The U.S. Commitment to Global Health: Recommendations for the Public and Private Sectors (2009)

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6 Set the Example of Engaging in Respectful Partnerships The profusion of new players in the field of global health—such as philan- thropies, nongovernmental entities, and public-private partnerships—has brought great energy, resources, and innovation to the field. Yet without global leadership and a coherent, unifying strategy to guide the actions of all these participants, a critical opportunity to improve global health could now be missed. The gov - ernance challenges involved are complex and cannot be addressed by any one country acting alone. However, the United States can do much to shape the health environment—for example, by setting norms to define the partnership between donors and recipients and improving coordination across all parties working on the ground to avoid burdening recipient countries with a proliferation of unco - ordinated initiatives. GLOBAL HEALTH GOVERNANCE1 The global health community—comprising more than 40 bilateral donors, 26 United Nations (UN) agencies, and 20 global and regional funds, all support - ing more than 90 global health initiatives—is now burgeoning with the entry of many new organizations engaged in global health (Alexander, 2007). Powerful new philanthropies and other nonstate organizations are affecting the direction of global health programs and policies in dramatic ways. The Gates Foundation, which has firmly established its place on the global health governance map by mobilizing resources for innovative financing mechanisms and product develop- 1 Inpreparing this section of the report, the committee drew heavily on the background paper prepared by Mr. Lawrence Gostin and Ms. Emily Mok (see Appendix E).  

 THE U.S. COMMITMENT TO GLOBAL HEALTH ment, has already spent approximately $9 billion on health projects since 1998 (McCoy et al., 2009). States and intergovernmental organizations have sometimes joined forces with nongovernmental organizations (NGOs) to address global health problems, forming public-private partnerships (PPPs), or “hybrid” organizations. About 75 to 100 global health PPPs focused on both implementation and research now exist worldwide (High-Level Forum on the Health MDGs, 2005; WHO, 2007a). Two PPPs that are changing the global health landscape and using new financing mechanisms to generate a large percentage of new funds for global health are the Global Fund to fight HIV/AIDS, Tuberculosis, and Malaria (the Global Fund) and the Global Alliance for Vaccines and Immunization (GAVI). All these participants in global health bring considerable resources to bear on the direction of global health policy. Yet because they answer to different stakeholders, their approaches are tied to institutional preferences, orientations, or biases and are often inconsistent with each other. Although there is now an emerging practice of establishing systems to monitor and evaluate their actions, the various organizations engaged in global health generally participate on a voluntary basis, with no mechanisms to enforce the achievement of goals. Coor- dination, accountability, and the most effective use of resources to support global health thus remain serious concerns, underscoring the need to think anew about strategies for global health governance (Gostin and Mok, 2008). The traditional system of international health governance, relying primarily on nations and intergovernmental organizations, is clearly inadequate in the new global health context (Dodgson et al., 2002). Organizations such as the World Health Organization (WHO) and the UN are comprised of member countries; while nonstate participants are recognized and engaged to some degree by both, they cannot vote in formal decision-making processes. At the country level, traditional mechanisms of bringing together external donors have neglected to engage NGOs and private sector providers, even though they play a crucial role in financing and delivering care. A space needs to be created for all relevant NGOs—including civil society and private entities—to be part of legitimate agenda-setting processes at the global and national levels (Gostin and Mok, 2008). While this proliferation of new participants is a welcome development that brings potentially great wealth and creativity into the global health arena, the response to vital challenges will remain ad hoc and highly fragmented unless their different initiatives and agendas are coordinated through effective global health leadership. The United States is well positioned to promote such coordina- tion by taking the steps detailed below. Indeed, if the goals of U.S. global health investments are to be realized, such U.S. collaboration with the global health community will be essential. 

 SET THE EXAMPLE GLOBAL PARTNERSHIP The U.S. government interacts with multiple UN agencies and other inter- governmental bodies on issues related to health, including the World Bank, the International Monetary Fund, GAVI, the Global Fund, UNITAID, the United Nations Children’s Fund (UNICEF), and UNAIDS, and wields considerable influ- ence in virtually all multilateral institutions, through both offering (or withhold - ing) dues and voluntary contributions and deploying its political and technical stature. The committee finds that the United States has much to gain from sup - porting WHO and sees a unique opportunity for U.S. leadership in strengthening this global body. For achieving a large set of global health goals, WHO is the most important multilateral agency with which the United States has a relationship. WHO is widely seen by low- and middle-income country health officials as the authorita - tive source for technical guidance, and it is the “home base” for generation of a broad set of health-related global public goods, from the International Health Regulations (IHR) to support for disease surveillance to collection and dissemina- tion of data about health system performance. What WHO says and does matters greatly for health in resource-limited nations, and what the United States says and does in its governance role and as a major funder of WHO matters greatly for that institution. Thus, one of the key U.S. assets in advancing global health is its relationship with WHO. Support and Collaborate with WHO WHO is uniquely positioned to provide global health leadership by virtue of its role in setting evidence-based norms on technical and policy matters, high - lighting best practices that improve health globally, and monitoring and coordi - nating action to address current and emerging global health threats. Examples of these can be seen in many areas. WHO played a crucial role in the response to the global tobacco epidemic. The agency adopted the Framework Convention on Tobacco Control (FCTC) in 2003, raising worldwide awareness of the dangers of tobacco. Although the United States has yet to ratify the convention, 164 countries have done so and have taken significant steps to reduce tobacco usage globally. WHO’s work in this area has influenced governments as well as independent philanthropic organizations within the United States, guiding their investments in sound and cost-effective health strategies. When New York City Mayor Michael Bloomberg recently joined forces with the Gates Foundation to commit $500 mil - lion to WHO’s program to reduce smoking in 15 countries where more than two- thirds of the world’s smokers live, his philanthropic program selected countries per the FCTC’s protocol and adopted its first six initiatives (Myers, 2008). In this 

 THE U.S. COMMITMENT TO GLOBAL HEALTH case, WHO’s evidence-based norms on technical and policy matters successfully guided private investment for greater impact. WHO also plays a vital role in global health governance by monitoring and coordinating action to address current and emerging global health concerns. Once threats have been identified, WHO provides evidence-based advice on technical and policy matters, such as the IHR, which countries must follow to identify and control disease outbreaks. To many countries in Africa, Asia, and South America, WHO is a trusted and invaluable resource for ongoing technical advice on current health issues. If this international agency did not already exist, it would have to be created. Unfortunately, however, the primacy of this organization has declined in recent decades. At the same time, other intergovernmental organizations, such as the World Bank, the World Trade Organization, UNICEF, and the United Nations Development Programme (UNDP), have emerged as important participants in the realm of global health (see Box 6-1) (Dodgson et al., 2002). WHO was created 60 years ago, in a very different era. Today, many aspects of the organization’s structure and function hinder its ability to provide effective leadership. Improving these mechanisms may require collaboration at the highest levels of the UN to clearly articulate the division of power among the numer- ous agencies working on global health, such as the World Bank and the United Nations Population Fund (UNFPA), and demonstrate commitment to WHO as the leading technical agency in global health. The creation of UNAIDS and UNFPA as UN priority initiatives outside the WHO structure demonstrates a lack of con - fidence in WHO to lead across UN agencies. So while many multilateral organizations are also crucial players in the health arena, the United States, along with the international community, should support WHO’s leadership position in global health. To this end, the United States should pay its fair share of the organization’s core budget and provide technical expertise, while also requesting a rigorous external review of the agency. Support Rigorous External Review The UN is currently undergoing a reform process, initiated in 1997 by then Secretary-General Kofi Annan and continued by his successor, Secretary-General Ban Ki-moon. This self-assessment is an important effort to “breathe new life and inject renewed confidence into a strengthened United Nations . . . which is effec- tive, efficient, coherent and accountable” in facing today’s growing humanitarian, health, and environmental challenges (UN, 2008). Yet at a time when WHO is struggling to work with more and more nongovernmental participants, coordi - nate its activities over multiple UN agencies, and reassert control over the global health agenda, it needs strengthening that goes beyond an internal assessment. Although this report is not prescriptive of a role for WHO, it does recom - mend an honest reassessment of the agency’s role and comparative advantages. 

 SET THE EXAMPLE BOX 6-1 Strengthen the World Bank’s Comparative Advantage Recognizing the connection between public health and its own mission of reducing poverty by investing in people in low- and middle-income countries (Abbasi, 1999), the World Bank moved beyond its core financier operations and launched the implementation of “a whole array of health initiatives . . . bringing new money and fresh ideas to tackle disease” (Gostin and Mok, 2008; Yamey, 2002). The combination of the World Bank’s financial power with aggressive health ini- tiatives led many observers to believe that the World Bank would displace WHO as the “premier global health agency” (Yamey, 2002). During the 1990s, this seemed possible because WHO had become stagnant in its international role. WHO did come to be sidelined, playing only a supporting role by providing medical expertise and technical support, while the World Bank worked on health initiatives with the ministries of health, finance, and planning in low- and middle-income countries (Abbasi, 1999; Gostin and Mok, 2008). In an attempt “to find its footing on shifting ground in global health” (Levine and Buse, 2006), the World Bank reevaluated its health sector strategy in 2007. The new strategy aims to enhance the World Bank’s capacity toward its comparative advantages and the less popular global health issues—such as health system strengthening at the country level, including financial sustainability, regulatory frameworks, and good governance in the health sector—as areas in which it has strengths to generate knowledge, provide policy and technical advice, and provide funding (Levine and Buse, 2006; Ruger, 2007). The strategy also reinforces recent attempts by UN agencies at a collaborative division of labor with global partners, leaving functions such as the technical aspects of disease control and human resource training in health to organizations such as WHO, UNICEF, and UNFPA (Gostin and Mok, 2008; Ruger, 2007). The United States should support the World Bank’s strategy of narrowing its focus to its traditional strengths in advising governments on strategic planning and health sector priorities, especially in light of the recent economic downturn. The World Bank is best positioned to assist low-income countries by maintaining and increasing spending in the health sector. In response to the current economic crisis, the agency is planning to triple its health loans from the $950 million ap- proved in 2008 to about $3 billion in 2009, while advising countries to spend on specific programs (such as nutrition for pregnant women and child immunization) aimed at populations that are most vulnerable during economic downturns. The committee advocates an early review of the organization and its six semi- independent regional offices, all of which have different strengths and weak - nesses. The U.S. government should support a rigorous, multinational, external review of WHO, with a view to producing future-oriented recommendations as part of broader UN reforms to ensure that the organization is appropriately struc - tured and funded to meet the global health challenges of the twenty-first century. 

 THE U.S. COMMITMENT TO GLOBAL HEALTH The goals of such a review would be to strengthen WHO’s normative role and to encourage WHO to play a larger role in ensuring coherence within the UN system as it relates to global health. Recommending such an independent, external review of a UN agency would not be unprecedented. In 2005, the Food and Agriculture Organization (FAO) agreed to undergo an Independent External Evaluation (IEE) to ensure that the agency was able to respond to the global food and agriculture needs of the twenty-first century. The evaluation was undertaken by a team of independent consultants, with oversight provided by a committee of the FAO Council for the IEE (FAO, 2007). A similar review could assist WHO in transforming itself into a global health leader that is well prepared for the challenges of the twenty-first century. The review could also include a broader investigation of WHO’s role within the UN and the potential for increased attention to health within the UN Office of the Secretary General. Pay Fair Share of WHO Budget WHO is woefully underresourced. The agency’s core budget—decided on by member states through democratic mechanisms—has been declining in real terms for almost a decade (Levine, 2006). At the same time, WHO faces a growing need to compete with other international agencies for the financial support of member nations and the nongovernmental and commercial sectors. The ongoing practice by member states of primarily funding outside the WHO core budget—which receives only 28 percent of non-earmarked funds, while 72 percent goes into specific programs2 that donors can control and claim credit for—has transformed WHO into a very “donor-driven” organization with increasingly fragmented and compartmentalized programs (Gostin and Mok, 2008; WHO, 2007b). This has also led to “unhealthy competition among departments within the WHO” (People’s Health Movement et al., 2008) and restricted the organization’s ability to direct and coordinate a forward-looking agenda (Burci and Vignes, 2004). Given all of these factors, WHO’s financial struggle hinders its ability to promote institutional leadership against the pressures of state sovereignty and to advance the application of its legal powers (Gostin and Mok, 2008; Taylor, 2004). Without the economic power to ensure funding of its core mission and functions, WHO will not be able to fulfill its broad mandate. Even though U.S. financial commitments to WHO are already lower than 2 A recent study by Stuckler et al. (2008) revealed that WHO’s general budget “was much more closely aligned with the actual global burden of disease than were the extra-budgetary funds.” WHO’s general budget (2006-2007) allocates 61 percent to infectious diseases, 38 percent to noncommuni - cable diseases, and about 1 percent to injuries. On the other hand, WHO’s extra-budgetary funds for the same year allocate 91 percent to infectious diseases, 8 percent to noncommunicable diseases, and about 1 percent to injuries (Gostin and Mok, 2008; Stuckler et al., 2008). 

 SET THE EXAMPLE those of other industrialized countries as a share of gross domestic product, the U.S. government has consistently declined to meet its commitments in a timely manner. As of November 2008, the United States owed more than $140 million in back dues for 2007 and 2008 (Smith, 2008)—a significant share of the $900 mil - lion that constitutes WHO’s core budget. Prompt payment of U.S. commitments would help WHO’s budgetary cycle and also set an example for other countries in their relationship with WHO. The U.S. government should go further and pro - pose an increase in assessed (non-earmarked) contributions to WHO’s budget (as compared to voluntary contributions, which are earmarked and today constitute almost 80 percent of the agency’s budget). Assessed contributions have been more or less frozen for the last 15 years. An increase in these non-earmarked contribu - tions would change the budget structure of WHO, allowing it the flexibility to implement the most important global health priorities. Support WHO with Technical Know-How, Remove Political Interference WHO is dependent on member states and external funders for financing and therefore vulnerable to pressure from these stakeholders, whose broad agreement it needs to support its mission and priorities. However, the agency’s function as a scientific clearinghouse can be jeopardized by undue interference from differ- ent countries (Levine, 2006). WHO scientific guidance must be protected from political pressures and competing political philosophies so that it can be trusted as a source of technically sound advice. The U.S. government should continue to support WHO headquarters and its country and regional offices with technical expertise as requested. For 50 years, the Centers for Disease Control and Prevention’s (CDC’s) tremendous concen - tration of technical expertise in public health has been a key source of input and support to a range of bilateral and multilateral organizations, with CDC staff being placed at WHO headquarters and in individual nations. This important in-country presence during the design, implementation, and evaluation of health initiatives has contributed to numerous programmatic successes. For example, in the late 1960s and 1970s, CDC staff—in partnership with WHO—helped lead the successful eradication of smallpox (Levine, 2008). The United States should build on this impressive record by continuing a high-level exchange and sending leading technical and policy experts from agencies such as CDC, the National Institutes of Health (NIH), and the Food and Drug Administration (FDA) to engage in WHO’s tasks as requested. 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 

0 THE U.S. COMMITMENT TO GLOBAL HEALTH also request a rigorous external review of the organization to develop future- oriented recommendations that maximize its effectiveness. (A) The U.S. government and global health enterprise, along with the international community, should support a rigorous, multinational, exter- nal review of WHO, with a view to producing future-oriented recommen - dations as part of broader UN reforms to ensure that the organization is appropriately structured and funded to meet the global health challenges of the twenty-first century. (B) Following the outcome of the external review and movement by WHO to enact the recommendations, Congress should propose an increase in assessed (non-earmarked) contributions to the WHO budget. (C) Federal executive branch agencies and departments—such as CDC, FDA, NIH, and the U.S. Agency for International Development—should continue to send leading technical and policy experts to engage in WHO’s tasks as requested. LOCAL PARTNERSHIP Beyond the recommendation for strengthened governance at the global level, greater leadership and coordination are also required at the country level. The multitude of new participants in health should not obscure the reality that national governments should ultimately hold responsibility for providing health services to their own populations. Low- and middle-income countries typically receive health assistance from numerous channels: bilateral and multilateral donors; intergovernmental organi- zations, such as the World Bank, UNICEF, and UNDP; and international NGOs, such as CARE and Save the Children. The arrival of new organizations like philanthropies and PPPs has increased and diversified the financial resources available to countries, but it has also had a crippling effect by confronting govern- ments with a bewildering array of global agencies from which to elicit support. Efforts to write proposals and reports for donors whose interests, activities, and processes sometimes overlap, but often differ, typically overburden health min- istries (Bloom, 2007). Even when working with a single disease the number of donors can often be overwhelming for ministries of health. Studies show that aid tends to be unpredictable, volatile, and short term, making it challenging for recipient governments to make long-term investments or plan budgets (Lane and Glassman, 2007). Analysis of trends over the last 10 years shows that aid for health is fragmented into large numbers of small projects; more than two-thirds of all commitments were for less than $500,000 (WHO et al., 2008). Coordinating multiple donors around the delivery of a basic health plan consumes time and resources, especially when short donor time scales (55 

 SET THE EXAMPLE percent of donor projects end within one year) lead to continual renegotiation (OECD, 2006). Countries have been so concerned about the long-term sustainability of donor funding that they have at times refused aid. In India, an immunization pro - gram promoted by GAVI was not implemented because the government believed it was not sustainable without continuous, long-term financial support (Lele et al., 2006). The U.S. government and other donors often provide aid “off-budget” so that it is delivered and managed either through NGOs outside the recipient government’s budgeting system (Schieber et al., 2006) or through U.S. embas- sies, which may be directly overseen by the ambassador or consular staff (Garrett, 2009). The United States is not alone in delivering aid in this way. In fact, only about 20 percent of global health assistance goes directly to support government health systems (Dodd et al., 2007; Foster, 2005). Even in Tanzania, a country where donor coordination efforts have been under way for a long time, many donors are continuing to put only a small fraction of their funds into this pooled approach and are keeping 95 percent for projects emblazoned with their own donor imprint (Ferranti, 2008). While delivering aid off-budget allows the U.S. government and other donors several benefits—greater oversight of how the money is spent, quality control over each program, and the ability to demonstrate a direct link between taxpayer money and results—it can create disincentives for the recipient country to accept long-term ownership and accountability for the health of its population. Emerging evidence suggests that off-budget donor financing can lead to decreased govern- ment spending on health. The World Bank estimates that a “10 percent increase in off-budget donor funding generates an 0.87 percent reduction in domestically funded government health expenditures” (Gottret and Schieber, 2006). Another disadvantage of off-budget aid is that its recipients, such as inter- national or domestic NGOs, rather than governments, take charge of healthcare delivery. This has left a number of countries with parallel health systems, as well as weaker control of their own health systems. Just as many would ques - tion whether a government-run health system is the best answer for the United States, the committee does not necessarily advocate that all health be deliv - ered by governments. Nongovernmental organizations can be a positive force in strengthening in-country capacity, provided they do not duplicate efforts or take responsibility away from the government. What remains important is the provi - sion of adequate resources and the inclusion of nongovernmental organizations in the private sector in health delivery and planning. Support for Country-Led Health Plans To reduce the burden on recipient countries in coordinating donor efforts around a basic health plan, donors should support countries in developing results- 

 THE U.S. COMMITMENT TO GLOBAL HEALTH focused, country-led agreements that rally all development partners around one country-led health plan, one monitoring and evaluation framework, and one review process. Country-led health plans, at a minimum, require countries to articulate a health strategy that is “consistent with the macroeconomic and fiscal policies of the country, articulates specific goals in a results-based framework, and aligns the development of health systems and cross-sectoral contributions to the health sector with the achievement of sustainable improvements in health outcomes through a balanced and multi-sector development strategy” (World Bank, 2006). This approach requires donors to engage in respectful partnership and support countries on a demand-driven basis, aligning their assistance with country-driven strategies and procedures. Country-led plans are not new and have been used with varying degrees of effectiveness over the last two decades. In response to the burdensome, frag - mented, donor-driven, and often duplicative aid model, the international commu - nity began to reform its methods of aid delivery using the Sector-Wide Approach (SWAp). Under SWAp, project funds contribute directly to a sector-specific umbrella and are tied to a defined sector policy under a government authority. A key characteristic of SWAp is that the government clearly leads and owns the program; external partners confine themselves to work in support of that program, including provision of all or a major share of funding for the sector, in keeping with the government’s unified policy and expenditure plan. While SWAps have been successful in some countries, they have received mixed reviews (WHO et al., 2008). This is in part due to their exclusion of disease-specific programs, such as the President’s Emergency Plan for AIDS Relief (PEPFAR), and commercial and nongovernmental organizations. Exclud - ing the work of large programs such as PEPFAR when planning donor operations can lead to much duplication and inefficiency. Mozambique provides an example of the successful integration of vertical programs, multilaterals, and NGOs into overall sector programs. Development partners are now part of Mozambique’s Health SWAp, and disburse monies through a common fund that is aligned with the country SWAp (WHO, 2009). Given the reality that the private sector plays an increasingly important role in health delivery in many low- and middle-income countries, ignoring its role can only hinder progress. Indeed, the need to regulate the activities of the private sector has become increasingly apparent. However, many countries have little experience of regulation, and in low-income countries the priority of health ministries is to deliver basic health care rather than implement regulatory frameworks (SDC, 2008; Soderlund et al., 2003). In addition, health ministries in many countries seem to be moving away from direct line management toward commissioning services through procedures such as contracting and accredita - tion (Egger et al., 2007). The United States can make an important contribution to the potential benefits for private providers and countries by building capacity within ministries of health to set standards and regulate the private sector while integrating it with the public system (Kadaï et al., 2006). 

 SET THE EXAMPLE Country-led plans that go beyond the public sector to coordinate with multilaterals, international NGOs, the private health delivery sector, and even disease-specific programs are emerging. In 2004, key donors reaffirmed their commitment to strengthening national AIDS responses led by the affected coun - tries themselves. To avoid duplication and fragmentation, donors endorsed the “Three Ones” principles: one agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; one National AIDS Coordinat- ing Authority, with a broad-based multisectoral mandate; and one agreed country- level Monitoring and Evaluation System (UNAIDS, 2004). The Paris Declaration, endorsed in March 2005, was an international agree- ment to “increase efforts in harmonization, alignment, and management of aid with a set of monitorable actions and indicators” (OECD, 2005). The accord was signed by more than a hundred ministers, agency heads, and other senior officials. Another example of a commitment by donors and recipient government agencies to utilize a common work plan is the International Health Partnership (IHP+), jointly supported by WHO and the World Bank. IHP+ is now taking the Sector-Wide Approach a step further in streamlining the management of health aid with the development of “Country Compact” agreements. Like SWAps, the IHP+ continues to exclude private business, NGOs, and disease-specific programs from its plans. Regardless of which of these country-coordinating mechanisms is used, donors should deliver aid in ways that support technically and financially sound country-led health plans to the greatest extent possible, in order to ensure that countries retain ownership and accountability for the health of their populations and to promote long-term sustainability. This does not necessarily mean that donors must pool their funding into “one country pot.” Yet delivering a greater proportion of aid that is predictable, long term, on plan, and on budget—and provided under the assumption that governments implement agreed-upon strate - gies in a transparent fashion—would be a tremendous step forward in supporting the long-term capacity of national health systems. It is preferable that funds be neither earmarked for specific purposes nor tied to being spent on U.S. goods or services (tied aid has been estimated to increase program costs by 15 to 30 per- cent) (Roodman, 2008). This would allow countries to use the funds to fill gaps that are agreed upon and to finance the most needed areas for improving health outcomes, as called for in the Paris Declaration. The committee acknowledges the trade-off that may arise when delivering a larger portion of aid through government-owned systems. Yet while some of the short-term resources may not end up serving population health due to bottlenecks and weaknesses in existing systems, taking steps to ensure that countries own and build capacity for addressing the health needs of their populations is imperative. By making efforts to deliver aid through budget support, the U.S. government and other donors will also strengthen the demand for, and delivery of, timely and transparent budgets and expenditure records by recipient countries. This 

 THE U.S. COMMITMENT TO GLOBAL HEALTH would complement technical assistance and capacity building efforts that focus on improving transparency, procurement management, and auditing in financial systems, all of which are known to reduce corruption (Carter and Lister, 2007; Powell-Jackson and Mills, 2007). A particular focus on strengthening ministries of health and finance in recipient countries is required, since both are central to the effectiveness of aid programs. Role of International NGOs International NGOs should neither replace the actions of governments nor merely duplicate their efforts. NGOs have an important role in increasing access to health services and promoting public and private partnerships to improve the health of populations. Rather than directly providing services, international NGOs should make capacity building and health systems strengthening their primary goals; by acting as catalysts or facilitators, NGOs can improve the sus - tainable delivery of services to marginalized populations. One of the most important roles an NGO can fill is as a collaborator between the various participants in public health, specifically communities, health institu - tions, bilateral and multilateral donors, academia, and other NGOs working in complementary fields. Working as a team allows the sharing of ideas and infor- mation and the expansion of coverage, while community participation is key to sustainability. NGOs occupy a unique position in having access to policy makers, as well as the communities affected by their policies, and can therefore provide useful community feedback to improve policies. While NGOs play an important role in global and local advocacy, this role could be strengthened by working in a coalition or partnership. Since NGOs can focus on priority populations, they can play a particularly influential role in empowering women. As the primary caregivers in families, women greatly influence the health and education of children. “Empowering women to participate in, negotiate with, influence, control, and hold accountable the institutions within their communities will build the capacity of the communi - ties themselves” (Gayle and Sinho, 2009). NGOs step in to fill a variety of needs in global health ranging from advo- cacy at the global and national levels to policy development, technical assistance, health service delivery, and emergency relief. These organizations bring unique advantages to the field of health that neither public nor private sector entities possess. The United States in particular has some of the most effective and experi- enced NGOs with a rich track record in reducing disability and disease. The U.S. global health enterprise should therefore continue to support NGOs—especially in providing emergency relief efforts and strengthening national health sys - tems—and should encourage their inclusion in country-led coordination efforts, 

 SET THE EXAMPLE while also supporting the overall alignment of U.S. NGOs working in the health sector. Role of U.S. Government To deliver health aid as recommended by the committee, the United States should coordinate its activities across the various agencies and departments at the country level to ensure coherence, while exploring other collaborative channels, for example, by leveraging the efforts of other multilateral participants on the ground. The absence of such coordination is currently fueling the administrative burden on many local governments; U.S. government agencies are sometimes found to be working in the same country on the same agenda and even contracting out to the same agency, without any coordination. To reverse this trend, the committee commends the 2008 reauthorization of PEPFAR calling for the establishment of country compacts. These nonbinding frameworks are created with partner countries to promote a more sustainable approach, characterized by strengthened country capacity, ownership, and leader- ship. The 2008 PEPFAR reauthorization uses the term “Partnership Framework” to describe the five-year joint strategic framework for cooperation between the U.S. government, the partner government, and in some cases, other partners to coordinate financial commitments. In keeping with donor harmonization and alignment efforts, the reauthorized PEPFAR Partnership Frameworks are required to be fully in line with the national HIV/AIDS plan of the host country and continue to emphasize sustainable programs with increased country ownership (including decision-making authority and leadership). This example set by the PEPFAR Partnership Framework is a sign of prog - ress toward correcting the incoherence of U.S. aid efforts; however, the commit - tee questions why this level of commitment to partner with countries does not encompass all U.S. government activities in health. U.S. government agencies should coordinate their global health activities with wider development programs, when relevant; these coordination efforts can be led by the local embassy or even by U.S.-based NGOs working in the country. However, a directive from the highest levels in the U.S. government will be required to harmonize aid to this degree; an agreement at the country level alone will not suffice to ensure routine cooperation and the removal of bureaucratic barriers. Recommendations 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 

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