of the Foreign Assistance Act will also provide greater coherency.
Funding not only needs to be better-coordinated, it also must be more flexible. Too often, funds are directed to specifically treat one disease, neglecting important contributing factors such as poverty, environmental factors like water, and the quality of the health system itself. An example of a program becoming more flexible is PEPFAR, which added “wraparound” components such as prevention of malaria, pneumonia, and diarrheal diseases to its menu of services, thus better meeting the multifaceted problems of fund recipients.
Many argue that PEPFAR needs to become more flexible still, putting increased emphasis on preventive services, allowing for more country-specific flexibility, and transitioning from an emergency response to a sustainable response. Another example of interest in flexible funding is the prospect of modifying the Paul Simon Water for the Poor Act to incorporate water, sanitation, and health issues.
Strengthening Health Systems
The short- and long-term viability of health programs depends on national and local health systems that can deliver results. A solid public health infrastructure requires the presence of sufficient trained health care workers, effective health policies, availability of supplies, good health finance systems, and strong delivery of health information.
I have left out many aspects of global health that deserve attention—including specific diseases, health’s broader role in development and diplomacy, and issues that affect health like infrastructure and the environment—but I hope this is a useful outline when looking at future health concerns and priorities. We have made great strides in some areas, but much remains to be done. I hope Congress will continue to fund global public health priorities, recognizing that improving the health of the world is in our own national interest.
Photo: Gib Clarke (second from left), courtesy of Dave Hawxhurst/Wilson Center.