PHM-Exch> US faces global health aid dilemma

[Claudio Schuftan]

From: Vern Weitzel <vern.weitzel at gmail.com>
crossposted from: "[health-vn discussion group]" health-vn at anu.edu.au

http://www.boston.com/news/nation/washington/articles/2009/06/14/us_faces_global_health_aid_dilemma/


US faces global health aid dilemma
Strategy sought to make best use of spending
By James F. Smith, Globe Staff  |  June 14, 2009

President George W. Bush scored major advances in his administration's
worldwide
campaign against AIDS. In fact, some critics say he was so successful that
other
dire needs in poor countries were squeezed out by the relentess American
focus
on AIDS.

Balancing the still-critical AIDS crisis against the many other Third World
problems is just one of the dilemmas confronting President Obama as he
redefines
the American role in Third World health and development.

The Obama administration believes it can leverage Bush's successes into an
assault against a much broader array of diseases that afflict poor
countries.

Deputy Secretary of State Jack Lew, who is leading a State Department review
of
development strategy, says the same health delivery systems that the United
States has built to treat more than 3 million HIV/AIDS patients should also
be
used to treat mothers and children with common, but deadly, ailments.

"It's not glamorous to treat diarrheal diseases in small children, but we
know
it saves a lot of lives," he said. "If you've got somebody who's coming into
a
facility that treats mothers with antiretroviral drugs, you've already got
the
capacity to treat their children. . . . If the capacity is there, it ought
to be
relatively easy to expand the scope of services provided."

Bush concentrated US global health spending on AIDS and two other diseases,
tuberculosis and malaria. He set up agencies to drive those programs, and
poured
in funding - $18.8 billion over five years - concentrated in 15 countries
where
AIDS was especially devastating, mainly in Africa.

Bush's critics complain that he tied more US development aid to national
security policy than ever before. In their view, he pushed too much foreign
aid
money toward Iraq and Afghanistan for short-term geopolitical goals, at the
expense of poverty relief and development in other countries that will pay
off
in better security down the road.

As a candidate, Obama pledged to double US foreign aid and to elevate
development to the same level as diplomacy and defense. That raised hopes in
the
development community of major changes in direction, including a reduced
role
for the Pentagon.

President Obama last month announced a global health initiative that will
increase funding next year by $460 million, to $8.6 billion. He pledged a
total
of $63 billion over six years, vowing to keep up the AIDS, tuberculosis, and
malaria campaigns, "while increasing and enhancing our efforts to combat
diseases that claim the lives of 26,000 children each day."

Those amounts would still fall well short of the Institute of Medicine's
recommendation last month of an increase to $15 billion a year for global
health
aid alone.

The budget is just one source of the frustration among those agitating for
Obama
and Secretary of State Hillary Rodham Clinton to take ambitious steps.

"There's a lot of confusion in Washington at this point," said Raymond C.
Offenheiser, president of Boston-based Oxfam America. "We see Secretary
Clinton
making speeches, and very compelling speeches, about the importance of
effective
development, of building civilian capacity and supporting rural development
in
many regions of the world, and the importance of poverty alleviation. The
problem is we just haven't seen that translated into specific commitments."

It's amid this high-stakes debate that Dr. Paul Farmer, the Third World
health
pioneer from Harvard Medical School and cofounder of Boston-based Partners
in
Health, is being considered for a top administration position. No one is
talking
publicly, but the speculation is that Farmer may be tapped either to lead
the US
Agency for International Development or to take a White House role directing
all
American global aid.

Just about everyone agrees on the need to revitalize USAID, which was
created in
1961 as part of President John F. Kennedy's first-year surge in global
development programs.

Laurie Garrett, a global health specialist at the Council on Foreign
Relations,
says USAID has gone from an organization that had more than 4,000
agronomists,
hydrologists, and other experts on staff in 1980 to just over half that
size. It
now relies heavily on contractors to deliver services abroad.

As USAID services were privatized and outsourced, more development programs
were
shifted to other departments, notably the Pentagon. The security component
of
foreign aid has risen steadily since Sept. 11, 2001, with the Pentagon now
channeling about 22 percent of all US foreign aid - up from 3.54 percent in
1998, Garrett noted in a study published by the council in January.

In 2006, USAID was effectively folded into the State Department. As
Offenheiser
put it, the Bush administration knocked down the wall between diplomacy and
development.

Senator John Kerry, the Massachusetts Democrat who chairs the Foreign
Relations
Committee, says the US foreign aid program is awash in over 150 policy
directives and goals. "When you prioritize everything, nothing is a
priority,"
Kerry said in a speech last month at the Brookings Institution.

"Right now, while 60 percent of our foreign aid goes to 10 countries for
political/military, counternarcotics, and HIV/AIDS, the other 40 percent is
spread thin in 140-plus countries," Kerry said. "We need a more balanced
approach, and a comprehensive development strategy to determine which agency
is
in charge, what we hope to achieve, and how best to accomplish our goals."

An audit done for Republican Senator Richard Lugar found that in some
countries
where the president's AIDS relief program is very active, doctors and nurses
are
being drawn into HIV/AIDS care "at the expense of primary and maternal
health,
[leading to] the unintended consequence of weakening a country's overall
health
infrastructure."

Nonprofit groups say the Bush administration's priorities left other needs
unattended.

"Africa is covered with HIV/AIDS money, but they're facing a global food
crisis
and we don't have a strategy for it," Offenheiser said. Kenya is facing a
major
governance crisis, but most US development assistance there goes to AIDS, he
noted. In Rwanda, where less than 3 percent of the population is
HIV-positive,
two-thirds of US assistance there is for AIDS, Garrett noted in her study.

Lew said the administration recognizes that the scattered US foreign
assistance
programs need better coordination and longer-term planning. Lew argues that
the
ambassador in each country should take on more authority directing all US
aid
programs.

"We're taking the view that even with the current structure, and assuming
you
didn't change any of the laws, there's an enormous coordination of programs
that
ought to be happening at country level, where we really ought to see our
ambassadors as true chiefs of mission, not just in title, but as CEOs who
have
the ability to look across all the programs and manage more effectively,"
Lew said.

However, Maurice Middleberg, a policy analyst at the influential Global
Health
Council in Washington, argues for an arm's-length relationship between the
State
Department and global development.

He notes that diplomacy is often crisis-driven and based on geopolitical
interests. Those aren't always the same as the need for social and economic
development in a country or region.

"There needs to be a loud and clear voice for development," Middleberg said.
"I'm not sure the ambassador is the right person."

But most agree that action is needed to make effective use of US money.

Garrett wrote in her report: "US programs continue to operate through
legislated
stovepipes, putting resources and cash into efforts, regardless of - and
often
in opposition to - the primary needs on the ground in recipient countries. .
. .
All too often, foreign assistance increases dependency, and aims at the
wrong
targets."
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