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Summary Global health is the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable disease, disability, and death. It can be attained by combining population-based health promotion and disease prevention measures with individual-level clinical care. This ambitious endeavor calls for an understanding of health determinants, practices, and solutions, as well as basic and applied research on risk factors, disease, and disability. In the United States, an area of study, research, and practice has emerged to contribute to the achievement of global health. The U.S. global health enterprise involves many sectors (both governmental and nongovernmental) and disciplines (within and beyond the health sciences) and is characterized by intersectoral, interdisciplinary, and international collaboration. U.S. leadership in global health reflects many motives: the national interest of protecting U.S. residents from threats to their health; the humanitarian obligation to enable healthy individuals, families, and communities everywhere to live more productive and fulfilling lives; and the broader mission of U.S. foreign policy to reduce poverty, build stronger economies, promote peace, increase national security, and strengthen the image of the United States in the world. The U.S. government, along with U.S.-based foundations, nongovernmental organizations, universities, and commercial entities, can take immediate concrete action to accelerate progress on the urgent task of improving health globally by working with partners around the world to scale up existing interventions, gen - erate and share knowledge, build human and institutional capacity, increase and fulfill financial commitments, and establish respectful partnerships. 

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 THE U.S. COMMITMENT TO GLOBAL HEALTH SCOPE OF THE REPORT The Institute of Medicine (IOM)—with the support of four U.S. govern - ment agencies and five private foundations—convened an expert committee to investigate the U.S. commitment to global health and articulate a vision for future U.S. investments and activities in this area. While global health encompasses the health of everyone (including U.S. citizens) and is a shared global aspiration that requires the work of many nations, this report focuses on the efforts of the United States, both its governmental and its nongovernmental sectors, to help improve health in low- and middle-income countries. The committee examined whether the existing architecture, investments, and activities of the U.S. global health enterprise are optimally geared to achieving significant, sustainable, and measurable global health gains. This report commu - nicates specific recommendations, not just for the U.S. government, but also for several nongovernmental sectors, including foundations, universities, nonprofit organizations, and commercial entities. Because health is inextricably connected to the broader goals of hastening development and reducing poverty, the committee recognizes that any action taken by the United States to support global health should be tied directly to broader discussions of U.S. commitments to global economic and human devel - opment, as well as the environment. The committee also recognizes that while the United States has the opportunity to support and advocate for a global plan to improve health, ultimately individual countries—both governments and civil society—are responsible for putting in place the social and economic policies that protect the health of their populations. U.S. CONTRIBUTION TO GLOBAL HEALTH IMPROVEMENTS Health achievements in the last 50 years have been remarkable. Globally, life expectancy has increased more in this period than in the preceding 5,000 years. The creation, dissemination, and adoption of knowledge have been among the main drivers of these health gains, delivering marked improvements in low- and middle-income countries that have invested in sustainable and equitable systems to deliver proven, cost-effective interventions. Both governmental and nongovernmental sectors in the United States have been an important source of global health knowledge, providing the scientific basis for many health successes worldwide through their research and capacity building efforts. The United States—in partnership with local communities, gov - ernments, and international organizations—has also played a critical role in the dissemination and adoption of knowledge by providing the financial and technical resources to expand public health infrastructure and access to health interventions in many countries, resulting in major public health achievements.

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 SUMMARY RECOMMENDATIONS FOR IMPROVED GLOBAL HEALTH The United States now has an unprecedented opportunity to improve global health. The promise of potential solutions to global health problems has captured the interest of a new generation of philanthropists, students, scientists, healthcare professionals, private sector leaders, and citizens—all eager to make a difference in this interconnected world. At the same time, the U.S. government has made record financial commitments to global health programming, for which the sup - port of the American people has been crucial. Neither the U.S. government nor any one U.S. organization can achieve global health by acting alone. Progress toward this goal requires the collabora - tion of all countries, donors, and recipients of aid to develop, finance, and deliver essential and cost-effective health interventions. The United States can, however, lead by setting an example of meaningful financial commitments, technical excel- lence, and respectful partnership. The committee examined many ways in which the United States, includ- ing the U.S. government and the nongovernmental sector, could contribute to advances in global health. The committee pursued those areas that draw on U.S. technical and scientific capabilities to generate knowledge; maximize growing involvement by the U.S. government, universities, foundations, and commercial entities; and address a significant deficiency in advancing global health. The com - mittee identified five areas for action by the U.S. global health enterprise: 1. Scale up existing interventions to achieve significant health gains. 2. Generate and share knowledge to address health problems endemic to the global poor. 3. Invest in people, institutions, and capacity building with global partners. 4. Increase U.S. financial commitments to global health. 5. Set the example of engaging in respectful partnerships. SCALE UP ExISTING INTERVENTIONS TO ACHIEVE SIGNIFICANT HEALTH GAINS The global health community has reached a critical juncture. The knowledge, innovative technologies, and proven tools to help millions of people in need are within reach. Yet even with demonstrated success in tackling certain health issues, a wide gap remains between what can be done with existing knowledge and what is actually being done. Existing interventions are not widely used even though many are inexpensive and easy to administer. Support the Millennium Development Goals by 2015 The globally recognized Millennium Development Goals (MDGs) were adopted by the Member States of the United Nations (UN) in 2000 to achieve

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 THE U.S. COMMITMENT TO GLOBAL HEALTH demonstrable reductions in poverty and improve specific health and social out - comes by 2015. Three of the eight goals pertain directly to health (Goal 4: Reduce child mortality; Goal 5: Improve maternal health; and Goal 6: Combat HIV/AIDS, malaria, and other diseases) and the other five, indirectly. While prog - ress has been made, the MDG targets remain a distant goal for many countries, particularly in sub-Saharan Africa and parts of South Asia. Recommendation 2-1. As part of a comprehensive approach to develop- ment and poverty reduction, the United States, both its governmental and its nongovernmental sectors, should support the UN’s Millennium Development Goals. In particular, the United States should partner with countries to pro - mote and finance the application of existing knowledge and tools to achieve the health-related MDGs by 2015 with special attention to areas that are lagging behind. (See Recommendation 5-1 for funding proposal.) Prepare for Emerging Challenges of the Twenty-first Century The timeless health problems associated with poverty are now coupled with new challenges. Infectious diseases are emerging at the historically unprecedented rate of one per year. With airlines now carrying more than 2 billion passengers annually and systems of trade more interconnected than in any time in human history, opportunities for the rapid international spread of infectious agents and their vectors have vastly increased. The recent spread of H1N1 influenza (swine flu) to more than 20 countries in the span of a few weeks highlights the speed at which new threats can travel. The rising tide of chronic diseases and injuries in low- and middle-income countries, where 80 percent of the world’s deaths from chronic, noninfectious diseases now occur, also cannot be ignored. Recommendation 2-2. The United States should partner with the global community to prepare for emerging challenges of the twenty-first century by increasing attention to pandemic infectious threats, noncommunicable diseases, and injuries. The U.S. government should demonstrate leadership in this area by adopting clear goals—such as improving global disease surveil - lance, decreasing deaths from tobacco-related illnesses, and reducing injuries from accidents—to guide U.S. global health investments. (See Recommenda- tion 5-1 for a detailed funding proposal.) Address Neglected Health Systems The drive to produce results for the MDGs and other health goals has led many donors to focus on specific disease outcomes. Yet undermining all efforts to reduce disease burden is the stress on health systems in low- and middle-income countries. Functional health systems—including access to adequate financing;

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 SUMMARY public health infrastructure and programming; essential medical products, vac - cines, and technologies; a well-performing health workforce; reliable and timely health information; and strategic policy frameworks to provide effective analysis, oversight, management, and governance—are sorely lacking in most low-income countries. Given the emergency conditions prompting the initial global response to AIDS, for example, it is not surprising that donors chose to circumvent exist - ing weak components of national health systems to set up programs devoted to immediate and demonstrable results. While this focus on specific diseases has led to significant health outcomes related to these diseases, the programs have sacrificed opportunities to strengthen local health systems. Recommendation 2-3. When delivering health assistance, federal executive branch agencies and departments should work with Congress to make U.S. government global health programs less formulaic and more performance- based, to permit resources to be used more easily within unique national health systems with the explicit objective of promoting stronger national health sys- tems and a better trained, more productive health workforce. GENERATE AND SHARE KNOWLEDGE TO ADDRESS HEALTH PROBLEMS ENDEMIC TO THE GLOBAL POOR One of the greatest contributions the United States can offer to the global campaign to improve health is to share America’s traditional strength—the cre - ation of knowledge—for the benefit of the global poor. The United States has a distinguished record in the generation of knowledge, spending more in this area than any other country. The United States and other wealthy nations focus the majority of their research resources on conditions that affect people within their own borders. As a result, diseases or conditions that are overwhelmingly or exclu- sively incident in low- and middle-income countries are often neglected. While the U.S. research community—comprised of the U.S. government, universities, commercial entities, public-private partnerships, and other non- profit organizations—has increased its research contributions to benefit global health (especially to combat AIDS, malaria, and tuberculosis), it is not currently mobilized to reach its full potential. The growing number of public-private part - nerships and university-based collaborative research models devoted to global health demonstrates the growing interest and untapped demand within the U.S. research community to engage with partners in addressing the health needs of the global poor.

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 THE U.S. COMMITMENT TO GLOBAL HEALTH Strengthen Knowledge on the Adoption and Dissemination of Existing Interventions The systemic bottlenecks in the health systems of low- and middle-income countries (such as poor surveillance systems, bottlenecks in drug supply pipe - lines, and chronic deficits in the health workforce) prevent the full benefits of existing public health knowledge and technologies from being realized. Research on healthcare systems is required to mitigate these effects. Currently, few pro - grams that deliver specific health interventions undergo rigorous evaluation. If U.S. efforts are to achieve sustainable and far-reaching outcomes, the importance of knowing what works is critical. Recommendation 3-1. The U.S. research community should increase research and evaluation efforts to address the systemic bottlenecks in health systems in low- and middle-income countries that keep the full benefits of existing medical and public health knowledge and technologies from being completely realized. (A) The U.S. research community should expand its research efforts through increased attention to health systems research (both for studies that can be generalized across countries and for operational and imple - mentation studies that are culturally and contextually relevant). (B) In addition to measuring inputs (such as dollars spent) and out- puts (such as drugs delivered), Congress and other global health funders should require that efforts to deliver health interventions be accompanied by rigorous country- and program-level evaluations to measure the effect of global health programs on saving lives and improving health. Continue Research to Develop Novel Health Technologies and Interventions Global health would greatly benefit from developing and disseminating a variety of novel behavioral and biomedical prevention strategies to combat infec - tious diseases. Antiquated diagnostics and treatments also need to be improved to achieve sustainable results in the management and control of disease and to reduce drug resistance that results from misdiagnosis or poor adherence to treat - ment regimens. One of the most promising approaches to bridge the enormous and widening gap in the availability of drugs, vaccines, and diagnostics to deal with the global disease burden is the advent of public-private product development partnerships (PDPs). This novel approach, coupled with U.S. expertise in science and bio - medical research, strong U.S. financial commitments (through funding from the National Institutes of Health [NIH] and the U.S. biomedical and pharmaceutical industry), and the synergies that exist when the government works in partnership

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 SUMMARY with the nongovernmental sector, can yield technologies and interventions to revolutionize global health. Recommendation 3-2. The U.S. research community, in collaboration with global partners, should leverage its scientific and technical capabilities to conduct research using state-of-the-art technology and innovative strategies to address health problems endemic to low- and middle-income countries. (A) The U.S. research community should continue to examine new inter- ventions for the prevention and treatment of global infectious diseases. (B) The U.S. research community should expand its research efforts in global health with heightened attention to two purposes: (1) to study the basic mechanisms of diseases that disproportionately affect the global poor, and (2) to identify means to control communicable and noncom - municable diseases by adapting existing knowledge for low- and middle- income countries. Share Knowledge that Enables Local Problem Solvers Research on global health involves not only generating knowledge rel- evant to the context of low- and middle-income countries, but also effectively transferring such knowledge and technologies to these settings and ensuring that its intended beneficiaries can apply it on a sustained basis. With research increasingly conducted globally through virtual communities of geographically dispersed scientists, it is critically important that information exchange promote sustainable cross-country research partnerships and enable the timely dissemina - tion of best practices. Recommendation 3-3. The U.S. research community should promote global knowledge networks and the open exchange of information and tools that enable local problem solvers to conduct research to improve the health of their own populations. (A) Funders of global health research should require that all work sup- ported by them will appear in public digital libraries, preferably at the time of publication and without constraints of copyright (through open access publishing), but no later than six months after publication in traditional subscription-based journals. Universities and other research institutions should foster compliance with such policies from funding agencies and supplement those policies with institution-based repositories of publica - tions and databases. (B) The U.S. government, universities, and other research institutions should develop new methods—such as simplified web-based procedures

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 THE U.S. COMMITMENT TO GLOBAL HEALTH for executing agreements like materials transfer and nondisclosure agreements—to expedite the sharing of information and research materials with researchers in low- and middle-income countries. (C) Scientists, clinicians, advocates, and other personnel involved in defined areas of global health should develop trustworthy websites that aggregate published literature, incorporate unpublished databases or clini- cal trial information, promote digital collaboration, and disseminate news and other information about common interests. (D) Universities and other research institutions that receive federal and philanthropic funding to conduct research should adopt patent policies and licensing practices that enable and encourage the development of technologies to create products for which traditional market forces are not sufficient, such as medicines, diagnostics, and therapeutics that primarily affect populations in low- and middle-income countries. INVEST IN PEOPLE, INSTITUTIONS, AND CAPACITY BUILDING WITH GLOBAL PARTNERS Although the United States can offer partial solutions to help resolve the challenges that low- and middle-income countries face in delivering basic health services, these countries require capable local leaders, analysts, researchers, and practitioners to identify problems and solutions that work and are sustainable in their own countries. Unlike the United States, where academia, nonprofit orga - nizations, and commercial entities play an important advisory role in domestic U.S. healthcare policy, in low- and middle-income countries, universities, science academies, and the research community are often absent from policy engagement. As a result, this community has been neglected as a partner by many external donors. Expand Commitment to Institutional Capacity Building The United States has an opportunity to address the neglect of universities and the research community in low- and middle-income countries by leveraging the growing involvement of U.S.-based universities, corporate entities, and foun - dations in global health by supporting institutional partnerships across nations. Such collaboration will not only strengthen capacity in leadership, research, teaching, and patient care for all the institutions involved, it will also create incen- tives for researchers and practitioners to stay in their home countries, by produc - ing a workplace environment conducive to continuing education and enhanced career opportunities.

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 SUMMARY Recommendation 4-1. Federal executive branch agencies, along with U.S. private institutions, universities, nongovernmental organizations, and com - mercial entities, should provide financial support and engage in long-term and mutually advantageous partnerships with institutions—universities, public health and research institutes, and healthcare systems—in low- and middle-income countries with the goal of improving institutional capacity. These partnerships should enable local and global problem solving and policy engagement by • Investing in training, • Creating an enabling institutional environment, • Funding a steady stream of diverse research grants, • Generating demand for scientific and analytical work that influences public policy, and • Contributing to the control of real and immediate health problems. Rectify the Health Workforce Crisis Institutional partnerships between organizations in low- and middle-income countries and the United States provide an opportunity to address the critical workforce deficits that hinder the achievement of health-related MDGs. Beyond the shortage of health workers, public health systems in these countries also lack capacity due to weak civil service and absenteeism, with limited incentives for good performance (including low salaries that lead to income supplementation strategies such as informal payments and dual-practice in the private sector). Underperforming market systems also typically have weak government capacity to regulate the quality of providers, leading to particularly insidious outcomes, such as price gouging and unnecessary or harmful care. The same poor working conditions that have created disincentives for health workers to perform at the highest level have also pushed many health profession - als in low- and middle-income countries out of the public sector. Many choose to emigrate to high-income countries that are experiencing a health workforce shortage. However, the committee finds that global migration is neither the main cause of, nor would its reduction be the main solution to, the worldwide human resource crisis in health. Attempts to merely increase the supply of workers by restricting emigration visas or reversing migration might have a modest effect on the numbers, but would not solve the problem and would put unnecessary restric- tions on the right of workers to migrate. National health resource plans that go beyond simply increasing the number of health workers and endeavor to understand and improve the dynamics of the labor market have been successful in stemming the tide of workforce migration and in recruiting and retaining labor for underserved areas. While such plans

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0 THE U.S. COMMITMENT TO GLOBAL HEALTH require commitments by governments to construct and finance sound human resource plans, the success of these plans is often dependent upon external donor assistance and cooperation. Recommendation 4-2. Federal executive branch agencies and departments, nongovernmental organizations, universities, and other U.S.-based organiza- tions that conduct health programs in low-income countries should align assistance with the priorities of the national health sector human resource plans and should commit and sustain funding in support of these plans. Recommendation 4-3. Congress should work with federal executive branch agencies and departments and U.S. universities to explore opportunities to leverage the U.S. workforce to contribute to solutions that partially address health workforce deficits in low- and middle-income countries. This explora- tion should include an inquiry into the willingness of Americans to partici - pate in a global health service corps; a determination of whether this kind of assistance would be well received by recipient countries; and an examination of whether specific opportunities exist to help migrants from low-income countries return home to work temporarily or permanently. INCREASE U.S. FINANCIAL COMMITMENTS TO GLOBAL HEALTH Given the severe resource constraints in low-income countries, their progress toward meeting the MDGs by 2015 will require increased and sustained foreign assistance for health care from the advanced economies. Over the last decade, the U.S. government has made record commitments to global health. Between 2001 and 2008, global health programming through the U.S. Agency for International Development (USAID) and the State Department grew by nearly 350 percent. As a result, health now makes up a significantly larger portion of both the U.S. foreign affairs budget and the overall overseas development assistance (ODA) budget. The extraordinary increase in the percentage of U.S. aid for health was driven mostly by new models of assistance, such as the Global Fund to fight AIDS, Tuberculosis, and Malaria; the President’s Emergency Plan for AIDS Relief (PEPFAR); and the President’s Malaria Initiative. In May 2009, President Obama announced the Global Health Initiative and requested that Congress provide $63 billion in appropriations for global health over the next six years (2009-2014). The proposal calls for an increase in funding from $8.186 billion in FY 2009 to $8.645 billion in FY 2010. Meet Existing International Aid Commitments The committee commends the increased U.S. spending on global health. The U.S. commitment to overall ODA, however, is less impressive. It is less than the

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 SUMMARY efforts of other high-income countries in relative terms and is among the lowest levels of net ODA as a percentage of gross national income (GNI). Even when private giving is included, per capita spending by the United States does not approach the level of most other wealthy nations. Meeting the MDGs would require advanced economies to devote 0.54 per- cent of their GNI to ODA, as determined by the UN Millennium Project. Accord - ingly, the committee estimates that the U.S. contribution to the health-related MDGs would be $13 billion per year by 2012. This level of spending, although still below the capacity of the United States and the overall resources needed for health, is justified on the basis of international norms and commitments. Additional resources will be required to respond to the contemporary chal - lenges of chronic and noncommunicable diseases and injuries, which are respon - sible for more than half of the deaths below age 70 in low- and middle-income countries but are not captured in the health-related MDGs. Cost-effective strate - gies, such as tobacco control, hold the promise of averting millions of premature deaths in these countries. Recommendation 5-1. The President and Congress should commit to invest- ing $15 billion in global health by 2012, with $13 billion of this directed to the health-related MDGs and an additional $2 billion to the challenges of noncommunicable diseases and injuries. (See Chapter 5 for more detailed recommendations.) (A) While pursuing the goal of $13 billion per year for the health-related MDGs, federal executive branch agencies should work with Congress to create balance in the traditional portfolio of global health spending that reflects the breadth of the health-related MDGs. (1) Congress should fulfill its implied commitments under PEPFAR reau- thorization to global AIDS programs ($7.8 billion per year), malaria ($1 billion per year), and tuberculosis ($800 million per year). (2) The U.S. government should use the remaining $3.4 billion per year to support programs such as health systems strengthening, children and women’s health, nutrition, family planning and reproductive health, and neglected diseases of poverty, all of which have been severely underresourced during the past decade. (3) Given concerns that PEPFAR costs could crowd out other equally important global health initiatives, the U.S. government should main- tain funding for ARV treatment for individuals already supported by PEPFAR but should also act diligently to ensure that the program prevents as many HIV infections as possible. (B) Federal executive branch agencies and departments—particularly the Centers for Disease Control and Prevention, the NIH, and USAID—

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 THE U.S. COMMITMENT TO GLOBAL HEALTH should work with Congress to identify specific ways to respond to the contemporary challenges of noncommunicable diseases and injuries and should commit to investing $2 billion for this purpose by 2012. Continue Strong U.S. Commitment to Fund Global Health Research The appropriate mix of health spending for care delivery and for research should be weighed against the requirements of combating a particular disease and the unique health needs of a local population. However, including research in health assistance can only increase its effectiveness. In the spirit of the 2008 Bamako Call to Action on Research for Health (which urged international development agencies and major funders to allocate 5 percent of global health development assistance for health research), the committee recommends that aid be flexible and allow for the funding of research to be conducted through the foreign affairs budget as it supports improvements to health in low- and middle-income countries. Recommendation 5-2. Federal executive branch agencies and departments should work with Congress to design a coordinated approach to funding global health research that leverages research subsidies through the Depart - ment of Health and Human Services budget and innovative funding mech- anisms for novel vaccine, drug, and diagnostic procurement through the foreign affairs budget. SET THE ExAMPLE OF ENGAGING IN RESPECTFUL PARTNERSHIP The U.S. government—the largest funder of many international organiza- tions and a significant donor of bilateral aid in some countries—carries consider- able influence in shaping the global health environment. While the global health community faces many complex questions about governance that will not be resolved by any one country acting alone, many opportunities exist for the United States to be an effectual leader, respectful partner, and good steward for health at both the national and the global levels. Support and Collaborate with WHO The flourishing global health community is vast and diverse and is greatly in need of effective leadership. While the proliferation of new participants in this field, such as PDPs and foundations, is a welcome development that brings with it fresh resources and innovation, global health activities will remain ad hoc, duplicative, and highly fragmented unless the different initiatives and agendas are coordinated through effective leadership. With so many committed partners based in different countries dedicated to improving global health, leadership would ideally be provided through a single

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 SUMMARY organization with a mandate for setting evidence-based norms on health-related technical and policy matters. Although not perfect, the World Health Organization (WHO) is such an organization, and if it did not exist, a similar one would have to be created—to lead a coordinated response to epidemic influenza, for example. The committee finds that the United States has much to gain from supporting WHO, despite the fact that many aspects of its current structure and function hinder its effectiveness. Recommendation 6-1. The U.S. government should support WHO as a leader in global health by paying its fair share of the organization’s budget and providing technical expertise to WHO, as requested. However, it should also request a rigorous external review of the organization to develop future- oriented recommendations that maximize its effectiveness. (See Chapter 6 for more detailed recommendations.) Align Aid with Country-Led Health Plans The effects of the proliferation of new participants in global health are perhaps most acutely seen at the national level. Low-income countries typically receive aid from multiple global agencies, resulting in overburdened health ministries. Given that a majority of investments are delivered and managed through local nongovernmental organizations operating outside the recipient government’s budgeting system, many countries struggle to maintain control of their own health priorities. Countries with weak control of their health systems lose the incentive and ability to create and support their own sustainable plans. Recommendation 6-2. To ensure that countries retain ownership and accountability for the health of their populations and to promote long-term sustainability, donors should support recipient countries in developing results- focused, country-led agreements that rally all development partners around one country-led health plan, one monitoring and evaluation framework, and a unified review process. Donors should also aim to build local capacity to regulate and integrate local private sector participants in the government’s health plan. Recommendation 6-3. To reduce the burden on countries in coordinating donor efforts around a basic health plan, all funders of global health should strive to deliver a greater proportion of aid in support of technically and financially sound country-led health plans provided on the premise that the recipient government implements agreed-upon strategies in a transparent fashion.

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 THE U.S. COMMITMENT TO GLOBAL HEALTH CALL TO ACTION At this historic moment, the United States has the opportunity to advance the welfare and prosperity of people within and beyond its borders through intensi - fied and sustained attention to better health. Even as the U.S. economy is under pressure, attention to global health remains essential. The financial policies and practices of the wealthiest nations, including the United States, are having painful consequences in low- and middle-income countries. During economic downturns, the health of a country’s population worsens due to lowered household income and reduced access to health care. Moreover, the poor in low- and middle-income countries are most affected because they pay a large portion of their healthcare costs out-of-pocket, without the benefit of social safety nets. It is therefore crucial for the reputation of the United States that the nation live up to its humanitar- ian responsibilities, despite current pressures on the U.S. economy, and partner with low- and middle-income countries in safeguarding the health of their most vulnerable members. Global Health Is a Responsibility and an Opportunity to Be Seized Health is a highly valued, visible, and concrete investment that has the power to both save lives and enhance the image of the United States in the eyes of the world. Through its policies and actions, the United States can take this opportunity to demonstrate that it fundamentally believes in the value of better health for all. Recommendation 7-1. The President should highlight health as a pillar of U.S. foreign policy. The U.S. government should act in the global interest, recognizing that long-term diplomatic, economic, and security benefits for the United States will follow. Priorities should be established on the basis of achieving sustained health gains most effectively, rather than on short-term strategic or tactical U.S. interests. Need for Coherent Strategy for U.S. Government Involvement in Global Health If health is to hold a more prominent position in U.S. foreign policy, the U.S. government will need to increase coordination among the multiple agencies and departments engaged in global health. The 1997 IOM report America’s Vital Interest in Global Health called for the establishment of a government Inter- agency Task Force on Global Health, led by the U.S. Department of Health and Human Services. The committee supports this recommendation in principle, but recommends that the interagency group be located more centrally, in the White House. Locating the effort in the White House, potentially within the National

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 SUMMARY Security Council (NSC) and reporting to the President through the NSC adviser, would give it convening authority among sometimes competing agencies and the ability to make policy recommendations directly to the President. Recommendation 7-2. Within the first year of his administration, the Presi- dent should create a White House Interagency Committee on Global Health to lead, plan, prioritize, and coordinate the budgeting for major U.S. govern - ment global health programs and activities. The President should also desig - nate a senior official at the White House (Executive Office of the President, potentially within the NSC) at the level of deputy assistant to the President for global health to chair this interagency committee. Call for Summit to Highlight U.S. Commitment to Global Health Working with partners around the world and building on previous commit- ments, the United States has the responsibility and chance to save and improve the lives of millions; this is an opportunity that the committee hopes the United States will seize. Recommendation 7-3. In recognition of the partnership needed to achieve global health, the President should call together world leaders for a summit meeting at the UN General Assembly General Debate and the meeting of the G20 in September 2009 to announce a commitment to the overall funding levels recommended in this report ($15 billion spent annually by 2012) and to emphasize the importance of the closely related issues of food and water security. In the interest of sovereignty and sustainability, the President should also ask low- and middle-income countries to commit publicly to providing additional resources by 2012 to finance their own health initiatives.

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