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Secretary Clinton on the Global Health Initiative: More on the WHAT and the WHO, but Not the HOW
August 17, 2010
Secretary Hilary R. Clinton spoke yesterday at SAIS on the objectives of the Global Health Initiative (GHI). The webcast of the event provided a forum for an interesting and interested set of tweeters (I participated) to point out what we heard and did not hear during the talk. My overall impression, echoed by several others (see here and here for two round ups of the discussion) was that while it was encouraging to hear Secretary Clinton reiterate the administration’s commitment to global health and its vision to transform the way in which global health is designed, delivered and managed, we did NOT hear anything new about the GHI: for example, no specifics on HOW the U.S. will “do” the GHI and apply all its commendable principles, metrics for success, and global leadership?
The Missing “HOW” of the GHI
While I recognize that we’re still in the early stages of this very complex initiative, I believe that the administration could and should strive to communicate more clearly with the global health community about the implementation of the GHI. HOW exactly is the GHI being rolled out? Even colleagues who work on the ground in GHI countries are perplexed about the roll out. It’s been well over a year since President Obama announced the GHI and stakeholders need to hear HOW the initiative is progressing. This communication is important for a few reasons:
Building stakeholder confidence with up-to-date evidence and information:
Stakeholders across the world are worried about the success of the GHI, even though they agree with the goals and embrace the policy shifts toward sustainable, country-led global health delivery. But, the lack of public information has led to a growing lack of confidence in HOW exactly these goals, objectives and principles will be achieved. A couple of examples:
- Financing plan and structure: As various groups battle for health funding, the administration needs to be very clear about its financing plan and structure by providing details about how they intend to overcome what Secretary Clinton pointedly referred to as “the pitfalls and obstacles” that threaten the GHI. For example, Congressional stove-piping can undermine the integration goal of the GHI (see here for issues we raised a while ago on the topic). HOW is the administration working here in DC and at the country level to overcome this potential obstacle? We need to learn more about what and how the GHI is doing to mitigate risks that might derail it’s goals and principles.
- Monitoring, Metrics and Evaluation: Ongoing discussions about the Monitoring, Metrics and Evaluation (MME) principle of the GHI indicate that this is a priority area. The GHI draft strategy document (the final version has yet to be released) described a strong commitment to monitoring programs, developing outcome measures, and investing in countries’ health information systems to promote the collection and ownership of good quality data. Secretary Clinton repeated all these important features in her remarks, BUT again, provided no specifics on HOW the MME principle is being applied.
Building stakeholder knowledge about the GHI for greater accountability at all levels
- Global-level leadership: The White House, the State Department, USAID, OGAC, CDC and others are all working to roll out the GHI and promote it as a development success story. But, who is really accountable? Will the GHI go down in history with no USG leader’s name attached to it, except Secretary Clinton? While an interagency process is laudable from an operations perspective (although that suggests even more bureaucratic delays!), from a management and accountability perspective, we need to know where the buck stops. Who is calling the shots in DC? Or is consensus-building slowing down implementation? Secretary Clinton mentioned that the interagency team leaders are running the GHI “under the guidance of Deputy Secretary Jack Lew.” (Although, Lew may leave the State Department in the near future to run the OMB.) This was one of the clearest articulations about GHI leadership, but that still doesn’t tell us about WHO is calling the shots and HOW final decisions are being made in this process-heavy endeavor.
- Country-level leadership: While country leaders may eventually become true partners (something we called for in 2007 in this HIV/AIDS Monitor report) in the GHI, it is critically important that citizens in the GHI countries are also well-informed and can hold their governments and NGOs more accountable for their financial commitments to health—whether it is with U.S. funding or domestic monies. The current lack of transparency is undermining the GHI’s goal to transform the “global health system” by pushing governments to “step up” and demonstrate these commitments. The U.S. and other donors can push governments, but an equally, if not stronger force from well-informed citizens has to pull. This was the topic of discussion at a CGD HIV/AIDS Monitor event on country ownership in June 2010, during which country-based panelists strongly suggested that information about the GHI—funding and program objectives, and progress—be made publicly available to ensure a chain of accountability: from beneficiaries to implementers (of both GHI- and government-supported programs) to governments to donors.
Following through with pragmatic, but innovative thinking and actions to match ambitious goals about transforming development
- Another GHI goal that Secretary Clinton raised, and one that I commend the administration for—trying to “embed a deep commitment to health” in countries—is at risk unless we can follow how the next phase of global health leadership is working towards this goal. Debates continue about whether aid is effective and transformative (here, here, and here are a few places where you can follow these conversations), and this administration needs to demonstrate HOW exactly it is overcoming many well documented challenges of the aid business to incentivize developing country leaders to commit to health priorities.
My wish list of actions for the GHI team:
Share information for greater learning and accountability
In the spirit of publish what you fund, I’m pleased to hear that we may have a USG GHI website very soon. This is very good news, but I sincerely hope that the website is an effective public relations/diplomacy tool AND a learning platform. Here’s what I would like to see.
When the web site goes up: I hope that the new site will include:
- An organization chart for the GHI team that tells us who is in charge of what.
- GHI Metrics and examples of HOW the MME plan is being rolled out. “We are rolling out the metrics, right guys?” Secretary Clinton added some humor to the event by checking with “the guys” (presumably Goosby, Shah and Frieden seated in the first row) when asked about the metrics of the GHI. But on a serious note, stakeholders and commenters on the GHI are worried, and in the absence of information, the GHI metrics have become a bit mysterious!
As the GHI progresses: One of the goals of selecting GHI+ countries is to create development learning labs and document the process and outcomes. It would be terrific and useful if we could actually see a page for every GHI+ country and easily track key provisions of this visionary plan. For example, have funds been used effectively to integrate AIDS family planning and maternal and child health services? How are countries “owning” (or failing to own) their respective programs? Different countries present different challenges and learning opportunities for the GHI, and present an enormous opportunity for many different stakeholders to learn across different contexts.
Try new ideas for transformative global health and development and share what you learn
There is a growing discussion among development thinkers about incentivizing country governments to get development results, but not many ideas about how to do it. One idea is Cash On Delivery (COD) Aid, developed by my CGD colleagues, Nancy Birdsall, Bill Savedoff and Ayah Mahgoub. They propose that donors pay governments (almost like a bonus) for results—actual development outcomes that can be measured and audited—that the country achieves with the existing (aid and domestic) resources. This is certainly one way to try to “embed a deep commitment” to global health and development, because countries, not donors, have to figure out how to design, implement and monitor their programs in order to succeed. The GHI could build pilots for COD Aid for specific health outcomes OR try other innovations to incentivize countries to produce results AND share this learning from GHI+ countries to demonstrate how development can begin to be transformative. This could be an exciting and innovative feature of the GHI.
Ultimately, the HOW of the GHI matters, especially when its goals and objectives are about changing the way in which development is done to produce long term and sustainable results. While health outcomes and impact measures will take time to achieve and to document, the GHI team must share its learning about implementation and interim measures towards expected impact, so that we can stop wondering if the GHI will ever realize its goals or not.
4 Responses to “Secretary Clinton on the Global Health Initiative: More on the WHAT and the WHO, but Not the HOW”
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August 18th, 2010 at 10:53 am
Thanks Nandini, for this great overview of what was notably missing from the speech, at least from my, admittedly technocratic, perspective.
To delve a bit more into the proposed emphasis on monitoring, metrics and learning…I don’t believe they can do anything differently on this front unless steps are taken to ratchet up considerably the health systems status and performance info that is consistently available in countries. Everyone and their brother has tried to improve their monitoring, but we call get stuck on the lack of info coming out of the countries. Until we have something like a DHS that covers service provision, and links to the household surveys, and other, qualitative info collected on the funding and stewardship side of these health systems, no donors will make headway on monitoring the impact of programs they fund on health systems. So, I hope GHI will take this issue on, and do something to address it as they did with the DHS.
August 25th, 2010 at 1:45 pm
Nandini, a good analysis of the GHI speech. great thanks. The prime objective of the GHI is to pursue a comprehensive whole-of-government approach to global health. It proposes to develop a new business model to deliver dual objectives: 1) achieve significant health improvements; and 2) create an effective, efficient and country-led platform for the sustainable delivery of essential health care and public health programs.
But since almost all of GHI is targeted to the public health sectors of the developing world, how can these objectives be met when the overwhelming expenditues on health delivery is in their private sectors? According to WHO, the private health sector expends 64% of total national expenditues in Bangladesh; 76% in Cambodia; 76% in Cameroon; 77% in Indonesia; 79% in Kenya; 83% in India; 75% in Vietnam, 80% in Nigeria, etc.
And these data are from the year 2000!
GHI funds, then, will go to the most vulnerable and poorest people in recipient countries. Nothing wrong with that, except that ‘sustainability’, ‘efficiency’, and ‘business models’ are metrics absolutely dependent upon the continuing presence of donors.
Secondly, how can measurements be taken on GHI outcomes when so many other donors are present in the same environment, and how can one measure improvements in IMR when the dominent providers are in the private sector?
September 23rd, 2010 at 12:10 pm
Here’s an answer to the HOW question regarding the $50,000,000 grant for health friendly wood stoves announced by Secretary Clinton. Please visit http://www.stoveteam.org This is an proven, in full production stove which is manufactured indigenously. Someone please tell the State Department. Ed Warren
October 12th, 2010 at 11:00 pm
Thanks Nandini for this excellent synthetic post.
I would really be curious to understand a bit more what place and role would be given to the NGO community. NGOs have picked up through the last decades an incredible knowledge based on field-experience. They were the ones to deal directly with public authorities and local partners. What would be left of that? Would NGOs for the next 10 years be mere technical advisors with little influence on cash control and programs impact monitoring? Besides, they are an innovative bunch. What sort of flexibility would be left for them in designing new mix of interventions, new models?
Although I understand perfectly well in term of sustainability USG’s wish to move to a more direct relationship with the aid recipients, I foresee considerable sources of waste in term of technical assets and the risk to create a little reactive machinery.
And thanks Jeremiah for pointing out the role and necessary involvement of the private sector at some point. Let’s not forget that in Europe most of the health care systems rely on a contractual approach in between the private and the public sector with an excellent outcome in term of coverage, provision and impact of services.
Warm regards to you all,
Vincent Guérard, general director @ Urban Care – http://www.urbancare.org