Global Health Policy

May 21, 2009

Institute of Medicine Releases Report on U.S. Commitment to Global Health

By Ruth Levine

The Twitter version of the IOM report on the U.S. Commitment to Global Health, which was formally released on Wednesday by committee co-chairs Ambassador Thomas Pickering and Harold Varmus, might look something like this:

Thanks for a good decade; don’t slack off now ($15b by 2012). Healthier world = happier, healthier us. It’s more than AIDS. Play nice with others. Get your act together.

That doesn’t quite do justice to more than a year’s worth of work by many (including me, as a committee member). So herewith a summary, adapted from a note prepared by IOM staff, for those with a slightly longer attention span. For the real global health junkies, on Thursday the Kaiser Family Foundation will host a webcast conversation among three panel members (Maria Freire, Jeff Koplan and me, moderated by Jen Kates) (details here.)

After making the case for a focus on global health on the grounds of both a humanitarian impulse and enlightened self-interest, the committee identified five areas for action:

(1) Scale up existing interventions to achieve significant health gains. The committee recognized the value of U.S. contributions to better health in developing countries, and the unprecedented levels of financial commitment during the past six years. We also noted that the concentrated attention to HIV/AIDS through the President’s Emergency Plan for AIDS Relief and more recently malaria through the President’s Malaria Initiative, admirable in many ways, left gaps in the areas of child and maternal health, other infectious diseases and non-communicable diseases. We recommended:

o That the U.S. government and private actors should promote and finance the scale-up of existing knowledge and tools to achieve the health-related Millennium Development Goals; and
o That U.S. government global health programs should be less blueprint-oriented and more performance-based to permit resources to be used more easily within unique national health systems.
o That in the area of non-communicable diseases, the U.S. should demonstrate leadership in this area by adopting clear goals—such as improving global disease surveillance, decreasing deaths from tobacco-related illnesses, and reducing injuries from accidents—to guide U.S. global health investments

(2) Generate and share knowledge to address health problems endemic to the global poor. Systemic shortcomings, such as poor surveillance systems, bottlenecks in drug supply pipelines, and chronic deficits in the health workforce, prevent the benefits of existing public health knowledge and technologies from being realized. The committee recommended an expansion of research efforts through increased attention to health systems research (both for studies that can be generalized across countries, and for operational and implementation studies that are culturally and contextually relevant).

In addition, the committee identified ways to leverage U.S. scientific and technical capabilities to conduct research to address health problems endemic to resource-limited countries. This includes an endorsement of rigorous country- and program-level impact evaluations to measure programmatic effect; and promotion of global knowledge networks and the open exchange of information and tools that enable local problem solvers to conduct research.

(3) Invest in people, institutions, and capacity building in resource-limited settings. Time and again in deliberations, the Committee returned to the need for investment over the long term in local institutions. The recommendation: Provide financial support and engage in long-term and mutually advantageous partnerships with organizations in low- and middle-income countries with the goal of improving institutional capacity by investing in training, funding a steady stream of diverse research grants, and generating demand for scientific and analytical work that influences public policy.

The issue of a shortage of health workers also was a theme. We recommended that the US and align health assistance with the priorities of national health sector human resource plans and commit and sustain funding in support of these plans.

(4) Increase U.S. financial commitments to global health. President Obama’s newly announced Global Health Initiative calls for $63 billion over six years (2009 – 2014) or an average of $10.5 billion per year. The 2010 budget proposal is $8.645 billion. This is heading in the right direction, although not quite up to the ambition of the IOM recommendation: To increase U.S. commitments to global health to $15 billion by 2012, allocated over a range of health programs, including system strengthening.

The IOM committee recommended that the U.S. design a coordinated approach to funding global health research that leverages push mechanisms—research subsidies through the Department of Health and Human Services budget (not included in the $15 billion)—and pull mechanisms—innovative funding for novel vaccine, drug, and diagnostic procurement through the foreign affairs budget (included in the $15 billion).

(5) Set the example of engaging in respectful partnerships.The U.S. government—the largest funder of many international organizations and a significant donor of bilateral aid in some countries—carries considerable influence in shaping the global health environment. The committee recommended that the U.S. government support WHO as a leader in global health by paying its fair share of the organization’s budget and providing technical expertise to the WHO, as requested. But it should also request a rigorous external review of the organization to develop future-oriented recommendations that maximize its effectiveness.

We also said that the U.S. should support recipient countries in developing results-focused, country-led agreements that rally all development partners around one country-led health plan, one monitoring and evaluation framework, and a unified review process.

Finally, the important inside-the-beltway message: The President should create a White House Interagency Committee on Global Health within his first year in office to lead, plan, prioritize, and coordinate the budgeting for major U.S. government global health programs and activities. The President should designate a senior official at the White House (Executive Office of the President, potentially within the National Security Council) at the level of Deputy Assistant to the President for Global Health to chair the Interagency Committee. Some progress on this score has already been seen. Zeke Emmanuel of the Office of Management and Budget announced this week that the White House has established an “interagency process” managed through NSC to coordinate U.S. global health activities, citing the IOM recommendation.

A radical departure from the emerging conventional wisdom? No. In fact, CGD will soon publish a short note that compares recommendations from our White House and the World essay, CSIS, the Global Health Council and others for a global health agenda under the Obama Administration; the main finding is the remarkable convergence across many of those who are observing and studying the U.S. activities in global health. The IOM reinforces others’ focus on living up to commitments, balancing the portfolio to include more than AIDS, and making better use of the U.S. assets in the area of science and technology and global leadership.

While it isn’t the most innovative set of recommendations ever developed, those who are listening (which I hope are people with influence in the U.S. public and private sectors) can be reassured by this contribution from an independent panel that adhered to a relatively high standard of evidence (as is the IOM tradition) and heard from many witnesses. Following this future-oriented agenda that balances ambition with realism is the right way to go.