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Is USAID Being Set Up to Fail on the GHI?
October 28, 2011
This is a joint post with Rachel Silverman.
Since the launch of the Obama administration’s $63 billion Global Health Initiative (GHI) in May 2009, we have followed its ups and downs with great enthusiasm (see for example: here, here, here and here), trying to better understand its structure and role within the U.S. government’s complicated global health architecture. One recurring question we have continually raised has focused on leadership: who, exactly, was to be in charge of this massive undertaking? Who would be accountable for meeting the initiative’s eight high-level targets and adhering to its seven guiding principles?
Last December, the State Department’s Quadrennial Diplomacy and Development Review (QDDR) appeared to put those questions to rest. According to the 200+ page document, USAID would assume leadership of the GHI by September 2012, contingent upon fulfilling a set of 10 benchmarks to demonstrate its capacity. But upon closer inspection of the GHI over the last year, the QDDR provision only seems to have generated a new set of questions that are more difficult to resolve. While there are no easy answers, the administration should consider these issues as it thinks through the tough decision of pulling the GHI together under one leader and demonstrating success by meeting its targets:
1) Who should lead the GHI? Leading the GHI to success will require a high level of technical capacity in health, development, and monitoring and evaluation. Though USAID is still rebuilding itself as the premier development agency (and isn’t quite there yet), we agree that it should lead this initiative. USAID is better-equipped than any alternative USG agency to deliver development assistance for health – which incorporates nutrition, better access to water, sanitation, education, and investments in research and development – all of which are core areas of USAID’s focus (see an earlier joint post with Connie Veillette). Moreover, leadership of the GHI is a key step towards building up USAID as the United States’ premier development agency. But…
2) What does leadership of the GHI actually mean? In theory, the leader of the GHI should be equipped to steer the initiative to success through budgetary, policy, and legal leverage. In reality, leadership appears to mean something rather different.
Let’s start by eliminating what GHI leadership is not. GHI leadership does not entail budget authority. It would not grant USAID decision-making authority for other agencies within the GHI’s purview. It is also our understanding that it won’t restructure the current reporting lines within the government, meaning that the heads of other GHI implementing USG agencies will not report to the USAID’s Administrator Raj Shah. So, you might ask, what else is there? Not a whole lot. Essentially, the GHI leadership as we see it holds a vague mandate to “coordinate” the GHI agencies. Except that the QDDR specifically exempts PEPFAR (see pages 84 and 217) – about 70 percent of the GHI’s total funding – from USAID leadership, stating that this program will remain under the Office of the Global AIDS Coordinator (OGAC). And OGAC is already responsible for coordinating USAID and other USG agencies under PEPFAR. So, if USAID coordinates the GHI, you get the picture—everybody will be coordinating each other!
To sum up: as the GHI leader, USAID will coordinate activities representing about 30 percent of the initiative’s total budget, with no authority over funding allocations, decision-making, or the actions of other agency leaders.
If this gives you a headache, you’ve got company. We tried to map out what the USG GH architecture might look like with USAID as the GHI leader, and OGAC as the PEPFAR coordinator; after several attempts to create a diagram, we gave up. In our effort to identify a practical solution for a way forward, we realized that maybe USAID is being set up for failure; not intentionally, but because the GHI was launched without any clear vision about how it could be operationalized under the current U.S. foreign assistance structure. By burdening USAID with eventual responsibility for the GHI’s success but with no authority or leverage to make it happen, the QDDR has inadvertently placed USAID in an impossible situation. Backtrack now and lose face – it will appear as if the State Department thinks USAID is ill-equipped to lead. But grant USAID nominal “leadership” of the GHI with no real authority, and they’re set up for failure.
We know the deadline for the GHI’s transition to USAID is still a year away, but the administration has some difficult decisions to make, and quickly. The President’s global development legacy is at stake if one of his biggest development initiatives is seen to fail. Here are the options, as we see them, along with their respective trade-offs–constraints, costs, and benefits:
1) Move PEPFAR to USAID. Perhaps this option makes the most sense programmatically (unified leadership, horizontal integration with reproductive health, etc)., but it’s a non-starter politically. PEPFAR is protected as an independent structure until its authorizing legislation expires in 2013, and there is no political will to challenge that status quo.
2) Keep the GHI at State. Under this scenario, the State Department would renege on its highly public QDDR plans to move the GHI to USAID, and would maintain control of the initiative under an executive director. State holds some authority over OGAC and could realistically serve as a coordination point between the GHI agencies, as it has done thus far. But there are two good reasons why this scenario doesn’t make sense: 1) global health is not the State Department’s area of technical expertise and the creation of another global health entity in State will be inefficient when plenty of expertise lies elsewhere in the USG. 2) This option could also be a public relations nightmare; the State Department would need to do serious damage control and protect USAID’s reputation. It will need to be clear about its rationale for the decision, emphasizing the structural considerations and why it’s best for the success of the GHI. However, this option will damage the administration’s efforts to build USAID as the premier U.S. development agency.
3) Remove PEPFAR from the GHI. If USAID is to lead the GHI but not PEPFAR, then PEPFAR, operationally, will cease to be a part of the GHI, especially because it has its own reporting line to Congress. If we continue down this path, the administration should formally remove PEPFAR from the GHI portfolio and eliminate the targets for HIV/AIDS treatment and prevention as GHI targets. Under this “efficiency” scenario, USAID would be able to focus its energy on the remaining GHI programs and goals – those which it actually controls – and could be realistically accountable for the corresponding results. However, this course of action would fundamentally alter the original intent and design of the GHI to build on PEPFAR’s “platform” and would demonstrate the unfortunate reality that funds appropriated in a siloed, vertical structure don’t really lend themselves to policy and program level integration . Forfeiting the opportunity to integrate HIV/AIDS programs with reproductive health efforts, for example, will unfortunately turn the GHI in to a more “business as usual” health program approach to global health.
The Bottom Line: Only USAID has the technical capacity to lead the GHI as a development initiative, and it is the natural choice for leadership of the initiative. But beware: by giving USAID responsibility for success without the mandate to meaningfully steer the initiative, USAID is being set up to fail.
We want to hear what you think. What is the best option for the GHI to succeed, knowing that there are tough trade-offs?
Possibly Related Posts
- The QDDR on USAID and the GHI: A Bridge to Nowhere?
- Global Health is Development: Why USAID Should Lead the GHI
- Road Under Construction: What Does the PPD Mean for USAID?
6 Responses to “Is USAID Being Set Up to Fail on the GHI?”
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October 29th, 2011 at 10:49 pm
Nandini: I refer your readers to QuOda http://www.cgdev.org/section/t.....ness/quoda . The U.S. scores badly on three of QuODA’s four dimensions of aid quality. Pepfar by the way is nowhere to be found. Though it has its own authorization and budget in the U.S. system, it doesn’t report as a separate agency to the international data base (the Creditor Reporting System of the OECD) to which USAID and another 15 or so agencies that manage aid programs overseas report. Why? I don’t actually know.
October 29th, 2011 at 11:34 pm
I have to admire your desire to be a cheerleader for GHI. Even after pointing out the inconsistencies and the fatal flaws in the GHI, you still want to salvage it. I see that whoever thought up the GHI wants USG’s aid to be more integrated and better coordinated, but you don’t achieve that by just writing nice strategy papers. If the funding and operational structure doesn’t support that integration, then you end up just wasting people’s time which is what the GHI is doing. If they really wanted to implement GHI, they would have had to dismantle PEPFAR, PMI, MCC and the other parallel aid structures that were established under Bush. By introducing the GHI on top of everything else, they have just added another set of strategy papers to the COPs, MOPs and country strategy plans, only with GHI there is no money to go with the plan.
All the principles of GHI could be followed and implemented through existing mechanisms. They didn’t need to create a new initiative to do it. On the ground, GHI seems to proceed from an assumption that programs are suffering from duplication and lack of coordination and then take a lot of time looking to solve problems that no one is suffering from. Then they claim results that would have happened without GHI. Honestly, if USAID and State are going to adopt evidenced based approaches, they should declare GHI a failure, stop it and let people get back to more productive work.
November 1st, 2011 at 11:30 am
This opinion piece is right to assert that moving PEPFAR to USAID is not a good option. Such a move would be inconsistent with Congressional mandates, but it would also ignore the track record of success that PEPFAR has had under the current structure, with OGAC focused on concrete results and able to work across the federal government, including with USAID. Even as PEPFAR has made progress against the global AIDS epidemic, it has also helped build a platform for delivery of broader health services, with a substantial share of PEPFAR investments going to health system strengthening. (Piot, Kazatchkine, and Dybul, in The Lancet 2009.) PEPFAR also has broad bipartisan support, a critical advantage that should be preserved, and which has helped it drive a robust US global health effort. Looking forward, PEPFAR can increasingly be a foundation for delivery of an array of health services. We also need a PEPFAR program fully dedicated to pursuing the vision of Ambassador Eric Goosby, who wrote with Ambassador Mark Dybul in September that we are, “poised to… achieve our goal of ending the epidemic.”
November 2nd, 2011 at 6:47 am
The opinion piece is well thought out. The GHI is a noble initiative that has fallen victim to the systemic inefficiencies inherent in the separate legislative and funding requirements. In the field we view GHI as a get out clause for the expensive but necessary, President’s Emergency Programme ( PEPFAR). This might be the reason PEPFAR is under GHI. The ring fence will be dismantled in 2013 and PEPFAR will be subsumed under GHI. We also know in the field at USAID is recognized for strong accountability and stewardship but not technical prowess. That prize goes to CDC. We just wonder how it will all pan out. Thanks
November 2nd, 2011 at 8:36 am
Thanks Nandini, an important contribution to the debate. When we debate bureaucratic turf wars, seems important to keep our eyes on the prize. Having seen what it’s like for a mothers who has to take her children to multiple clinics – this one run by that donor, that one run by a different charity – we have to look at it from her point of view.
Multiple donors is bad; multiple donors from the same country is just ridiculous. USAID is the development agency we make it, and if we’re not happy with its current state, we need to fix it, as Raj Shah is trying to do, not spin off new agency after new agency. If it’s too difficult to explain to the patient why she can’t meet all her basic health needs at one clinic, it’s probably not a good idea.
November 2nd, 2011 at 4:17 pm
@ Ernest: Since the systemic inefficiencies and barriers were well known before the GHI was designed or launched, it seems inaccurate to say it is a “victim” of those inefficiencies. I think it is more accurate to say GHI was badly designed (even if its intentions are noble) because it did not identify a solution or even a strategy for dealing with those problems.