GLOBAL HEALTH RECOMMENDATIONSfor a New Administration and Congress

Partners In Health

François-Xavier Bagnoud Center for Health and Human Rights

Physicians for Human Rights

Health Alliance International

RESULTS

ActionAid

François-Xavier Bagnoud Center for Health and Human Rights

1

GLOBAL HEALTH RECOMMENDATIONS

for a New Administration and Congress

Introduction

We are at a pivotal point in United States history as the Obama Administration and the 111th Congress begin. We embrace the message of change and hope that brought this new administration to ascendance and look forward to the application of these principles in all sectors of government. While the U.S. financial crisis is likely foremost on the minds of many in Washington, the current global crisis threatens to worsen the extreme privation suffered by those in the developing world. At the writing of this document, 25% of the developing world lives in dire poverty and 80% of the world lives in countries where income inequality is worsening. Such social inequity threatens not only the health of the globe but peace, security, and the prospects of financial recovery. The U.S. government’s role in providing aid for health and development has never been more critical.

In the year 2000, the 189 member states of the United Nations agreed upon a set of goals—the Millennium Development Goals (MDGs)—the achievement of which would be prioritized by both developing countries and the wealthier countries that provide assistance. The MDGs highlighted the critical links between improving health, education, and the status of women and children and achieving meaningful and equitable development for the world’s poor. However, with little financial commitment from the developed world, meager progress has been made towards achieving the MDGs.

Much of the assistance to poor countries in the last three decades has been given with the goal of building market-based strategies to attain development, with the idea that these strategies would be self-sustaining. Yet, as we see in our own country today, the private sector has insufficient responsibility to protect the vulnerable. Not surprisingly, market strategies in the developing world have failed to provide the services needed to the world’s poorest. Additionally, money for health has typically been given to U.S. organizations to deliver a single or small cluster of interventions as opposed to building systems to deliver care and addressing the root causes of disease. We believe that accountability and a rights-based approach is best served if services are delivered in the public sector in a democratic society in which the populace has a say in the implementation.

A poignant example of the failure to deliver health to the world’s poor is the fact that the number of women who die in childbirth has remained constant despite 40 years of development assistance targeted toward “safe motherhood.” Programs taught traditional birth attendants sterile techniques for home deliveries and when to refer women for medical care. Yet no money was spent on the development of modern medical facilities with access to blood, surgery, and the skilled providers needed to avert maternal death. The rare services that do exist in poor countries are

2

simply too costly for the majority of poor women.

We believe that U.S. health and development assistance should address both the root causes of ill health—poverty and inequality—and be directed toward building public sector institutions to help governments respond to the needs of their people. Aid should be transparent on both donor and recipient sides and accountable to the target population: the poor who need services most. The new Administration and Congress have a unique opportunity to redefine foreign aid policy to help those most impoverished and to save lives. Implementing the recommendations of this paper would have an enormous impact.

3

Targeting the World’s Major Health Challenges

Stock-taking

The global community is united in the effort to rectify the social injustices that affect the world’s poor and destitute. The most striking success of such targeted advocacy and funding to date is the treatment of HIV through direct support from governments and non-governmental organizations; initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund or GFATM) and bilateral programs like the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), have had a profound impact on communities across the globe. Today more than 3 million people living with AIDS in resource-poor settings are receiving life saving antiretroviral therapy, a feat that many deemed impossible only ten years ago.

The Millennium Development Goals (MDGs), adopted at the 2000 United Nations Millennium Summit, represent the commitments of a global partnership that require the participation and collaboration of all governments, civil societies, the private sector, and the public as a whole. Despite the remarkable ground covered in the fight against killer diseases such as HIV/AIDS and malaria, the global community remains far from the finish line. Recent efforts have focused on finding solutions for disease-specific crises. This approach has worked well and U.S. efforts against HIV/AIDS, tuberculosis, and malaria should be expanded as authorized by Congress in 2008. Simultaneously, the U.S. should mount a robust response to areas that have been neglected, such as child and maternal mortality, and strengthening comprehensive primary health care. This requires a more concerted focus on prevention and health care delivery in addition to treatment. Instilling this innovative change in global health campaigns will require a greater appreciation of the power of grassroots organization and the ability of poor communities to identify, confront, and monitor their own health challenges.

Achieving the Millennium Development Goals

The incoming administration has stated that achieving the MDGs will become U.S. policy. The MDGs are well suited to serve as benchmarks of success and failure in achieving universal health equity. However, progress towards these goals to date has been poor. While headway on some focused targets, such as the treatment of HIV, is a reality, the fulfillment of many other targets, most notably targets that are tied to social and economic rights, remains stagnant. i

In the pursuit of realizing health care as a human right, it is critically important to establish indicators to measure progress. Although the MDGs cover a range of poverty-related targets, all goals have the right to health at their core. For several MDGs, this connection to health is explicit: Goals 4, 5, and 6—to reduce child mortality; improve maternal health; and combat HIV/AIDS, malaria and other diseases, respectively—set forth clear charges to deliver health care to the world’s poor. Beyond that, experience and evidence confirm that failure to place a priority on improving human health and wellbeing will undermine progress towards all of the other MDGs. The table below summarizes some of the ways that poor health is negatively synergistic with poverty and reduces the likelihood of achieving the MDGs.

4

While the MDGs are often viewed in isolation, as objectives that can be individually targeted, true victory over poverty is unlikely to occur without addressing its complex, multi-faceted roots. To that end, the right to health provides a framework with which to understand the inter-relatedness of all goals. Poor health is both a cause and a consequence of poverty. The inter-related dynamic of health and poverty underlines why any serious effort to eliminate poverty must place a strong focus on health, and why a focus on health best highlights the connections between the MDGs.

In working toward the MDGs for health, particular care will need to be taken to ensure that the poor (particularly those living on less than $1.25 a day) share fully in the progress achieved, as they are least likely to be reached by development assistance in the absence of targeted outreach. Unlike the hunger goal, which explicitly targets people below the poverty line, the health goals are expressed in terms of national averages; improvements in those averages can all too easily be achieved through progress that primarily benefits better-off groups. Therefore, U.S. foreign assistance for health must proactively seek to reach the poor.

While progress toward achieving the MDGs has been made, the likelihood that the international community will succeed in reaching all of them by 2015 is unlikely without a renewed commitment to increased funding and a fresh approach to meeting targets. As documented in the 2008 UN Millennium Development Goals Report, many indicators have either decreased only slightly or have remained relatively static (consider maternal deaths per 100,000 live births in sub-Saharan Africa: 920 in 1990 and 900 in 2005; or under-five mortality rate per 1,000 live births in developing regions: 103 in 1990 and 80 in 2006). For the incoming U.S. administration, the need to accelerate progress on MDG 8, develop a global partnership for development, is particularly relevant and urgent. Far from making progress toward the longstanding goal of providing official development assistance equal to 0.7% of GDP, wealthy countries recently reduced the level of assistance from 0.33% in 2005 to 0.28% in 2007. In recent months, the governments of the OECD countries have committed hundreds of billions of dollars to bolster the international financial system. Far less money, but an equal sense of urgency, will be required to fulfill commitments to eliminate the burden of debt and unfair trade policies and to increase development assistance to the world’s poorest and most vulnerable countries and people.

What is encouraging about progress in the past decade is the extent to which knowledge regarding disease prevention and treatment and access to care in resource-poor settings has expanded. Countless studies, focus groups, and field projects have given those committed to ending poverty and securing health for all a detailed roadmap to securing these aim. What remains is the need for an impassioned U.S. administration and Congress to apply this knowledge on a global scale with the necessary and appropriate zeal for justice.

5MD

GSe

lect

ed ta

rget

sC

ause

s and

cons

eque

nces

: he

alth

-dev

elop

men

t fee

dbac

k lo

opPr

ogre

ss to

dat

e(a

rrow

s sho

w d

irec

tion

for

prog

ress

, dot

ted

lines

show

cu

rren

t pro

gres

s nee

ded

to b

e on

pac

e to

rea

ch ta

rget

)

1. E

radi

cate

ex

trem

e po

verty

an

d hu

nger

• Hal

ve, b

etw

een

1990

and

20

15, t

he p

ropo

rtion

of p

eopl

e w

hose

inco

me

is le

ss th

an $

1 a

day

• Hal

ve, b

etw

een

1990

and

20

15, t

he p

ropo

rtion

of p

eopl

e w

ho su

ffer f

rom

hun

ger

• Pov

erty

and

hun

ger a

re th

e un

derly

ing

caus

es o

f mos

t di

seas

e. C

onve

rsel

y, p

oor h

ealth

cre

ates

and

per

petu

ates

po

verty

by

prev

entin

g ch

ildre

n fr

om a

ttend

ing

and

achi

evin

g at

sc

hool

and

adu

lts fr

om fi

ndin

g an

d re

tain

ing

prod

uctiv

e w

ork.

• A

ccor

ding

to th

e m

ost r

ecen

t WH

O re

port

on th

e gl

obal

bu

rden

of d

isea

se1 ,

child

hood

and

mat

erna

l und

ernu

tritio

n re

pres

ent f

ar a

nd a

way

the

bigg

est s

ingl

e ris

k fa

ctor

for l

oss

of h

ealth

y, p

rodu

ctiv

e ye

ars o

f life

, acc

ount

ing

for m

ore

than

al

mos

t 200

mill

ion

Dis

abili

ty A

ffect

ed L

ife Y

ears

(DA

LYs)

. • W

orld

wid

e, c

omm

unic

able

dis

ease

s, m

ater

nal a

nd p

erin

atal

co

nditi

ons,

and

nutri

tiona

l defi

cien

cies

are

resp

onsi

ble

for

561

mill

ion

lost

yea

rs o

f hea

lthy,

pro

duct

ive

life,

with

a

cons

erva

tivel

y es

timat

ed c

ost o

f $1.

1 tri

llion

.

2. A

chie

ve

univ

ersa

l pr

imar

y ed

ucat

ion

• Ens

ure

that

, by

2015

, chi

ldre

n ev

eryw

here

, boy

s and

girl

s al

ike,

will

be

able

to c

ompl

ete

a fu

ll co

urse

of p

rimar

y sc

hool

ing

• Lac

k of

edu

catio

n un

derm

ines

hea

lth. O

ne re

cent

stud

y fo

und

that

pro

vidi

ng u

nive

rsal

prim

ary

educ

atio

n co

uld

save

at l

east

7

mill

ion

youn

g pe

ople

from

con

tract

ing

HIV

ove

r a d

ecad

e.2

• Mal

nutri

tion

and

poor

hea

lth a

re m

ajor

fact

ors i

n re

duci

ng

atte

ndan

ce a

nd p

erfo

rman

ce a

t sch

ool.

Low

birt

hwei

ght,

prot

ein

ener

gy m

alnu

tritio

n, ir

on d

efici

ency

ane

mia

and

io

dine

defi

cien

cy h

ave

all b

een

linke

d to

cog

nitiv

e de

ficits

that

re

duce

chi

ldre

n’s a

bilit

y to

lear

n. Io

dine

defi

cien

cy a

ffect

s an

estim

ated

1.6

bill

ion

peop

le w

orld

wid

e an

d ha

s bee

n as

soci

ated

w

ith a

n av

erag

e 13

.5 p

oint

redu

ctio

n in

IQ fo

r a p

opul

atio

n.

3. P

rom

ote

gend

er e

qual

ity

and

empo

wer

w

omen

• Elim

inat

e ge

nder

dis

parit

y in

prim

ary

and

seco

ndar

y ed

ucat

ion

pref

erab

ly b

y 20

05,

and

at a

ll le

vels

by

2015

• Poo

r hea

lth is

one

of t

he p

rinci

pal c

onse

quen

ces o

f gen

der

ineq

ualit

y, a

s wom

en a

nd g

irls s

uffe

r dis

prop

ortio

nate

ly

from

mal

nutri

tion

and

from

lack

of a

dequ

ate

fund

ing

for

repr

oduc

tive

heal

th a

nd o

bste

trica

l ser

vice

s. • E

limin

atin

g ge

nder

dis

parit

y in

edu

catio

n w

ould

yie

ld

imm

edia

te a

nd im

porta

nt im

prov

emen

ts in

hea

lth fo

r wom

en

and

thei

r fam

ilies

. The

Wor

ld B

ank

rece

ntly

con

clud

ed th

at

achi

evin

g th

is g

oal i

n 45

cou

ntrie

s tha

t app

ear l

ikel

y to

fall

shor

t wou

ld sa

ve th

e liv

es o

f mor

e th

an 1

mill

ion

child

ren

a ye

ar a

nd re

duce

mal

nutri

tion

rate

s by

seve

ral p

erce

ntag

e po

ints

.

05

1015

20

05

1015

2025

3035

Prop

ortio

n un

dern

ouris

hed

(%)

Hun

ger i

n de

velo

ping

cou

ntrie

s

1990

2007

Prop

ortio

n un

dern

ouris

hed

(%)

Hun

ger i

n su

b-Sa

hara

n A

fric

a

1990

2007

MD

G ta

rget

on p

ace

MD

G ta

rget

on p

ace

Prop

ortio

n of

chi

ldre

n w

ho c

ompl

ete

prim

ary

scho

ol (%

)

1991

2006

Prim

ary

scho

ol c

ompl

etio

n in

dev

elop

ing

coun

trie

sM

DG

targ

eton

pac

e

Prop

ortio

n of

chi

ldre

n w

ho c

ompl

ete

prim

ary

scho

ol (%

)

1991

2006

Prim

ary

scho

ol c

ompl

etio

n in

sub

-Sah

aran

Afr

ica

MD

G ta

rget

on p

ace

020

4060

8010

0

020

4060

8010

0

020

4060

8010

0

020

4060

8010

0

Gen

der r

atio

in d

evel

opin

g co

untr

ies

Gen

der r

atio

in s

ub-S

ahar

an A

fric

aM

DG

targ

et

on p

ace

Girl

s p

er 1

00 b

oys

in s

eco

nd

ary

sch

oo

ls

Girl

s p

er 1

00 b

oys

in s

eco

nd

ary

sch

oo

ls

1991

2006

1991

2006

6MD

GSe

lect

ed ta

rget

sC

ause

s and

cons

eque

nces

: he

alth

-dev

elop

men

t fee

dbac

k lo

opPr

ogre

ss to

dat

e(a

rrow

s sho

w d

irec

tion

for

prog

ress

, dot

ted

lines

show

cu

rren

t pro

gres

s nee

ded

to b

e on

pac

e to

rea

ch ta

rget

)

4. R

educ

e ch

ild

mor

talit

y• R

educ

e by

two-

third

s, be

twee

n 19

90 a

nd 2

015,

the

unde

r-five

mor

talit

y ra

te

• Pov

erty

and

hun

ger a

re th

e un

derly

ing

caus

es o

f dea

th fo

r m

ore

than

hal

f of t

he n

early

10

mill

ion

child

ren

who

die

eac

h ye

ar b

efor

e re

achi

ng th

eir fi

fth b

irthd

ay. A

mon

g th

e le

adin

g ca

uses

of d

eath

are

dia

rrhe

al d

isea

se (s

prea

d by

lack

of a

cces

s to

cle

an w

ater

), pn

eum

onia

(tre

atab

le w

ith a

ntib

iotic

s), a

nd

mal

aria

(whi

ch c

an b

e pr

even

ted

with

inex

pens

ive

bedn

ets)

.• C

hild

mor

talit

y an

d po

or h

ealth

in c

hild

hood

are

a m

ajor

dr

ain

on fa

mily

reso

urce

s and

an

impo

rtant

obs

tacl

e to

ec

onom

ic d

evel

opm

ent.

5. Im

prov

e m

ater

nal h

ealth

• Red

uce

by th

ree-

quar

ters

, be

twee

n 19

90 a

nd 2

015,

the

mat

erna

l mor

talit

y ra

te

• Nea

rly a

ll of

the

536,

000

wom

en w

ho d

ie e

ach

year

from

co

mpl

icat

ions

of p

regn

ancy

and

chi

ldbi

rth a

re v

ictim

s of

pove

rty a

nd im

pove

rishe

d he

alth

syst

ems t

hat a

re u

nabl

e to

pr

ovid

e pr

enat

al a

nd o

bste

trica

l ser

vice

s, su

ch a

s em

erge

ncy

C-s

ectio

ns, t

hat a

re u

nive

rsal

ly a

vaila

ble

in m

ore

afflu

ent

coun

tries

and

com

mun

ities

. • M

ore

than

10

mill

ion

wom

en a

yea

r suf

fer s

ever

e or

long

-la

stin

g iln

esse

s or d

isab

ilitie

s, in

clud

ing

obst

etric

fist

ula,

in

ferti

lity,

infe

ctio

ns, a

nd d

epre

ssio

n, c

ause

d by

com

plic

atio

ns

of p

regn

ancy

and

chi

ldbi

rth.

• Mat

erna

l and

new

born

mor

talit

y ha

ve b

een

estim

ated

to

caus

e a

$15

billi

on lo

ss in

pot

entia

l pro

duct

ion

each

yea

r.

6. C

omba

t HIV

/A

IDS,

mal

aria

an

d ot

her

dise

ases

• Hav

e ha

lted,

by

2015

, and

be

gun

to re

vers

e th

e sp

read

of

HIV

/AID

S• H

ave

halte

d, b

y 20

15, a

nd

begu

n to

reve

rse

the

inci

denc

e of

mal

aria

and

oth

er m

ajor

di

seas

es

• Pov

erty

and

hun

ger s

pur r

isky

beh

avio

r (in

clud

ing

trans

actio

nal s

ex a

nd m

igra

nt la

bor)

that

acc

eler

ates

the

spre

ad o

f HIV

/AID

S.• H

IV a

ttack

s peo

ple

durin

g th

eir m

ost p

rodu

ctiv

e w

orki

ng

year

s, pl

ungi

ng fa

mili

es a

nd c

omm

uniti

es in

to p

over

ty a

nd

slow

ing

econ

omic

dev

elop

men

t. A

rece

nt st

udy

base

d on

dat

a fr

om th

e ea

rly 2

000s

cal

cula

ted

that

HIV

had

redu

ced

annu

al

GD

P gr

owth

by

an a

vera

ge o

f 1.1

% in

33

Afr

ican

cou

ntrie

s.3

• Lac

k of

acc

ess t

o in

sect

icid

e-tre

ated

bed

nets

con

dem

ns m

ore

than

1 m

illio

n pe

ople

, mos

tly c

hild

ren,

to d

ie o

f mal

aria

eac

h ye

ar. H

unge

r mor

e th

an d

oubl

es th

e ris

k th

at m

alar

ia w

ill b

e fa

tal t

o ch

ildre

n w

ho c

ontra

ct it

.• M

alar

ia h

as b

een

estim

ated

to c

ost A

fric

a $1

2 bi

llion

per

ye

ar in

lost

pro

duct

ivity

.

020

4060

8010

012

0

050

100

150

200

Child

mor

talit

y in

dev

elop

ing

coun

trie

s

Child

mor

talit

y in

sub

-Sah

aran

Afr

ica

MD

G ta

rget

on p

ace

MD

G ta

rget

on p

ace

Un

der

-�ve

mo

rtal

ity

(per

1,0

00 li

ve b

irth

s)

Un

der

-�ve

mo

rtal

ity

(per

1,0

00 li

ve b

irth

s)

1990

2006

1990

2006

010

020

030

040

050

0

Mat

erna

l mor

talit

y in

dev

elop

ing

coun

trie

s

020

040

060

080

010

00

Mat

erna

l mor

talit

y in

sub

-Sah

aran

Afr

ica

MD

G ta

rget

on p

ace

MD

G ta

rget

on p

ace

Mat

ern

al d

eath

s (p

er 1

00,0

00 li

ve b

irth

s)

Mat

ern

al d

eath

s (p

er 1

00,0

00 li

ve b

irth

s)

1990

2005

1990

2005

020

4060

8010

0

Acce

ss to

trea

tmen

t in

deve

lopi

ng c

ount

ries

Acce

ss to

trea

tmen

t in

sub-

Saha

ran

Afr

ica

020

4060

8010

0

MD

G ta

rget

on p

ace

MD

G ta

rget

on p

ace

Pro

po

rtio

n o

f peo

ple

in n

eed

rece

ivin

g t

reat

men

t (%

)

Pro

po

rtio

n o

f peo

ple

in n

eed

rece

ivin

g t

reat

men

t (%

)

2006

2007

2006

2007

7MD

GSe

lect

ed ta

rget

sC

ause

s and

cons

eque

nces

: he

alth

-dev

elop

men

t fee

dbac

k lo

opPr

ogre

ss to

dat

e(a

rrow

s sho

w d

irec

tion

for

prog

ress

, dot

ted

lines

show

cu

rren

t pro

gres

s nee

ded

to b

e on

pac

e to

rea

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8

Improving Means of Funding

Funding for global health

One of the major obstacles to achieving the MDGs is funding. There is no specific funding mechanism to achieve the MDGs. Currently, donor and recipient countries partner to generate bilateral funding, which is inherently political and less flexible. U.S. foreign assistance generally does not provide direct budgetary support to governments. The current system of U.S. funding often goes to U.S. non-governmental organizations that have enormous overhead rates and are not required to report to Congress on specific targets and outcomes.

More money is needed to support programs that promote the social and economic rights of the world’s poor so that local and transnational communities organized around specific diseases can unite under one effort. Rich countries need to be held responsible for their pledges to support poor countries. The United States should be leading the way and fulfilling the promise to increase Official Development Assistance to 0.7% of GNI. In doing so, we must fully fund the $48 billion commitment to PEPFAR. More funding should also be channeled through multilateral agencies including the Global Fund to Fight AIDS, Tuberculosis and Malaria as well as transparent UN agencies with clear project objectives and outcomes. Multilateral funding reduces the political restrictions that often inhibit the allocation of aid. The United States is in a unique position to lead the world by example by redefining international aid as evidence-based and streamlined.

Over 30 years of effort: little progress

The Declaration of Alma-Ata (1978) (the Declaration) broke new ground in global health, advocating an approach focusing on primary care and establishing guiding principles for a wider social movement rather than treating health issues in isolation. The Declaration, in essence, promoted two approaches: the first addressed population health and sought to modify the overall structure and functioning of health systems; the second, stressing collaboration within governments and across sectors, sought to address the social determinants of health and the long-term transformation of the structures and relationships in a society that propagates disease and ill health. This dual approach integrated health education, food and nutrition, an adequate supply of safe water and basic sanitation, and maternal and child health care (including family planning, immunization, prevention and control of locally endemic diseases, appropriate treatment of common diseases and injuries, and provision of essential drugs). Coordination at the national, intermediate, and community levels with other social and economic sectors of society was of paramount importance. While the Declaration was widely embraced by health activists and the global South, it was never followed with the funding that was needed to achieve its goals. Overall health did not improve and inequality—the driving force of the social determinants of disease—worsened. The AIDS epidemic, which rolled back the gains in child mortality as well as massively decreasing life expectancy, laid bare the inadequacies of the health and social welfare structures of the world’s poor.

It is now clear that a comprehensive approach is needed to address the root

9

causes of illness, as well as to sustainably counter specific diseases like HIV/AIDS. A comprehensive approach that provides primary health care within a functioning health system and ensures proper treatment of prevalent and complex diseases costs money and demands collaboration between government and non-governmental actors, and between public and private sectors. The development of such a system requires maximum involvement of all specialized personnel—policy makers, programmers, organizers, as well as donors and NGOs—and hence needs national, regional, and international support. Whether this new paradigm is termed a “comprehensive” or “diagonal” approach, the need to shift toward fully integrated services is as relevant now as it was during the drafting of the Declaration.

Expanded initiatives – a comprehensive approach

There has been great discussion comparing the benefits of vertical and horizontal approaches to funding. A more comprehensive approach attempts to bridge the ‘stand-off’ between the vertical and horizontal approaches to illness and disease. It also attempts to address a major shortcoming of vertical interventions: the inability of the health system to integrate or expand the intervention. For example, in the case of HIV/AIDS, vertical programming eventually ‘hits the ceiling of insufficient health workers and dysfunctional health systems.’ ii

The comprehensive (or “diagonal”) approach has been described by Julio Frenk and Jaime Sepulveda as a ‘strategy in which we use explicit intervention priorities to drive the required improvements into the health system, dealing with such generic issues as human resource development, financing, facility planning, drug supply, rational prescription, and quality assurance.’ iii The Government of Mexico successfully adopted a comprehensive approach through its efforts to address the various intellectual and programmatic traditions of public health, focusing on social determinants of health, disease-specific interventions, and the general structure and function of health systems. By taking a comprehensive, integrated approach, the Government made health the central principle of a larger social agenda, making significant advancements in health equity. iv

The comprehensive approach to health

1. Develop sustained financing to effectively and efficiently disburse funds to health programs with multi-year funding cycles rather than annual appropriations.

2. Increase Official Development Assistance to 0.7% of GNI and proportionately increase funding for all global health programs, capitalizing on vertical funding currently available, with a focus on maximizing outcomes.

3. Fully appropriate the authorized $48 billion for HIV/AIDS, tuberculosis, and malaria for 2009-2013 (PEPFAR).

4. End the vertical versus horizontal funding debate and commit to a comprehensive health care approach.

RECOMMENDATIONS

10

Inefficiency of aid

In the last year, there have been many calls for development assistance reform, including a number of groups and organizations recommending a cabinet-level department for global development.v While we support calls for a fundamental shift in development assistance, there are more immediate changes that can be implemented by the new administration, especially in areas of measurement and evaluation, to determine that the programs we fund are effective.

We must refocus our attention to national plans and de-fragmentize funding streams to limit the dozens of NGOs on the ground in each country that are doing the same job with varying results. Donor funding, driven by the emergency response to HIV/AIDS, has reached levels never seen before in the history of global health. Over the past five years, while emergency HIV/AIDS funding focused on establishing a rapid response, the level of quality from program to program has been inconsistent. Some programs have clearly performed better in various areas and poorer in others. So what is the best model to promote? As we work with the reauthorized PEPFAR legislation and shift from an emergency response to longer-term programs, focus needs to be placed squarely on the quality of the programs and specific patient outcomes, rather than concentrating solely on treatment figures and other targets.

The U.S. Government must take action to maximize health outcomes with each program it supports. To do so, it should improve the method of performance evaluation of programs and individual projects and examine the variability of impact that may not be seen at the macro level. The new administration must, therefore, establish a yard stick that can measure effectiveness and create a normative framework for identifying model programs and systems. Each agency and initiative will first need to establish a consensus on how effective performance can be measured, selecting several criteria that accurately evaluate success. The government should also make a commitment to evidence-based strategies to improve outcomes, such as prevention and harm reduction programs, cash transfers, task-shifting, and employing community health workers. In addition to program evaluation, agencies should evaluate money flows in these programs and make decisions to channel money through more efficient multilateral mechanisms and NGOs. Using this new means of measurement, the U.S. government will sharpen its focus on program effectiveness, improve its return on investment in terms of health outcomes, and save more lives.

However, given the lack of data provided by many agencies, such measurement will not be easy. In order to achieve an improved level of program evaluation, there must be increased transparency in U.S. foreign aid. USAID’s tuberculosis funding, for instance, lists its annual commitments, but more detailed information regarding these commitments is not easily accessible to the public. Such programs report whether recipient countries are meeting their targets, but it is difficult, if not impossible, to determine the quality of the program services. Greater disclosure of such information would likely increase the amount of funding spent in recipient countries. Increased transparency would shed light on the inefficiencies of U.S. foreign assistance, like wasteful overhead costs, over-priced and ineffective technical assistance, and improper contracting, which significantly hamper the positive power of this nation’s aid. The use of expatriate development consultants,

11

whose salaries, cost of living expenses, rent, and family-related expenses, like children’s school fees, often amount to many times the cost of hiring local experts and the tying of aid to other services and goods from the donor country account for an increase of costs between 15% and 40%, according to the OECD. vi

Improving Health Care Delivery

Build local / national capacity for health care delivery and improved outcomes

Investment in public sector

Widespread deficiencies in public sector health infrastructure and workforce are commonly acknowledged to be some of the principal causes for the failure to achieve health-related MDGs and other major health goals. For example, many new HIV treatment projects “are being implemented without adequate investment in strengthening the weak and, in some cases, collapsing health systems in sub-Saharan Africa.” vii

Treatment expansion fueled by new large-scale funding from PEPFAR, the Global Fund, and the World Bank has been slowed considerably by insufficient health infrastructure. An emerging consensus among donors and local governments now recognizes the urgency of strengthening the public sector through workforce expansion, infrastructure investment, and management capacity building. With sufficient support, national health care systems can coordinate large-scale programs and bring integrated, quality services, such as HIV/AIDS and other chronic disease treatment and care, to the greatest number of people most equitably. However, much of the new development assistance for health has gone to international NGOs or private sector interventions at the expense of direct support for public sector health systems.

Furthermore, donors have been reluctant to invest in public sector health systems or provide the kind of aid necessary for long-term planning and sustainability. Aid policies should be flexible enough to support long-term, multi-year funding that: provides pre-service education, including elementary, secondary, and pre-professional education programs; enables countries to fully implement needs- and rights-based, comprehensive human resources for health plans; strengthens basic infrastructure including water, power, and other basic requirements of health systems; improves management capacity at the national, regional, and local levels; and supports research, evaluation, and information systems.

Inefficiency of aid

1. Develop a framework to better evaluate programs and measure their effectiveness and efficacy.

2. Require all agencies and initiatives to assess performance of programs and individual projects; examine money flows and the variability of impact, which may not be seen at the macro level, so as to determine more efficient multilateral mechanisms and NGOs through which to channel money.

3. Institute a policy of complete transparency in U.S. foreign aid, shedding light on the costs that significantly decrease the percentage of aid reaching recipient countries.

RECOMMENDATIONS

12

Health care professionals / community health workers

The number of health care workers is grossly insufficient to address the health needs of populations in resource-poor settings. Many countries have turned to task-shifting as one response to the critical shortage of professional health workers. Although this may alleviate the short-term crisis, we must not lose sight of the need to develop and retain an adequate cadre of licensed health professionals including doctors, nurses, midwives, pharmacists, laboratory technicians, and mid-level providers in both poor and rich nations. The 2008 Lantos-Hyde Act requires training and retention support for 140,000 new health workers, with a special focus on health professionals. The legislation also recognizes the target from the WHO’s 2006 World Health Report of 2.3 doctors, nurses, and trained midwives and 1.8 health auxiliaries (including CHWs) per 1,000 residents, which is a very low estimate of the number needed.viii Meanwhile, our aid policies should ensure that community health workers and other paraprofessionals receive the necessary and continual education, support, and compensation to carry out their duties.

Over recent years, several international cooperative efforts have attempted to address the problem of weak health systems and the human resource crisis. The U.S. government has supported these efforts, but more still needs to be done. The Paris Declaration on Aid Effectiveness and the Global Health Workforce Alliance Kampala Declaration are two examples that the U.S. should more fully support. Furthermore, the U.S. government should follow the lead of other high-income countries in developing policies to prevent aggressive recruiting of health professionals from low-income countries and invest instead in developing its own health workforce to prevent “brain drain” from developing countries.

Finally, increased investment in public health systems by low-income countries is challenging and sometimes impossible in the context of IMF-imposed, supported, or inspired fiscal and monetary policies that result in limitations on the expansion of the public sector and health budgets. The U.S. must prioritize loosening these constraints as a pre-requisite for any expanded public sector investment.

Build local / national capacity

1. Direct more U.S. aid to recipient country public sectors to develop health systems and encourage other donor countries to follow suit. Such funds should be allocated to refurbish facilities, hire and train new clinical and administrative staffs, compensate existing Ministry of Health staff, and waive patient user fees.

2. Increase the total number of health workers in resource-poor areas to, at a minimum, 2.3 doctors, nurses, and trained midwives and 1.8 health auxiliaries (including com-munity health workers) per 1,000 residents; provide full support for pre-service train-ing and retention for at least 140,000 new health professionals.

3. Revise U.S. policy regarding compensation of community health workers for their services, moving beyond an unsustainable model that relies on local residents to volunteer their time for health and development projects that benefit the community.

RECOMMENDATIONS

13

Reduce child mortality

Children in resource-poor areas are the most vulnerable members of society in terms of disease mortality and morbidity. Millennium Development Goal 4, reduce child mortality, has set a target for the world to achieve; while there has been modest progress, we are off the pace to reach it. 2006 was the first year since records have been kept that under-five mortality fell below 10 million, to 9.7 million globally compared to 12.7 million in 1990.ix However, the majority of these children still die from preventable diseases; the major causes of death for children under five are: neonatal infection (36%), pneumonia (acute respiratory infection) (19%), diarrheal disease (17%), malaria (8%), measles (4%), and AIDS (3%).x Malnutrition is often the underlying contributor to mortality.

The leading causes of child mortality are avoidable. We know how to prevent and treat them. Yet there has been a clear failure in providing care to every child who needs it. We, therefore, must renew our commitment to basic care, such as antibiotics, vaccines, food, improved water and sanitation systems, and vitamins. We must continue investments in time-proven, cost-effective measures in child health programs. This should include enhanced nutritional services, which can help ensure that children remain strong and healthy, and less susceptible to illness.However, along with a need to refocus on basic care, a new approach to child health must also be taken. This approach must look beyond the old policy of “child survival” and look to a newer policy that supports “children’s well-being.” The goal must be to see children thrive, not just survive. In the spirit of the Declaration of Alma-Ata, we must take on an integrated strategy that encompasses health care services for children with nutrition, clean water, sanitation, education, family support, and social protection. Investments in these areas will provide far greater returns on child welfare and provide far greater reductions on child mortality.

Improve women’s health and decrease maternal mortality

Pregnancy-related complications continue to be the leading cause of mortality globally among adult women of reproductive age. Over half a million women die each year as a result of pregnancy and childbirth, mainly from hemorrhage, infection, and complications of abortion. Nearly all of these deaths are preventable—99% of them occur in developing countries, where health systems

Reduce child mortality

1. Support child health programs with an integrated approach focusing on family, clean water, nutrition, health care, education, and social protection to adequately address the essential elements of children’s lives.

2. Continue to make greater investments in vaccination campaigns to address the threat of pneumonia, polio, measles, tetanus, and diphtheria – common killers of children in resource-poor areas.

3. Combat malnutrition by enhancing preventive efforts by providing nutritious foods, increasing use of ready-to-use therapeutic food, and acknowledging access to food as a vital component in improving child health.

RECOMMENDATIONS

14

are weak and quality of care is substandard.xi In addition, over 10 million women a year suffer severe or chronic obstetric related illnesses and disabilities including complications from obstetric fistula, infections, infertility, and depression caused by complications of pregnancy or childbirth.xii

Millennium Development Goal 5, improve maternal health, is often described as the most seriously “off track” of all the health-related MDG indicators. Analysis of trends shows that, at the global level, maternal mortality has decreased at an average of less than 1% annually between 1990 and 2005—far below the 5.5% annual decline, necessary to achieve MDG 5. To achieve that goal, Maternal Mortality Ratios (MMRs) will need to decrease at a much faster rate in the future, especially in sub-Saharan Africa where the annual decline has so far been approximately 0.1%.xiii

“Of all the human development indicators, the greatest discrepancy between developed and developing countries is in maternal health.” xiv Worldwide, more than half a million women die during pregnancy and childbirth every year, while cervical cancer kills nearly 300,000 more. As identified in Millennium Development Goal 5, the vast majority of these women are poor; they die not because treatment has yet to be identified, but because they lack access to basic medical care like prenatal check-ups, deliveries assisted by skilled professionals, routine pap smears, and an operating room where safe Caesarean sections can be performed. Where such services are readily available, mortality rates plummet.

The means to improve women’s health and decrease maternal mortality are evident. Yet despite such clarity, the global community has allowed cost to serve as a barrier to progress. Providing adequate care for women, as with other specific diseases, requires the foundation of a strong, basic health care infrastructure. Infrastructure is needed for lying-in centers, private exam rooms, operating rooms, and hospital beds for deliveries and post-partum recovery. Thousands more health personnel need to be appropriately trained and re-trained to provide pre- and post-natal care and safe deliveries. Health centers and hospitals need to be placed in accessible locations for catchment areas and transportation services need to be provided. All of these essential components require substantial funding. The stagnant statistics of the past twenty years are proof that a quick, cost-limited fix for maternal mortality and women’s health does not exist.

Science-based policy should once again become the measure for U.S. foreign assistance policies. The “Abstinence, Be Faithful and Use a Condom” policy in PEPFAR should be revised to reflect scientific evidence on measures that are most effective in preventing HIV and pregnancies. Additionally, the Mexico City Policy (the Global Gag Rule) should be repealed.

In addition to the costs incurred to provide health care services for women, the policy of user fees must also be eliminated. The vast majority of those living in poverty are women. As a result, millions of women forego needed care when faced with the decision to provide food for their families, send their children to school, or pay medical fees. To that end, social and economic rights of women are inextricably linked to health. However, eliminating user fees is not enough to assure these internationally-recognized human rights. Millennium Development Goal 3,

15

promote gender equality and empower women, recognizes the need to eliminate the gender disparity in primary and secondary education to promote women’s health. More funding is necessary to provide women with tools like access to clean water, food, shelter, job opportunities, and psychosocial support that will empower them to break out of the cycle of poverty.

Combat HIV/AIDS, tuberculosis, malaria and other diseases / universal access

HIV/AIDS

Since AIDS was first recognized in 1981, it has claimed the lives of more than 25 million people and infected more than 65 million. A disease that disproportionately affects the poor and destitute, 95% of the estimated 33 million people living with HIV/AIDS reside in developing countries, further perpetuating the cycle of poverty in these areas. Despite the initial skeptical debate, it has been proven and accepted that treatment can save lives while strengthening both HIV prevention and primary health care.

The key to successful HIV/AIDS treatment is a comprehensive approach. Nutritional and social supports are critical components of the life-saving medicines and treatments that HIV/AIDS advocates and other members of the global community fought to make accessible in terms of delivery and cost. Community health workers provide the “missing infrastructure” that is often cited as an obstacle to HIV/AIDS care in poor countries. This community-based approach has proven successful in even the direst of circumstances—from massive political turmoil to devastating natural disasters—to ensure that patients do not miss a single dose of medication. It is also essential that HIV/AIDS prevention and treatment are provided in the context of primary care so as to improve overall well-being for patients and the community at large. Included in this primary care approach to HIV/AIDS are advanced care for tuberculosis and other opportunistic infections, screening, and treatment of sexually transmitted infections, as well as an emphasis on women’s health. As tuberculosis (TB) is the leading killer of people living with HIV/AIDS in developing countries, PEPFAR must continue to scale up resources and programming devoted to TB-HIV collaborative activities, including ensuring that all people living with HIV/AIDS are screened for TB and provided appropriate treatment.

Treatment protocols that are not used in developed countries should no longer be acceptable in developing countries. No HIV-positive mother in the United

Improve women’s health

1 Increase funding for reducing maternal mortality, family planning, and reproductive health services; revise the ABC policy using scientific evidence; and repeal the Mexico City Policy (i.e. the Global Gag Rule).

2. Remove financial barriers to care, specifically user fees for prenatal and obstetrical services, since maternal mortality is strongly correlated with poverty.

3. Address issues documented to be inextricably linked to women’s health, including economic empowerment for women, psychosocial support, and support for women who are victims of domestic abuse/violence.

RECOMMENDATIONS

16

States is counseled to breast feed her infant. However, because clean water often adds complexity and expense to HIV programs, the standard of care in developing countries is for HIV-positive women to breastfeed their infants. We must improve and expand HIV programs to include free clean water and infant formula in order to prevent transmission of HIV to infants.

Tuberculosis

Tuberculosis (TB) is the world’s leading infectious killer of adults after HIV/AIDS, claiming 1.7 million lives each year. TB typically impacts people in their most economically productive years, straining economies at both the macro and micro levels. The immense global burden notwithstanding, TB can be successfully treated with a course of drugs costing as little as $20 per patient. We are failing, however, to reach all those who need these life-saving therapies. In response, we must expand access to TB treatments in high burden countries and develop a strategy to reach the U.S. target of providing 4.5 million successful directly observed therapy (DOTS) treatments. The rising tide of drug-resistant TB makes U.S. leadership all the more critical. Drug-resistant TB is entirely human-made, emerging in response to inadequate treatment for regular TB. Far more deadly and exponentially more costly to treat, extensively drug-resistant strains have yielded mortality rates approaching 85%, thus spotlighting the urgent need to research and develop new TB tools and expedite the global distribution of new technologies. However, with well-funded, community-based programs that integrate CHWs and wrap-around services, cure rates of 60% were possible in one of the first studies.xv

While a pandemic in its own right, TB is also undermining the response to HIV/AIDS, a disease to which the U.S. has committed extraordinary resources. TB is the leading cause of death for people living with HIV in the developing world, yet WHO data suggest a mere 1% of people living with HIV/AIDS are screened for TB.xvi To reverse the mounting toll of either disease requires a coordinated response to both. PEPFAR has, in many ways, been a leader in coordinating TB-HIV efforts, but programmatic scale-up has lagged and progress still falls far short of the need. TB control is among the world’s most cost-effective health interventions. U.S. investment in TB control abroad would save lives, reduce sickness, and save resources domestically over time.xvii Additionally, working with governments of afflicted countries to reduce the burden of TB would serve both public health and public diplomacy.

HIV/AIDS

1. Ensure the $48 billion Congress has authorized for HIV/AIDS, TB and Malaria over the next five years is fully appropriated.

2. Remove the social and economic barriers to treatment adherence by providing “wrap-around services” such as nutrition, clean water, housing, and childcare support.

3. Fund development of new prevention and treatment technologies – vaccines, more reliable diagnostics, and new classes of therapeutics.

4. Scale up coordinated TB-HIV services and require PEPFAR recipients to incorporate the Three I’s (intensified case finding, isoniazid preventive therapy, and infection con-trol) into programming in high TB-HIV burden countries.

RECOMMENDATIONS

17

Malaria

Malaria represents one of the more striking examples of the need to reform foreign aid. It is a clear case study of how, despite well-established means of prevention and treatment, failure in developing a coherent strategy and failure in implementation led to the breakdown of programs and the ineffective use of aid and resources. According to the 2008 World Health Organization’s World Malaria Report, malaria continues to cause nearly one million deaths worldwide, the majority in children yet to reach the age of five. The delivery of relatively inexpensive prevention and treatment interventions in malaria-endemic regions (long-lasting insecticidal nets, artemisinin-based combination therapy, and indoor residual spraying of insecticide) fell far below the 80% World Health Assembly target in 2006. These statistics become more unsettling when one considers that the UN declared 2001-2010 the “Decade to Roll Back Malaria,” that the World Bank pledged in 2000 to cut malaria deaths in Africa by 50%, and that the amount of global aid devoted to malaria coming from donor nations and NGOs increased by over 200% between 2003 and 2006.

To make gains in prevention and treatment of malaria, there must be significant improvements in funding, as well as improvements in program implementation. An evaluation of where malaria aid money has been spent reveals why progress is so abysmal. In 2005, USAID testified to Congress that more of its malaria funds were spent on consultants than on simple solutions such as bed nets, (which cost approximately $6 each and last for years). The 2004 malaria budget of the agency devoted only 5% to medicines, insecticides, and nets.xviii Improvements in malarial initiatives must focus on the basics of how aid is delivered and it can start now. The President’s Malaria Initiative (PMI) Coordinator must initiate a review of all policies and programs to determine their effectiveness and establish criteria for best practices with funding recipients. Additionally, the PMI Coordinator should set limits on the use of technical assistants and consultants. The government does not need to significantly rely on consultants to understand that spraying and nets are the best approach to malaria prevention.

Tuberculosis

1. Create a presidential initiative on global tuberculosis. 2. Expand access to TB treatment in high burden countries and develop a strategy to

reach the U.S. target of providing 4.5 million successful DOTS treatments. 3. Address drug-resistant TB by expanding laboratory capacity and treatment in high

burden regions and funding development of new, effective diagnostic tools and drugs.

4. Fully fund U.S. bilateral TB programs supported through PEPFAR, USAID, and CDC; contribute the U.S. fair share of funding to programs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.

RECOMMENDATIONS

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Decrease extreme poverty and hunger

Pervasive food and nutritional insecurity is the number one health problem of the poor. Already, 2 billion people suffer from hidden hunger and micronutrient deficiencies. Malnutrition underlies over 50% of all the 25,000 child deaths daily and drastically increases complications for pregnant women and adults with HIV and tuberculosis. Yet, despite the fact that food and nutrition are essential to disease prevention and treatment, resources to combat hunger from donors such as the United States and other nations have decreased over the past five years. Even with Millennium Development Goal 1, eradicate extreme poverty and hunger, drawing greater focus to the issue, there has been limited progress.

Significantly more public investment is necessary to halve the number of people suffering from food insecurity by 2015, especially in light of the recent global financial turmoil and food price increases, which have driven another 75 million people into extreme poverty and hunger. Food aid is required in various forms from ready-to-use therapeutic food, which is an essential medicine in the treatment of child malnutrition, to monies for seeds, fertilizers, and irrigation, which are fundamental to agricultural development.

In addition to generating more funding, it is critical to establish a system to track and ensure that aid is efficiently and effectively spent in recipient countries through support for small-hold farmers, local purchase programs, and cash transfers. Currently, ineffectual policies serve as major barriers to efficient aid distribution. The U.S. needs to revise disruptive food and agriculture policies such as the U.S. cargo preference laws, which require 75% of food aid to be shipped on U.S.-flag carriers and result in 65% of U.S. food aid expenditures being spent on transport and administrative costs.xix Likewise, the U.S. government needs to pressure international financial institutions to alter the fiscal and monetary policies that prevent governments from developing sustainable food production and supply systems. Such restrictions need to be replaced by a human rights centered policy framework driven directly by the recipient country.

Malaria

1. Require the PMI Coordinator to comprehensively evaluate all programs to determine effective and ineffective programs and policies; use these findings to promote best practices with all PMI fund recipients.

2. Place a greater focus on implementation and health care delivery via a newly devel-oped Malaria Initiative Strategy.

3. Set concrete limits on the use of PMI funds, which may go to technical assistance and consultants.

4. Fully fund U.S. bilateral malaria programs through PMI, USAID, and CDC and contrib-ute the U.S. fair share of funding to programs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.

RECOMMENDATIONS

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Revising Development Policies and Financing Architecture

Aid conditions should support, not restrict, efforts to strengthen public health systems

Mounting evidence in recent years suggests that the economic policies promoted and enforced by the International Monetary Fund (IMF) may be preventing developing countries from being able to generate and spend more in their national budgets. Health and education budgets are held at needlessly low levels at a time when major increases are needed. As many countries in Africa and Asia face severe education and health workforce shortages, a major concern is that additional doctors, nurses, and teachers cannot be hired when government budgets are constrained by the unnecessarily restrictive fiscal policies (deficit-reduction targets) and monetary policies (inflation-reduction targets) that are attached as binding conditions on IMF loan programs.

Additionally, the IMF has amassed tremendous power for itself as the final arbiter of what supposedly constitutes appropriate policies for “macroeconomic stability.” As a consequence, most bilateral and multilateral lenders and aid donors look to the IMF for its “red light/green light” signal before giving foreign aid, loans, or debt cancellation to developing countries. In this way, the IMF has come to play the role of the head of a foreign aid cartel, in which most other foreign aid donors have abdicated their own individual ability to assess the economic policies of their borrowers.

IMF-supported fiscal programs have discouraged higher public spending by often being too conservative or risk-averse, or failing to even explore certain options. Beyond behavior to limit public sector spending, IMF policies have also had a tendency to divert aid increases into building international currency reserve levels and servicing debt repayment. As a result, only about $2.70 of every $10 in annual aid increases actually address spending on health, education, infrastructure, or other development needs.xx In recent years, the IMF has suppressed government spending through the use of caps on the amount of money used for paying the wages of public sector employees. Consequently, countries receiving debt

Decrease extreme poverty and hunger

1. Immediately fund additional emergency food assistance to prevent further death and disease.

2. Direct the State Department, USDA, USAID, U.S. Treasury, and other agencies to assist governments in developing food sovereignty by allowing them to support small-hold farmers, improve market access in developing countries, and utilize protective tariffs for food production.

3. Collaborate with recipient countries to institute progressive policies on land reform and agricultural development.

4. Track food aid to ensure its efficient and effective delivery and substantially decrease the large amounts of aid to U.S. transport companies and agribusiness.

RECOMMENDATIONS

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cancellation have been obligated to spend the savings from debt relief because of the continuing restrictive policies that limit spending. Without strong internal leadership directing any real policy changes, IMF staff simply reverts back to prioritizing macroeconomic stability over other goals.xxi

Aid should flow to those who need it most, not for political or defense purposes

The Bush administration has initiated two important trends that have begun to reshape and reorganize U.S. foreign aid. The first trend has been a controversial process by which USAID is being brought under the administrative control of the State Department. The second trend has been the growing involvement of the Defense Department in administering various elements of U.S. foreign aid. Both trends have raised concerns that U.S. foreign and development policies may become subordinated to a narrow, short-term security agenda at the expense of broader, longer-term humanitarian and diplomatic goals.

The U.S. has a unique opportunity at this time to redefine our foreign aid policy and goals, which are still based on the 1961 Foreign Assistance Act and a Cold War mentality. A new policy should be developed to reflect today’s geopolitical realities with a focus on lifting the burden of poverty and saving lives. Increased attention must also be paid to correcting the macroeconomic framework that has characterized the conditions for aid by most donors over the last 30 years.

When will aid recipients be able to pay for their own health care?

There is a striking lack of clarity about the long-term intention and purpose of foreign aid within the aid community and among the major aid donors. Apart from short-term humanitarian relief efforts, one assumes that aid is for helping recipient countries to develop. However, amid the massive number of aid projects in multiple countries, there is no generally accepted and widespread definition of “development”, or what supposedly constitutes successful development, or a concerted discussion on these issues. The current debates about streamlining efficiency and “aid effectiveness” are not addressing, let alone questioning, the dominant paradigm of the “Washington Consensus” policies. Instead, over time, the terms “poverty reduction”, “development” and “foreign assistance” have come to be used interchangeably, demonstrating a lack of definitional precision with which to properly inform assessments of “aid effectiveness”.

There is an important need to revisit and question the economic model itself and its failures. The current global credit crisis has raised serious questions about the utility of some tenets of neoliberalism, such as financial deregulation, capital account liberalization, and financial sector liberalization. However, much donor aid is still conditioned either directly or a priori on further trade liberalization, privatization, and deregulation.

Despite the rethinking that may be going on about some neoliberal policies in the wake of the global credit crisis, USAID still will not give aid to countries unless the IMF has first signaled that the recipient country has the “right” macroeconomic policies in place. Similarly, the U.S. Treasury will not allow its representative on

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the Executive Board of the World Bank to approve any loans for countries unless they are in satisfactory compliance with IMF-approved macroeconomic policies. By perpetuating ideological blind spots and eschewing pragmatism and evidence-based policymaking, this lingering dominance of neoliberalism within donor aid conditions hampers the efforts of health advocates and others who believe in the centrality of health to human development.

The MDGs are an important list of crucial development needs that must be met, but they are not a development strategy. As more countries are involved in official processes for drafting long-term National Development Strategies, the U.S. donor community must likewise be engaged with such broader, overarching questions. The creation of a Department of Global Development could provide an opportunity to rethink preconceived or nonexistent notions of development and revisit underlying assumptions and questions.

International health NGOs can stop the “internal brain drain” by integrating the principles of the NGO Code of Conduct

International health NGOs do life-saving work in developing nations, but their actions, fueled by the pressure for quick results, can often be inadvertently detrimental to public health systems. The tendency for international groups in developing countries to hire health workers from struggling public health systems is particularly damaging. “The NGO Code of Conduct for Health Systems Strengthening” xxii, launched in May 2008, is a response to the recent growth in the number of international health NGOs that has been spurred by increases in aid flows to the health sector. The code serves as a guide to encourage NGO practices that contribute to building public health systems and to discourage those that are harmful.

Supporters intend for the code to bring attention back to the issue of the public health care system and to encourage the use of the public system as the platform for the delivery of services. Additionally, there is hope that the code will help ease shortages of health workers in developing countries. Signatories of the code have pledged to avoid hiring health or managerial professionals from the local public sector. They have also agreed to work towards fair salary structures in all sectors of the health care system, including appropriate monetary compensation for community health workers. The code urges long-term NGO investment in education and training to help increase the number of health staff in the country overall rather than perpetuating a zero-sum game between public and nongovernmental workforces. It also calls for NGOs to coordinate better with ministries of health.

Revising development policies and financing architecture

1. Instruct the Department of Treasury to work with the IMF Executive Board to review and change the restrictiveness of IMF macroeconomic policies, and widely publicize such policy changes.

2. Work with the Department of Treasury and IMF to develop increased public spending policy options, which have been fully vetted by a broader group of stakeholders.

3. Require U.S. government contractors to adhere to the principles of the NGO Code of Conduct.

RECOMMENDATIONS

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Recognizing the full scope of human rights by ratifying currently signed treaties

As a final note, we have stressed several times within this paper that the right to health is interconnected to all social and economic rights. Recognizing and respecting such rights fits within the concept of social justice that is embraced within the Universal Declaration of Human Rights. Unfortunately, the political history of the United States has established a misconceived priority for civil and political rights. As a result, the U.S. government has signed, but not ratified several treaties that strengthen the fundamental rights of each individual. Although the United States participates in discourse on international human rights legislation, we have failed to lead by example. The new administration needs to immediately ratify the following international agreements in their entirety:

• The International Covenant on Economic, Social and Cultural Rights • The Convention on the Elimination of All Forms of Discrimination

Against Women • The Convention on the Rights of the Child • The International Convention on the Protection of the Rights of All Migrant

Workers and Members of Their Families • The International Labor Organization Conventions • The International Criminal Court • The Kyoto Protocol

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Endnotes

i. United Nations (2008). The Millennium Development Goals Report 2008. New York: United Nations Department of Economic and Social Affairs. Available from: http://www.un.org/millenniumgoals/reports.shtml, accessed on January 12, 2009.

ii. Ooms G, Van Damme W, Baker B, Zeitz P, Schrecker T (2008). The ‘diagonal’ approach to Global fund financing: a cure for the broader malaise of health systems?. Globalization and Health, 4(6): 1-7.

iii. Frenk, J (2006). Bridging the Divide: Comprehensive Reform to Improve Health in Mexico - Lecture. Nairobi: WHO Commission on Social Determinants of Health. Available from: http://www.who.int/social_determinants/resources/frenk.pdf, accessed on January 12, 2009.

iv. Ibid.

v. Modernizing Foreign Assistance Network (2008). New Day New Way: U.S. Foreign Assistance for the 21st Century. Available from: http://iis-db.stanford.edu/pubs/22192/New_Way_New_Day_Report.pdf, accessed on January 12, 2009; Commission on Weak States and U.S. National Security (2004). On the Brink: Weak States and U.S. National Security. Available from: http://www.cgdev.org/section/initiatives/_archive/weakstates, accessed on January 12, 2009; Marienau S, Zeitz P (2008). A Defining Moment: Transforming America’s Development Assistance System. Washington, DC: Global AIDS Alliance Fund. Available from: http://aidsalliance.3cdn.net/cc09a7a5100ba0c4e2_dnm6ii3ht.pdf, accessed on January 12, 2009; Sachs J, Hindery L, Smith G (2007). Revamping U.S. Foreign Assistance. HELP Commission Minority Report. Available from: http://www.earth.columbia.edu/sitefiles/File/about/director/documents/HELP_Minority_Report.pdf, accessed on January 12, 2009; McLean SA, Gartner D (2007). Reforming the Structure of U.S. Foreign Assitance. Available from: http://aidsalliance.3cdn.net/881558ea8ed6fefee7_ldm6bxvlt.pdf, accessed on January 12, 2009; Brainard L (2008). U.S. Foreign Assistance: Reinventing Aid for the 21st Century. Washington, DC: The Brookings Institution. Available from: http://www.brookings.edu/testimony/2008/0123_foreign_assistance_reform_brainard.aspx, accessed on January 12, 2009.

vi. Joint Progress Toward Enhanced Aid Effectiveness, High Level Forum (2005). Harmonisation, alignment, results: progress report on aid effectiveness. Paris: Organisation for Economic Co-operation and Development and the World Bank. Available from: www.oecd.org/dataoecd/38/9/36189229.pdf, accessed on January 12, 2009 ; see also, ActionAid International (2008). Real Aid 2: Making Technical Assistance Work. Available from: http://www.actionaid.org.uk/doc_lib/real_aid2.pdf, accessed on January 12, 2009.

vii. McCoy D, Chopra M, et al (2005). Expanding Access to Antiretroviral Therapy in Sub-Saharan Africa: Avoiding the Pitfalls and Dangers, Capitalizing on the Opportunities. American Journal of Public Health, 95(1): 18.

viii. World Health Organization (2006). World Health Report 2006. Available from: http://www.who.int/whr/2006/en/, accessed on January 12, 2009.

ix. United Nations International Children’s Emergency Fund (2008). Website, Trends in Child Mortality, Progress for Children: A World Fit for Children Statistical Review. Available from: http://www.unicef.org/progressforchildren/2007n6/index_41802.htm, accessed on January 12, 2009.

x. United Kingdom Department for International Development (2008). Website, The State of the World’s Children Report 2008- Key facts and figures. Available from: http://www.dfid.gov.uk/news/files/state-world-children-facts.asp, accessed on January 12, 2009.

xi. World Bank (2006). Website, Public Health at a Glance - Maternal Mortality. Available from: http://go.worldbank.org/OZ7F9L07H0, accessed on January 12, 2009.

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xii.United Nations Fund for Population Activities (2008). Website, Population Issues, Facts about Safe Motherhood. Available from: www.unfpa.org/mothers/facts.htm, accessed on January 12, 2009.

xiii. World Health Organization, United Nations International Children’s Emergency Fund, United Nations Fund for Population Activities, and the World Bank (2007). Maternal Mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: World Health Organization. Available from: http://www.who.int/reproductive-health/publications/maternal_mortality_2005/mme_2005.pdf, accessed on January 12, 2009.

xiv. Padmanathan I, Liljestrand J, et al (2003). Investing in Maternal Health in Malaysia and Sri Lanka. Washington, DC: World Bank.

xv. Mitnick C, Shin S, et al (2008). Comprehensive Treatment of Extensively Drug-Resistant Tuberculosis. The New England Journal of Medicine, 359(6): 563-74.

xvi. World Health Organization (2008). Global Tuberculosis Control: Surveillance, Planning, Financing. Geneva: World Health Organization.

xvii. Schwartzman et al (2005). Domestic returns from the control of tuberculosis in other countries. New England Journal of Medicine, 353(10): 1008-20.

xviii. Bate R (2005). The Blind Hydra – U.S.AID policy fails to control malaria – testimony. Africa Fighting Malaria to the Subcommittee on Federal Financial Management, Government Information, and International Security. Available from: http://coburn.senate.gov/ffm/index.cfm?FuseAction=Files.View&FileStore_id=e10fb146-0747-4c6f-a95c-d6902c734612, accessed on January 12, 2009.

xix. United States Government Accountability Office (2007). Foreign Assistance: Various Challenges Impede the Efficiency and Effectiveness of U.S. Food Aid. Available from: http://www.gao.gov/new.items/d07560.pdf, accessed on January 12, 2009.

xx. ActionAid (2007). Changing IMF Policies to Get More Doctors, Nurses and Teachers Hired in Developing Countries. Washington, DC: ActionAid. Available from: http://www.ifiwatchnet.org/sites/ifiwatchnet.org/files/4-pager%20--%20IMF%20and%20health.pdf, accessed on January 12, 2009.

xxi. Independent Evaluation Office of the International Monetary Fund (2007). The IMF and Aid to Sub-Saharan Africa. Washington, DC: Independent Evaluation Office of the International Monetary Fund. Available from: http://www.imf.org/External/NP/ieo/2007/ssa/eng/pdf/report.pdf, accessed on January 12, 2009.

xxii. NGO Code of Conduct for Health Systems Strengthening Initiative (2008). Website, Code Content. Available from: http://ngocodeofconduct.org, accessed on January 12, 2009.

François-Xavier Bagnoud Center for Health and Human Rights

Partners In HealthDonna Barry – dbarry@pih.org617-432-5256

François-Xavier Bagnoud Center for Health and Human RightsArlan Fuller – afuller@hsph.harvard.edu617-432-0656

Physicians for Human RightsPat Daoust – pdaoust@phrusa.org617-301-4200

Health Alliance InternationalWendy Johnson – wendyj@igc.org206-543-8382

RESULTSPaul Jensen – pjensen@results.org202-783-7100

ActionAidKaren Hansen-Kuhn – karen.hansen-kuhn@actionaid.org202-835-1240

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