America’s Global Health Programs at a Crossroads

February 26, 2009

President Obama thrilled the global health community during his campaign—he pledged to double foreign aid by 2012, including $50 billion over five years to fight HIV/AIDS. Although he backed off his timetable for doubling aid during the Presidential Debates, it was still rare for a presidential candidate to talk so boldly about the benefits of foreign aid to a skeptical public. The President believes strongly that America’s global interests are best served with a better balance of foreign aid, diplomacy, and defense.

The global health promises are noteworthy because they come on top of President Bush’s record of rapid growth in health programs—his huge global HIV/AIDS program called PEPFAR (President’s Emergency Plan for AIDS Relief), malaria and tropical disease initiatives, safe drinking water, investments in fragile health systems, and expanded medical research.

As the world’s economies shrink in the current crisis, can the President deliver on his promises? Likely not. His new budget for 2010 seeks increases in foreign aid, but at a slower rate of growth than previous years, and with new spending priorities. The challenges of getting more money for foreign aid are daunting:

• America’s collapsing economy makes policy makers look ever inward. Most Americans know little about foreign aid; they think the U.S. gives away more than it actually does; and they think it’s too much. They barely noticed either Obama’s campaign pledge to double aid or his retreat from the promise when asked what he would “scale back” in response to the economic crisis. Americans give generously to humanitarian emergencies, but want government largesse to stay at home when their jobs, health insurance, and homes are at risk. Foreign aid relies heavily on Presidential leadership and bi-partisan Congressional support. The economic crisis will severely test this fragile “coalition.”

• The global recession may force a shift in overseas priorities. The crisis is now seen as a bigger security threat to America than terrorism. Countries important to the U.S. may need financial assistance for the first time and aid may take new forms, e.g. financial support and debt relief for many more failing economies, and a sharp increase in disaster-type aid for food, public health, and refugee emergencies. The President has some new priorities, too. He wants greater investment in counter-terrorism assistance, non-military aid to Afghanistan and Pakistan, and human capital at the State Department and USAID. New priorities mean more competition for limited aid dollars.

• A debate over foreign aid reform may draw attention away from growing resource needs. Obama called for reform of foreign aid to improve coherence, effectiveness, and transparency. These needs are real and reform proponents play key roles in the Administration, but this debate threatens to dominate the policy landscape and compromise the huge challenge of securing funds to pay for all the promised programs.

• A looming fight between global health and poverty-reduction advocates could harm both sides. Many development experts believe that global health receives too large a share of foreign aid at the expense of economic development. Global health advocates are not anti-development, but they will passionately oppose any effort to re-distribute what they have fought for in recent years. A messy fight between these groups risks alienating policy makers who could end up punishing both sides by budgeting fewer total dollars.

• Global health advocates seem headed for a fight of their own over how much to devote to AIDS. Many experts say spending is out of balance with AIDS consuming too much, effectively short-changing high return investments on childhood vaccination and immunization, maternal health, and family planning. Here again, an ugly battle among health advocates could harm everyone.

The details of the President’s budget request won’t be available until April, but the overview released this week is sobering. What will get shortchanged? What is the public appetite for deficit spending to help foreigners? With Bush gone, will Republicans demagogue increases in foreign aid?

Global health advocates cannot afford to fight each other. The environment is too risky. Here are some steps they should take:

1. Stick together. Put the slings and arrows aside and join other foreign aid advocates to focus on the “prize” they have in common—the totality of the President’s foreign aid promises, especially the large funding increases.

2. Make the case. Do a better job of explaining why foreign aid serves the national interest, i.e. by enhancing stability, saving lives, making friends…and making us feel better about ourselves.

3. Go public and to Congress to argue the case. Presidents rarely get all the foreign aid money they request. This year there may be strong arguments for even more than the President seeks. This can only happen if the advocates stay united.

4. Be realistic and don’t burn bridges. Economic conditions are deteriorating rapidly; many political promises will be broken. So, advocates should be civil, persistent, and strategic. They must not harm relationships that will be needed annually in what is a marathon, not a sprint.

5. Postpone fighting among themselves. There will be plenty of time for that once total foreign aid funding is set.

photo credit: USAID, http://gemini.info.usaid.gov/photos/displayimage.php?pos=-181

Allen Moore is a Distinguished Fellow at the Henry L. Stimson Center. He was Policy Director for then Senate Majority Leader Bill Frist, M.D. (R-TN) when Bush’s global HIV/AIDS program was created in 2003.