Nandini Oomman, the Center for Global Development’s director of the HIV/AIDS monitor, co-wrote a blog piece with Rachel Silverman raising several important questions about the Global Health Initiative (GHI). The State Department-led Quadrennial Diplomacy and Development Review (QDDR) – which next month will be one year into its implementation – stipulates that the U.S. Agency for International Development (USAID) assume leadership of GHI in September 2012, contingent upon fulfilling a set of 10 benchmarks. But what the QDDR does not make clear is exactly what leadership of GHI means. Oomman leaves the administration with three options going forward: move PEPFAR to USAID; keep the GHI at State; or remove PEPFAR from GHI. Read the full piece here and see below for details on the three options:
We know the deadline for the GHI’s transition to USAID is still a year away, but the administration has some difficult decisions to make, and quickly. The President’s global development legacy is at stake if one of his biggest development initiatives is seen to fail. Here are the options, as we see them, along with their respective trade-offs–constraints, costs, and benefits:
1) Move PEPFAR to USAID. Perhaps this option makes the most sense programmatically (unified leadership, horizontal integration with reproductive health, etc)., but it’s a non-starter politically. PEPFAR is protected as an independent structure until its authorizing legislation expires in 2013, and there is no political will to challenge that status quo.
2) Keep the GHI at State. Under this scenario, the State Department would renege on its highly public QDDR plans to move the GHI to USAID, and would maintain control of the initiative under an executive director. State holds some authority over OGAC and could realistically serve as a coordination point between the GHI agencies, as it has done thus far. But there are two good reasons why this scenario doesn’t make sense: 1) global health is not the State Department’s area of technical expertise and the creation of another global health entity in State will be inefficient when plenty of expertise lies elsewhere in the USG. 2) This option could also be a public relations nightmare; the State Department would need to do serious damage control and protect USAID’s reputation. It will need to be clear about its rationale for the decision, emphasizing the structural considerations and why it’s best for the success of the GHI. However, this option will damage the administration’s efforts to build USAID as the premier U.S. development agency.
3) Remove PEPFAR from the GHI. If USAID is to lead the GHI but not PEPFAR, then PEPFAR, operationally, will cease to be a part of the GHI, especially because it has its own reporting line to Congress. If we continue down this path, the administration should formally remove PEPFAR from the GHI portfolio and eliminate the targets for HIV/AIDS treatment and prevention as GHI targets. Under this “efficiency” scenario, USAID would be able to focus its energy on the remaining GHI programs and goals – those which it actually controls – and could be realistically accountable for the corresponding results. However, this course of action would fundamentally alter the original intent and design of the GHI to build on PEPFAR’s “platform” and would demonstrate the unfortunate reality that funds appropriated in a siloed, vertical structure don’t really lend themselves to policy and program level integration . Forfeiting the opportunity to integrate HIV/AIDS programs with reproductive health efforts, for example, will unfortunately turn the GHI in to a more “business as usual” health program approach to global health.