Remarks to the Consortium of Universities for Global Health on the U.S. Global Health Initiative

J. Stephen Morrison, CSIS
Remarks to the Consortium of Universities for Global Health (CUGH) Plenary on the U.S. Global Health Initiative
Tuesday September 21, 2010 8:30am-10:45am
University of Washington, Seattle

Many thanks to Mike Merson and our University of Washington hosts, King Holmes and Judy Wasserheit, for the honor and opportunity to speak here today.

I had the chance to speak at the first annual gathering a year ago at NIH in Bethesda, and it is remarkable the expansion of university engagement CUGH has demonstrated here today. Congratulations!

I do hope that I and my colleagues at the Center for Strategic and International Studies (CSIS) can continue to support CUGH’s efforts.

When Mike participated in the CSIS Commission on Smart Global Health Policy, from spring of 2009 through spring of this year, we discussed at some length the dynamism on American campuses, what factors drove the explosion of interest in global health, whether it was sustainable and how it could contribute to the advancement of U.S. global health approaches. As part of the Commission’s work, Mike authored a terrific paper on this subject that we published available on

We also joined together in staging an event in October of last year in the Research Triangle that brought together universities, research groups, foundations, implementers, political leadership and the business sector to discuss how global health was driving that region’s economy, generating jobs, innovation and genuine partnerships outside our borders. And how these multiple interests could be organized as a coalition for common future global health goals.

That was a successful experiment, which we went on to repeat in the Bay Area, hosted by Haile Debas and Charles Smukler of University of California, San Francisco; in Boston hosted by Jerry Keusch, of Boston University; in New York host by Debra Spar president of Barnard College and one of our CSIS commissioners; and most recently here in Seattle, hosted by Lisa Cohen, executive director of the Washington Regional Alliance for Global Health and Chris Elias, President and CEO of PATH.

All of these experiences were enriching and convinced me that universities have emerged as a vital constituency and a catalyst in these regional centers of global health excellence.
We’ve heard from Eric Goosby, Office of the U.S. Global AIDS Coordinator (OGAC) Director, and Kevin De Cock, head of the newly launched Centers for Disease Control (CDC) Global Health Center, on the status of GHI.

It is clear from the details they have laid out that GHI is making progress. It is also clear that we are at a moment of big transition that is complex and fluid.

There are a few factors that account for this progress that deserve additional comment.

First, the most critical factors are the high quality of the team that the Obama administration has put in place; the relatively smooth transition that took place at key institutions in the transfer of power from the Bush to Obama administrations; and the interagency process led by Deputy Secretary Lew that has been reliant on the leadership of Eric Goosby (OGAC), Tom Frieden (CDC), and Raj Shah (USAID).

By early this year, Eric had his complete team in place at OGAC, an impressive collection of experts with considerable experience in government and without. Over the summer, Kevin DeCock assumed his position at CDC, aided by a year of careful prior planning. At USAID, Raj Shah succeeded in enlisting Amie Batson and Ruth Levine. Deputy Secretary Lew has benefitted considerably from his senior aide Dana Hyde; Ambassador Verveer has had comparably high quality of support from Jennifer Klein and Rachel Vogelstein.

Second, another fundamental factor is the inherited reality of PEPFAR itself, along with PMI. These are large programs, with substantial funds and operating systems built up over the past seven years in PEPFAR’s case, and five years with respect to PMI. They proved their value, and a consensus has formed across a range of opinions and perspectives that they are successes and among the most notable achievements of the Bush era.

Third, much of the proof for the concept of GHI – its core objectives and principles – rests in the quality and implementation of plans put together in the GHI Plus countries. The interagency planning effort is moving ahead. Because it is reliant, far more than has been the case in the past, on partner country participation and formalized commitments, the process by definition will be slow and require patience. It is important to emphasize also that GHI’s launch occurs at the same time as startup of the administration’s Feed the Future initiative, the three-year $3.5 billion global food security effort. In combination, GHI and FTF present formidable implementation demands.

I would like to turn now to a few select areas of concern for GHI and its future.

First is our changed domestic and international environments.

When PEPFAR was launched, it was during a time of perceived global health and international security emergencies: budgets were reasonably ample, there were other G-8 partners joining with us in elevating their contributions, bipartisan support in Congress was strong, and these initiatives were signature White House priorities.

Powerful other voices were also very important: UN Secretary General Kofi Annan; Bill Gates and former President Bill Clinton, and their respective foundations; Bono and the One Campaign; and vocal African heads of state such as then Nigerian President Obasanjo and current Ugandan President Museveni.

Today, at the macro level, this decade is shaping up to be a quite different era.

We have entered an era of austerity and realism. At the same time that the perceived external health threat has fallen off, there is enhanced economic pain and social dislocation at home, worsening budgetary uncertainty, frayed bipartisanship, and rancor and polarization across global health constituencies themselves. Global health is still a White House priority, as we will hear during President’s address tomorrow at the MDG Summit, and there is still bipartisan goodwill in favor of U.S. leadership on global health. But these persist unsteadily today in a radically different context.

G-8 leadership on development and global health has narrowed to the United States and the UK. This summer in Muskoka, the G-8 quietly retired the ambitious Glen Eagles 2005 commitments to double foreign aid assistance in five years. The G-20 may become more engaged in development and health, but it will be slow to evolve and its emerging powers will not – in the near or medium term – fill the role played by the wealthy core of the G-8 in the past decade.

Where do these changes leave us? I frankly am not certain. We have not yet digested these realities and come up with a new strategy for advancing global health, one that takes these realities adequately into account. That is the core challenge now before us.

The perception of an AIDS global health emergency has faded significantly, even if the reality on the ground has not. Related to this is the perception that pandemic influenza is now less of a threat: H1N1 has faded, as have H5N1 and SARS. We may very much live to regret this.

Our domestic climate has obviously worsened, driven by the worst financial crisis since the Great Depression. Our national budgets, by comparison with a short while ago -pre- September 2008 – are now severely strained, and an historical moment of reckoning on taxes and spending is still to be confronted. Our national budget process presently is in gridlock, with no agreement on targets and priorities.

Annual deficits of $1.4 trillion last year, almost 10 percent of GDP, and $1.3 trillion this year, just over 9 percent of GDP, are not sustainable. How to reduce them without worsening the recession, though, is unclear.

As we head past the November elections and into the next presidential round, which will begin in earnest in January, front and center will be a national debate on deficit reduction, spending, and the means to move our country out of durable high unemployment.

Will foreign assistance be battered in the process? Or ring-fenced as the Cameron/Clegg government has proposed for UK foreign aid? The answer is not yet clear. In the now stalled budget process of this year, GHI fared relatively well in the House and Senate committee actions. There was resistance, significantly, to providing the relatively modest $200 million flexible spending for GHI Plus countries.

The shift underway in the United States does not preordain disaster for U.S. approaches for global health. It does raise the questions of whether we are at a plateau point and how are we to best defend the gains that have been made and build consensus on forward movement.

Reaching the $63 billion goal over the six year period for the GHI (2009-2014) is not impossible but, realistically, it will be difficult. It will depend in part on how the accounting is done, and what funding sources are included.

At present, the U.S. global health budget is $6.8 billion. If all related investments are included, as the Kaiser Family Foundation has calculated, the number rises to $9.6 billion. If we are to achieve the $63 billion target, we will need to reach over $13 billion per year in the next three years.

Bipartisanship around all matters domestic and international has frayed. The base consensus on global health remains, albeit in a more fragile, vulnerable condition. We cannot assume there will be unbroken continuity of bipartisan support.

We do not know what the outcome will be from the November elections. We can predict a few things, beyond what I have said about the unfolding historic domestic debate on deficits, taxes, spending and renewal of jobs and economic growth.

Power will be more split between Democrats and Republicans, and the White House will have far less functional or directional control over Congress, policy directions and budgets. It will become a less predictable environment.

Republican power will include a segment of diverse newly elected officials – including Tea Party activists, who are unfamiliar with and uncommitted to global health and foreign aid, hostile overall to spending, and able at least in the near to medium term to attract considerable media attention. They have not yet grabbed on to foreign assistance as a target, but could potentially find that a convenient and attractive path.

It will be essential in this coming phase to reaffirm the Republican faith in global health that undergird the Bush administration’s championing of PEPFAR, PMI and the Global Fund.

Obama policy choices have also complicated GHI’s progress.

First, in retrospect, it was inherently hazardous to expand the global health agenda by adding new very worthy priorities – namely maternal and child health, family planning, neglected tropical diseases, health systems -- at the very moment when resources were becoming scarce.

That unfortunate convergence aggravated preexisting divisions within the global health constituencies and contributed to rancorous, often ugly competition for shares.

Beneath the surface, as Princeton Lyman, Senior Fellow at the Council on Foreign Relations, laid out in a recent article was a building clash between ever- higher demands for ARV treatment and other competing development demands. (See Foreign Affairs, July/August 2010 ‘No Good Deed Goes Unpunished, The Unintended Consequences of Washington’s HIV/AIDS Programs.’) Lyman further elaborated this argument at the ‘Fault Lines in Global Health’ debate that CSIS hosted in August. It is important also to acknowledge that Mead Over of the Center for Global Development, in his writings over the course of this year, pioneered debate around these issues.

As these tensions have intensified, the Obama administration has not been not very deft or effective in defusing them. Until economic growth resumes and budgets loosen, of course, there will be no easy solutions to these clashes. For now, however, more confrontations can be expected, and the pressures will persist for the administration to do better in managing them.

Second, GHI has not been aided by the administration’s internal foreign aid reform process which has dragged on unresolved for 18 months and has pitted one vision centered in the State Department against another centered in the White House. This process contributed to the delay in the appointment of the USAID administrator for over a year. And today, USAID’s other senior ranks remain unfilled, almost mid-way through the administration’s first term. Specific to GHI, it itself lacks a clearly designated leader and face. We may see some resolution of these persistent problems, I hope, in the coming weeks and months.

Third, GHI is not the whole story of US global health policy. It does not yet effectively integrate or reflect NIH research commitments, nor does it reflect the U.S. government work under way in pandemic preparedness. A more unified and coherent approach is still wanting.

Final thoughts: what might this mean for the university community that CUGH represents? How you frame the argument for GHI will matter significantly. There are several core themes that will resonate best in our evolving climate.

  • Global health fulfils an important value-based, humanitarian mission. It also is fundamental to national security, U.S. foreign policy objectives, and helping promote economic growth and recovery.
  • GHI can be an effective vehicle for reform: for achieving greater efficiencies and effectiveness; for streamlining and integrating programs; for creating greater transparency and accountability through better measurement tools.
  • GHI can be a successful vehicle for leveraging genuine partnerships in which governments assume over time true commitments to budgets, staffing and delivery of services.

In closing, I mentioned earlier that American universities remain an underleveraged voice and actor in global health. They are a rising constituency within American society that can catalyze others from foundations, business, implementers, and political leadership.

As CUGH moves forward, it will need to be careful to avoid appearing as just another additional competitor for scarce resources. And it will be critical that universities advance their dialogue with a full spectrum of American political interests and opinion.

Most importantly, American universities will need to answer clearly and powerfully the question of what special and unique assets they possess that can help advance core GHI objectives: the range of universities’ multidisciplinary strengths; their ability to operate globally in partnership with government bodies, ability to expand service delivery, strengthen evaluation and measurement, pursue a systems approach to building health capacities, and conduct research and training.

Thank you.

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