President-Elect Obama has a strong commitment to, and policy on, international development assistance for health. However, during the election, he rarely discussed global health, and with the financial crisis he may turn his attention to pressing economic issues. America’s commitment to global health is not only a moral imperative, but also is critically important to our national interests in security, trade, and human development. A major initiative by the new President on Global Health Diplomacy would help transform America’s world image. Here, I offer ten priorities on global health for the Obama Administration.
With a new administration starting in January, it is an opportune time to propose fundamental reform of America’s policy on development assistance for health:
1. Appoint a cabinet level official on international aid. Development policy cuts across multiple sectors, including foreign affairs, health, agriculture, energy, and the environment. A cabinet level official with direct access to the President is needed to advocate a “health in all policies” approach and coordinate the currently fragmented activities across agencies.
2. Fulfill America’s pledge to devote 0.7% of GNI per annum to ODA. America should fulfill its pledge to ensure scalable and sustainable global health assistance. G8 leaders in Toyako, Japan this year reaffirmed their long-standing pledges, while committing to full, annual measurements of progress.
3. Meet basic survival needs of the world’s poor. American aid should be directed primarily to meeting what I call “basic survival needs,” including sanitation and sewage, pest control, clean air and water, diet and nutrition, tobacco reduction, and essential medicines and vaccines. Meeting everyday survival needs may lack the glamour of high-technology medicine or dramatic rescue, but what it lacks in excitement it gains in impact by targeting the major determinants of health.
4. Strengthen health systems. American aid should aim to improve health systems in developing countries, including human resources, data systems, laboratories, primary care, and public health infrastructure. The G8 experts group in Toyako recommended, and countries committed to, health system improvement as a better way to improve health for the world’s poor.
5. Reverse the “brain drain.” The WHO estimates that 4.3 million more health care workers (HCWs) are required to meet the Millennium Development Goals, particularly in Africa, which has 25% of the world’s disease burden, but only 3% of the world’s health workers. Rather than improving the workforce in developing countries, the U.S. actively recruits HCWs. The U.S. should build the supply of skilled workers at home, limit international recruitment, and “give back” by building human resources in poor countries through cash payments, scholarships, clinical training, and HCW exchanges.
6. Improve maternal, newborn, and child health. Each year more than half a million women die in pregnancy, and the same number of children die from easily preventable causes such as diarrhea, pneumonia, and malaria. Many women and children would survive if they received antenatal and postnatal care, skilled birth attendants, childhood vaccines, adequate nutrition, and inexpensive lifesaving interventions.
7. Create fair trade for developing countries. The United States has aggressively defended free trade through the World Trade Organization, as well as even more stringent regional and bilateral treaties. This has created obstacles for poor countries in accessing essential vaccines and medicines, developing domestic health and safety protections, or competing fairly with richer countries. The world’s poorest people, for example, were made even more vulnerable when the wealthy West and rising East refused to eliminate farm subsidies, leading to the collapse of the Doha round of agricultural trade negotiations.
8. Collaborate and coordinate with multiple players. A proliferation of actors now occupy the field of global health, resulting in rampant problems of fragmentation and duplication in a sea of funding and activities that span the global health domain. Related to fragmentation is the growing competition between foreign aid workers and local service providers, hindering efforts at greater country ownership and control. The U.S. should work with stakeholders and consult local leaders to foster effective partnerships, create synergies, and avoid destructive competition.
9. Promote accountability, transparency, and monitoring. Accountability in global health is problematic. WHO is accountable to its Member States, but often lacks detailed and realistic targets. States are accountable to their electorate, but routinely renege on pledges to the poor. Civil society, foundations, and corporations report to an array of different interest groups and cannot be held accountable for their failures. The U.S. should work with the international community to create rules for accountability, transparency, and monitoring progress to achieve goals.
10. Agree to fair terms of international cooperation on global health. The U.S. has been resistant to global health governance, refusing to ratify vital treaties or work cooperatively. The U.S. could make a genuine difference by agreeing to fair terms of cooperation through international agreements, such as a Framework Convention on Global Health. See Lawrence O. Gostin, Meeting Basic Survival Needs of the World’s Least Healthy People: Toward a Framework Convention on Global Health, 96 Georgetown Law Journal 331-392 (2008), available at http://ssrn.com/abstract=1014082.
Effective global health governance could dramatically improve life prospects for millions of people and diminish our collective vulnerabilities. That is an ideal worth pursuing by President-Elect Obama.
Lawrence O. Gostin, Linda and Timothy O'Neill Professor of Global Health Law, Georgetown Law