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1 Introduction In 1997, an Institute of Medicine (IOM) report America’s Vital Interest in Global Health: Protecting Our People, Enhancing Our Economy, and Advancing Our International Interests brought to the American public and policy makers an appreciation for America’s direct stake in the health of people around the globe (IOM, 1997). More than a decade later, the IOM—with the support of four U.S. government agencies (the Centers for Disease Control and Prevention, Department of State, Department of Homeland Security, and National Institutes of Health) and five private foundations (the Bill & Melinda Gates Foundation, Burroughs Wellcome Fund, Google.org, Merck Company Foundation, and the Rockefeller Foundation)—convened an expert committee to revisit the U.S. com - mitment to global health and articulate a fresh vision for future U.S. investments and activities in this area. (See Appendix A for the official committee Statement of Task.) To coincide with the U.S. presidential transition, the IOM committee pre- pared an initial report outlining its ideas for the U.S. government’s role in global health under the leadership of a new administration, The U.S. Commitment to Global Health: Recommendations for the New Administration (released on December 15, 2008) (IOM, 2009). This is the committee’s final report; it com- municates specific recommendations, not just for the U.S. government, but also for several nongovernmental sectors, including foundations, universities, other nonprofit organizations, and commercial entities. (For more information on the committee’s approach to the study process see Box 1-1.) 

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 THE U.S. COMMITMENT TO GLOBAL HEALTH BOX 1-1 The Committee’s Approach to the Study Process The Institute of Medicine formed a 17-member committee in March 2008 to examine the U.S. commitment to global health and make recommendations for fu- ture action in this area. (Committee member biographies are provided in Appendix B.) The study process consisted of three committee meetings—two of which in- cluded outside speakers—and four public working group meetings in Washington, DC. Over the course of the study process, the committee heard public testimonies from 75 global health experts and received input from numerous organizations. The first committee meeting, held in March 2008, featured the project sponsors and other eminent figures in global health to discuss the committee’s charge and the role of the United States in global health broadly. At the second committee meeting in July 2008, the committee heard from a range of experts on opportuni- ties to strengthen health systems in low- and middle-income countries. The third committee meeting was held in October 2008 in closed session to formulate recommendations and draft this report. (Public committee meeting agendas can be viewed in Appendix C.) To provide more detailed input into the committee’s deliberations, the com- mittee formed four working groups to concentrate on key areas in global health: human and financial resources for global health; U.S. engagement in global health governance; gaps and priorities in U.S. contributions to global disease challenges; and the creation and diffusion of knowledge in global health. (Public working group meetings can be viewed in Appendix D.) In June 2008, the human and financial resource working group held a public meeting on human resources for health in low- and middle-income countries, with presentations from experts on human resource migration and capacity building. The working group considered the effect of health sector human resource deficits on health outcomes and how the United States can support country efforts to implement human resource plans. DEFINING GLOBAL HEALTH AND THE SCOPE OF THIS REPORT Global health is the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable disease, disabilities, and deaths. 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 disease and disability, including their risk factors. Although 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 only on the efforts of the United States, both its gov - ernmental and its nongovernmental sectors, to help improve health in low- and middle-income countries.

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 INTRODUCTION Also in June 2008, the global health governance working group convened a public meeting on the U.S. engagement in global health governance, with speak- ers representing major intergovernmental organizations such as the World Health Organization and the World Bank, as well as representatives from civil society, industry, public-private partnerships, and academia. Mr. Lawrence Gostin, Linda D. and Timothy J. O’Neill Professor of Global Health Law at Georgetown Univer- sity Law School, was commissioned by the committee to provide a background paper on the state of global health governance (see Appendix E). In July 2008, the working group on global disease challenges held a meet- ing on the gaps and priorities in U.S. contributions to global disease challenges, building on the work of the Disease Control Priorities Project. Meeting presenters included distinguished academics and practitioners to discuss prominent diseases and disabilities, and their risk factors, as well as the effect of weak health systems on delivering interventions. In April 2009, the working group examining the creation and diffusion of knowledge hosted a public consultation to gather information on capacity building, knowledge sharing, and novel models of collaboration in global health research. Dr. Anthony So, director of the Program on Global Health and Technology Access at the Sanford School of Public Policy at Duke University, was commissioned by the committee to provide a background paper on sharing research knowledge for global health (see Appendix F). As outlined in the study statement of task, the IOM commissioned the Program on International Policy Attitudes to conduct an opinion poll of the American public to understand its views on the U.S. commitment to global health. The results of the poll can be viewed at www.worldpublicopinion.org. Findings from the public testimonies, commissioned works, and information provided to the committee by outside stakeholders and organizations informed the committee’s deliberations, the content of this report, and the final recommen- dations for how the United States should invest in global health interventions, research, and capacity building over the coming decade. Greater Opportunities for Meaningful Partnerships Progress in global health and development has challenged the traditional thinking in foreign assistance. In the last century, and even today, it has been quite common to divide the world into “North” and “South” when referring to “developed” and “developing” countries. This nomenclature ignores major eco- nomic, demographic, and social changes of the last decades. In the past, there were two clear categories of rich and poor; today, some poor countries (mostly in Africa) have become poorer, while the majority of rich countries have become richer. However, several countries have since sharply improved their economic situation and acquired the label of “emerging economies,” rendering the earlier terms less relevant. The growing importance of the G20 is one clear indication that countries

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0 THE U.S. COMMITMENT TO GLOBAL HEALTH such as Brazil, India, South Africa, Egypt, and China should be playing a greater role in partnering with countries to improve health outcomes and reduce pov- erty. The emerging economies not only bring additional resources but also bring experience that may help bridge any gap in understanding between the wealthy and the least wealthy nations. These partners can bring creative thinking about how to deliver and develop interventions that are geared toward settings that may have limited infrastructure and human and financial resources. For this reason, the committee adopted the terms low-, middle-, and high-income countries to more appropriately portray the countries involved in global health progress. Global Health Is Inextricably Linked to Broader Development Agenda The modern era of global health is distinguished by the commonly accepted view that health is inextricably connected to the broader development and pov - erty agenda (Bloom and Canning, 2000). Policies that promote unsanitary living conditions and inadequate nutrition, limit access to clean water and quality health systems, stifle economic and educational opportunity, and disregard discrimina - tion and inequity undermine individual and population health. The realization that policy choices in all sectors have the potential to affect health was the topic of an extensive study by the World Health Organization (WHO) to examine the social, economic, environmental, and political determinants of health. WHO’s recom- mendations (see Box 1-2) are consequently far-reaching and require considerable investment, major change, and most importantly, political will, even as they draw attention to the need for a comprehensive multisector approach to global health that reaches well beyond the health sector (Marmot et al., 2008). The IOM 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 development, as well as the envi - ronment (though these areas are beyond the scope of this report). The committee also recognizes that while the United States has the opportunity to support and advocate for a global agenda to improve health, ultimately individual coun- tries—both governments and civil society1—are responsible for putting in place the social and economic policies that protect the health of their populations (CSDH, 2008). Global Health Inequities Persist Along with Dramatic Improvements A failure on the part of governments, civil society, and global institutions to enact “healthy” policy choices has contributed to global inequities in health and 1 To safeguard the health of their citizens, governments need to be supportive of civil society, which can play a powerful role in channeling the preferences and needs of a population (Blas et al., 2008). Civil society also has the potential to advocate for the underserved and neglected and to hold governments accountable for health inequalities (Lancet, 2008).

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 INTRODUCTION BOX 1-2 WHO Commission on the Social Determinants of Health In 2005, WHO established the Commission on the Social Determinants of Health to “ensure that all people have the chance to lead healthy lives” (Friel et al., 2008) and to “marshal the evidence on what can be done to promote health equity and to foster a global movement to achieve it” (Marmot et al., 2008). The social determinants of health are “aspects of people’s living and working circumstances and . . . their lifestyles” that may initially seem outside the realm of health but, in reality, impact the burden of disease and cause of mortality across populations (WHO, 2003). More than 350 researchers, practitioners, policy makers, civil society repre- sentatives, and representatives from 100 institutions in both high-income and resource-limited countries evaluated the impact made on the social determinants of health by the actions of governments, civil society, and international institutions (Blas et al., 2008). In August 2008, the commission identified the following three principles to guide governments, international agencies, and civil society in closing the health equity gap within the next generation: 1 . Improve daily living conditions. Improve the well-being of girls and women, put major emphasis on early childhood development and education, improve living and working conditions, provide social protection policies, and create conditions for a secure life for the elderly. Policies to achieve these goals would involve civil society, governments, and global institutions. 2 . Tackle the inequitable distribution of power, money, and resources. Ad- dress inequities, such as those between men and women, in the way society is organized. In addition to a committed and adequately financed public sec- tor, this would require strengthened governance that provides legitimacy for civil society, rules for an accountable private sector, and support for people to invest in collective action in the public interest. 3 . Measure and understand the problem and assess the results of action. Na- tional governments and international organizations, with the support of WHO, should set up national and global surveillance systems for routine monitoring of health inequity and should evaluate the health equity impact of their own policies and actions. This requires investment in the training of policy makers and health practitioners in understanding the social determinants of health and a strong focus on taking these determinants into account in public health research. SOURCE: Adapted from the CSDH, 2008. development both within and across countries. A girl born in Sierra Leone can expect to live only half the lifetime (42 years) of a girl born in Japan (86 years), and the chance of a child’s dying before age 5 in Angola is nearly 90 times higher than in Finland or Iceland (WHOSIS, 2008). Marked inequities in health can be seen even within wealthy countries such as the United States.

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 THE U.S. COMMITMENT TO GLOBAL HEALTH Yet despite the persisting health, social, and economic inequities worldwide, the committee finds that global health achievements in the last 50 years have been remarkable (Laxminarayan et al., 2006); global life expectancy has increased more in this period than in the preceding 5,000 years.2 Average life expectancy— the age to which a newborn baby is expected to survive—was approximately 40 years in low- and middle-income countries in 1950; it is now about 65 years, having risen more than 60 percent (Levine, 2008; McNicoll, 2003). Most of the improvements in life expectancy are derived from reduced health risks for young children. Since recordkeeping on child mortality began in 1960 (when 20 million children died annually, with 180 deaths per 1,000 live births), the number of children dying before their fifth birthday has been reduced by more than half, to 9.2 million in 2007 (72 deaths per 1,000 live births) (UNICEF, 2007, 2008). Knowledge and Its Dissemination a Main Driver of Health Improvements Contrary to expectation, increased wealth is not always the main driver for improved health outcomes. For example, levels of child survival in Niger and Eritrea are 74 and 91 percent, respectively, even though these countries have similar levels of gross domestic product (GDP) per capita (see Figure 1-1). India has the same child survival rate as Eritrea although its GDP per capita is three times higher. Vietnam has the same income per capita as India but a higher child survival rate (98 percent). Strikingly, the poorest 20 percent of Vietnam has higher child survival rates than the richest 20 percent of India (Gapminder, 2008). Economic well-being, then, is not a sound predictor of health status. In fact, economic growth has been shown to account for less than half of the health gains in low- and middle-income countries between 1952 and 1992 (Jamison et al., 2008; WHO, 1999). Instead, technological innovation and the diffusion and adoption of knowl - edge have been the main drivers for improved and prolonged lives in even the most impoverished settings (Davis, 1956; Global IDEA Scientific Advisory Com- mittee, 2004; Jamison, 2006; Jamison et al., 2008). Simple and cost-effective interventions such as the introduction and widespread use of vital vaccines and antibiotics, along with advances such as access to clean water, good sanitation practices, and improved nutrition, have been found to help save lives in countries around the world during any phase of economic development. Globalization has greatly helped to diffuse knowledge about the best inter- ventions, as well as the methods for their delivery. For example, diarrhea-related 2 Gains in life expectancy are the result of an epidemiological transition—the shift from infectious (communicable) diseases to chronic noncommunicable diseases, which typically lead to death later in life than infectious diseases. This transition has allowed the aging of populations and reflects public health successes in the prevention and control of infectious diseases and child deaths (Beaglehole and Bonita, 2008; Mathers and Loncar, 2006).

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 INTRODUCTION FIGURE 1-1 Infant mortality rates by income per person. 1-1.eps NOTE: This figure reveals the relationship between income per person (GDP per capita) and infant mortality rates (per 1,000 births) for 2006. Each circle represents a country, and the size of the circle is relative to its population size. For example, Niger and Eritrea have similar population sizes and income per person, but Niger’s infant mortality rate (148/1,000) is more than three times that of Eritrea (48/1,000). Vietnam and India have the same income per capita, but India’s population is much greater and its child mortality rate is quadruple that of Vietnam. SOURCE: Gapminder, 2008. deaths among children have fallen by several million a year, partly as a result of the development of oral rehydration therapy, much of which was the product of work from research laboratories in Bangladesh that was adopted on a global scale (see Table 1-1 for other examples) (Global IDEA Scientific Advisory Com - mittee, 2004). Research indicates that “the pace of such dissemination in a country, and the willingness and ability of those who live there to act on the information, governs the rate of health improvement much more than the level of income”

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 THE U.S. COMMITMENT TO GLOBAL HEALTH TABLE 1-1 Example of Science Contribution to Decline in Infectious Disease Mortality in the Twentieth Century Annual deaths before Annual deaths after Condition and intervention intervention (reference year) intervention (reference year) ~5,200,000 (1980) 1,400,000 (2001) Polio, diphtheria, pertussis, tetanus and measles— immunization programs Small pox—eradication campaign ~3,000,000 (1950) 0 (1979) Diarrhea—oral rehydration ~4,600,000 (1980) 1,600,000 (2001) therapy Malaria outside Africa—residual ~3,500,000 (1930) <50,000 (1990) indoor spraying and acute management Malaria in Africa—limited use ~300,000 (1930) 1,000,000 (1990) of residual indoor spraying and acute management SOURCE: Global IDEA Scientific Advisory Committee, 2004. (Laxminarayan et al., 2006). A study examining infant mortality in 70 low- and middle-income countries revealed that even in periods of rapid economic growth, the diffusion of technology and educational improvements were far more important than income changes in explaining why infant mortality rates varied across countries (Jamison et al., 2004). These findings have been borne out by the experiences of European countries in the late nineteenth and early twentieth centuries and, more recently, of countries such as Bangladesh, Costa Rica, and Sri Lanka, where appropriate and timely policies have greatly reduced mortality even without high or rapidly growing incomes (Laxminarayan et al., 2006). Therefore, while governments, civil society, and global institutions should continue to promote economic development, improve daily living conditions, and tackle inequity, the committee finds that immediate health gains (especially among the most disadvantaged populations) can be achieved by investing in sustainable and equitable systems to disseminate best practices, deliver cost- effective interventions, and develop future interventions. This report therefore focuses specifically on how the United States, by working with the governmental and nongovernmental sectors in low- and middle-income countries and with the international community, can advance global health by improving the delivery of effective interventions through the health sector. BUILDING ON PRIOR SUCCESS AND NEW COMMITMENT TO STRENGTHEN GLOBAL HEALTH ACHIEVEMENTS In the United States, an area of study, research, and practice has emerged to contribute to the achievement of global health. Termed the U.S. global health enterprise, it involves many sectors (both governmental and nongovernmental)

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 INTRODUCTION and disciplines (within and beyond the health sciences); it is characterized by intersectoral, interdisciplinary, and international collaboration. In preparing this report, the committee examined whether the existing architecture, investments, and activities of the U.S. global health enterprise are optimally geared to achiev - ing significant, sustainable, and measurable global health gains. Historically, the United States has contributed greatly to the achievement of global health gains, through both its governmental and its nongovernmental sectors, by working with partners around the world to develop and deliver cost- effective health interventions. While improving the health status for all people around the world will require a long-term and widely shared global commitment, the United States has the opportunity to take concrete steps toward this goal by building on past achievements, continuing successful partnerships, and leverag - ing new commitments to global health. Significant U.S. Role in Global Health Progress The United States has been an important source of global health knowledge, providing the scientific basis for many health successes worldwide through the research and capacity building efforts of its governmental and nongovernmental sectors. The United States has also played a critical role in the dissemination and adoption of knowledge to improve health in low- and middle-income countries, often in partnership with other countries and intergovernmental organizations. Underlying several global health successes is the strong U.S. commitment to research, especially in the fields of science and medicine. The National Insti - tutes of Health (NIH) and the National Science Foundation in collaboration with researchers at universities have provided the foundation for many public health and clinical discoveries that have a global impact. For example, the National Institute of Allergy and Infectious Diseases at NIH has supported scientists in conducting a broad portfolio of infectious disease research from diagnosing pan - demic influenza to treating HIV/AIDS. Another example of U.S. research with significant global benefit is the story of vitamin A. The distribution of this simple pill, which costs about 2 to 3 cents per capsule, as part of a supplementation program in low-resource settings was found to save the lives of millions, reducing child mortality by as much as 23 per- cent (Beaton, 1993; Fawzi et al., 1993; Glasziou and Mackerras, 1993; Sommer et al., 1983; Tonascia, 1993). Today, as a vital component of child survival strat - egy, more than 60 nations have vitamin A supplementation programs; many of these are supported by the U.S. Agency for International Development (USAID) (McCarthy, 2005). Research and programming by USAID have also contributed to other significant public health gains, such as the use of oral rehydration salts, which have reduced deaths from diarrheal dehydration by 82 percent among infants in countries such as Egypt (Levine, 2008; NRC, 2006). The Centers for Disease Control and Prevention (CDC) has also played a historic role in global health progress, achieving remarkable successes such as

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 THE U.S. COMMITMENT TO GLOBAL HEALTH the worldwide eradication of smallpox and eliminating polio in many parts of the world, in partnership with other entities (Levine, 2008). In addition to its part in controlling and preventing infectious diseases, the CDC developed the Global Youth Tobacco Survey, in collaboration with WHO, to monitor tobacco use among youth in 140 countries. This surveillance system has played a key role in guiding national tobacco prevention and control programs in low- and middle- income countries (CDC, 2007). The Department of Defense (DoD) is also an important player in infectious disease research and surveillance. The Military Infectious Diseases Research Program (MIDRP) develops vaccines and drugs to prevent and treat diseases that are important to the U.S. military, while the DoD-Global Emerging Infections Surveillance and Response System collects and analyzes epidemiological data to help control major infectious diseases in low- and middle-income countries. While currently engaged in the worldwide search for a malaria vaccine, MIDRP has already played a significant role in the development of several lifesaving vac- cines (USAMRMC, 2007).3 A model of how cutting-edge science and regulatory activity can work to improve public health on a global scale was provided by the Food and Drug Administration (FDA) when a pharmaceutical ingredient (heparin) from China mysteriously caused hundreds of deaths worldwide (Blossom et al., 2008; Schwartz, 2008). The FDA worked with academic and industrial scientists to find the bacterial contaminant in Chinese heparin and moved quickly to ensure that the incoming supply was safe. The U.S. commercial and nonprofit sectors have also been instrumental in achieving many global health successes. In an ambitious effort involving the pharmaceutical company Merck & Company, Inc., river blindness (onchocercia - sis) has been virtually eliminated in West Africa. The program was led by WHO and included a host of countries and agencies, such as the World Bank, the Food and Agriculture Organization, and the United Nations Development Programme. Merck’s donation of the drug Mectizan for 45 million people—combined with a grassroots effort by village volunteers and aerial spraying with environmentally safe insecticides—was critical to the program’s success (Levine, 2008). This Mectizan Donation Program, now in effect for more than 20 years, is the larg - est ongoing disease-specific drug donation program in history (Colatrella, 2008; Merck & Co., Inc., 2008; Thylefors et al., 2008). Similar efforts to eradicate disease in sub-Saharan Africa have been led by other U.S. organizations. The Carter Center leads an ambitious program to eradicate guinea worm disease (dracunculiasis), an affliction that has existed since ancient times and one that causes devastating disability, pain, and infection. The program is supported by the Bill & Melinda Gates Foundation and imple - mented through an international coalition comprising WHO, CDC, the United 3 Rubella (1969), adenovirus 4 and 7 (1980), tetravalent meningococcal bacteria (1981), hepatitis B (1981), oral typhoid (1989), Japanese encephalitis (1992), and hepatitis A (1995).

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 INTRODUCTION Nations Children’s Fund (UNICEF), and several countries. The program—to provide clean water and health education and to contain and manage guinea worm cases—has already succeeded in reducing the prevalence of this disease in Africa by 99.7 percent (Levine, 2008). Many other examples of success through partnership can be found, espe - cially among vaccination programs. PolioPlus, the most ambitious program in the history of Rotary International, is the volunteer arm of the global partnership dedicated to eradicating polio (Rotary International, 2009). In the last 20+ years, Rotary (in partnership with UNICEF, WHO, and CDC) has vaccinated more than 2 billion children and prevented 5 million cases of paralysis (International Polio - Plus Committee, 2009). The Measles Initiative partnership (a collaboration of the American Red Cross, CDC, the United Nations Foundation, UNICEF, and WHO) is another example of a successful partnership that reduced measles deaths by 74 percent worldwide and by 89 percent in Africa (Measles Initiative, 2008). As these examples demonstrate, U.S. government institutions have worked alongside U.S.-based foundations, nongovernmental organizations, universities, and commercial entities to provide the technical and financial resources necessary to expand public health infrastructure, increase access to health interventions, and improve health globally. These initiatives—often undertaken in partnership with local organizations, foreign governments, and intergovernmental organiza- tions—are widely regarded as some of the most successful public-private health collaborations in the world. Unprecedented Commitments to Global Health The promise of potential solutions to global health problems has captured the interest of a new generation of philanthropists, private sector leaders, scientists, healthcare providers, students, and citizens—all eager to make a difference in this interconnected world. This attention is reflected in the record funding that global health has drawn in recent years, both from the U.S. government and from a variety of private sources, and in the growth and diversification of the U.S. global health enterprise. U.S. Government Investment in Health at All-Time High Over the last decade, the U.S. government has made record commitments to global health, in keeping with the nation’s rising interest in the well-being of populations around the world. In 2009, U.S. global health funding reached an all-time high of $8.186 billion (White House, 2009). This extraordinary increase was driven mostly by new models of assistance, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and the President’s Emergency Plan for AIDS Relief (PEPFAR). Between 2001 and 2003, the United States spent $3.5 billion on the global fight against AIDS; since the inception of the Global Fund in 2002 and PEPFAR

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 THE U.S. COMMITMENT TO GLOBAL HEALTH in 2004, the United States has spent a combined total of more than $25 billion on AIDS (PEPFAR, 2008, 2009). PEPFAR constitutes the largest commitment ever by any nation to a global health initiative dedicated to a single disease (White House, 2008). PEPFAR’s achievement—bringing lifesaving drugs to 2.1 million people and more than quadrupling the number of HIV-infected people receiving treatment in sub-Saharan Africa in 2003 (PEPFAR, 2009)—demonstrated the success the United States is capable of achieving when it seriously commits to improving health outcomes. Other major health initiatives by the U.S. government include two five- year programs: the President’s Malaria Initiative, which earmarks $1.2 billion to halve malaria-related deaths in Africa, and the Neglected Disease Initiative, which commits $350 million to target tropical diseases, mainly through afford - able treatment made possible by drug donations from manufacturers. Global health is also part of the U.S. government’s Millennium Challenge Corporation, which aims to reduce global poverty through the promotion of sustainable eco - nomic growth. U.S. investments in global health have come to form a prominent part of U.S. foreign policy. Repeated polls in the last few years have shown public support for this approach, with health now ranking among Americans’ top priorities for development assistance—not merely to protect U.S. interests, but also as a way of promoting human development worldwide (Research!America, 2006; World - PublicOpinion.org, 2009). Increased Resources for Global Health from Philanthropy U.S.-based grant-making institutions have a long tradition of making sig - nificant contributions to global health successes. The Rockefeller Foundation has launched programs since 1913 to address hookworm, malaria, and yellow fever, funding some of the earliest research on such diseases and establishing many of the world’s first public health schools (Rockefeller Foundation, 2009). The Ford Foundation began making grants for welfare projects in 1936 (Ford Foundation, 2009). Exceptional philanthropic commitments have recently been made to further combat disease and resolve healthcare delivery problems. Between 1995 and 2005, total charitable giving by U.S. foundations tripled (Garrett, 2007). Extraor- dinary wealth creation in recent years has produced a large number of extremely wealthy individuals with an interest in philanthropy that “involves using money for maximum impact by investing in potentially disruptive technologies4 . . . and 4A disruptive technology or disruptive innovation is a technological innovation, product, or service that overturns the existing dominant technologies or products in a market by using a “disruptive” strategy (e.g., a pre-exposure prophylactic product to prevent HIV infection), rather than a “sustain - ing” strategy such as a latex condom to prevent HIV infection.

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 INTRODUCTION in social enterprises that can be scaled up as required”; the result has been “finan- cial rigor as well as an appetite for risk” (Do it right, 2008). The most notable example of private philanthropy has been the Bill & Melinda Gates Foundation. Now the world’s largest charitable organization (Gar- rett, 2007; Okie, 2006), this foundation has added unprecedented resources to the pool of available grant money. It nearly doubled its global giving between 2002 and 2004 to $1.2 billion (Rose et al., 2008), but after a recent contribution from the financier Warren Buffett, it is expected to increase its total giving to $3.8 billion, spending approximately half of this on global health programs (Gates, 2009). Increasingly, many well-established foundations are turning their attention to global health; this is especially true for foundations focused on domestic science and health research, such as the Burroughs Wellcome Fund (1955) and the Doris Duke Charitable Foundation (1996). New foundations are also joining in exist- ing global health efforts, such as the Google Foundation (2005) and the Clinton Global Initiative (2005). Increased Resources from Growing Number of Nonprofits Involved in Global Health Perhaps not surprisingly, the number of U.S. nonprofits engaged in global health has also increased. U.S. nonprofits spent an estimated $1.9 billion on global health programs in 1995, of which approximately 70 percent ($1.3 billion) was privately funded, with the remainder coming from the U.S. government. In 2005, U.S. nonprofits contributed $5.7 billion to global health, of which 76 per- cent was privately funded ($4.3 billion) (Rose et al., 2008). Of the 556 nonprofit organizations registered with USAID, 411 (or 74 percent) report working in global health (Rose et al., 2008). Catholic Relief Services (1943), CARE (1945), and World Vision (1950) are a few examples of international nonprofits that have long served at the forefront of humanitarian efforts—aiding in emergency relief, food security, poverty reduc- tion, and economic development. Yet many new nongovernmental organizations devoted to global health have emerged in the last decade; some of these organiza- tions, such as GAIN (2002), are building public-private partnerships to counter specific problems such as malnutrition, while others have joined together with the ONE (2004) advocacy campaign to broadly fight preventable diseases and end poverty. A recent, private sector initiative called the Global Health Corps was created with the aim of building a pipeline of new global health leaders by funding promising young adults (applicants must be under 30 years of age) to work with selected partner organizations in low-income countries for one year (Global Health Corps, 2009).

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0 THE U.S. COMMITMENT TO GLOBAL HEALTH Public-Private Partnerships for Innovative Financing In the last decade, many new organizations have taken the form of public- private partnerships (PPPs), which have changed the landscape for global health and for infectious diseases in particular (Barr, 2007; Widdus, 2005). As of 2004, the database of the Initiative on Public-Private Partnerships for Health (at the Global Forum for Health Research) listed 91 international partnerships in the health sector, of which 76 are dedicated to infectious disease prevention and con - trol, notably against acquired immunodeficiency syndrome (AIDS), tuberculosis (TB), and malaria (Nishtar, 2004). Two of the largest such PPPs are the Global Alliance for Vaccines and Immunization (GAVI) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). GAVI is a partnership that includes low-, middle-, and high-income country governments, their vaccine industries, several research and technical institutes, civil society organizations, the Bill & Melinda Gates Foundation, WHO, UNI- CEF, and the World Bank. GAVI is committed to delivering stable aid flows, with a particular focus on reducing child mortality by increasing access to immuniza - tion in poor countries. While working with innovative finance mechanisms that link its diverse partners, GAVI also accepts direct contributions from industri - alized countries, 67 percent of which are multiyear commitments with at least three-year terms (GAVI Alliance, 2009). The Global Fund works in partnership with industrialized donor countries, recipient countries, private foundations, industry, and multilateral organizations to finance programs that support the prevention and treatment of AIDS, TB, and malaria. The U.S. government provided the founding pledge to the Global Fund in 2002, and it continues to provide nearly one-third of all Global Fund contribu - tions through PEPFAR (Friends of the Global Fight, 2007). Although primarily supported by high-income countries, the Global Fund also receives funding from private foundations, as well as from innovative finance mechanisms. Public-Private Product Development Partnerships to Tackle Neglected Diseases One of the most promising approaches to address the enormous and widening gap in the availability of drugs, vaccines, and diagnostics to deal with the global disease burden is the emergence of a type of PPP known as a product develop - ment partnerships (PDP). Tapping philanthropic and government financing, PDPs create innovative business models that bring cutting-edge technology to bear on some of the world’s most devastating scourges (Matlin et al., 2008; McKerrow, 2005). In many instances, PDPs are virtual pharmaceutical and biotechnology partnerships driven by the commitment to a single goal: the development of products for which there is little potential financial return on investment. Several PDPs have emerged over the past decade to deal with global health challenges (Widdus, 2005), creating an infrastructure on which future invest- ments can build. In 2007, nearly one-third of grants for biomedical research

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 INTRODUCTION for AIDS, TB, malaria, and other neglected diseases were routed through PDPs and other intermediary organizations, representing nearly 25 percent of product investments ($577 million) (Moran et al., 2009). Business Acumen for Global Health The commercial sector is using these new models of collaboration to respond to opportunities to apply technology and business acumen to enduring social problems. Many companies have initiated socially responsible programs in the field of health. The importance of such corporate social responsibility or corpo - rate citizenship has increased over the last decade, with a corporation’s reputation increasingly under scrutiny by nongovernmental organizations and individual consumers.5 In 2007, 95 percent of CEOs surveyed by McKinsey & Company stated that “society now has higher expectations of business taking on public responsibilities than it did five years ago” (Franklin, 2008). For example, (RED) is a business model that appeals to a consumer’s social conscience to direct money to the Global Fund ((PRODUCT)RED, 2008). Promi- nent companies such as Gap and Starbucks pay (RED) a fee to carry the Product (RED) label on some of their products. In return for the opportunity to increase their revenue through sales of these products, a percentage of the proceeds is donated to the Global Fund. Corporate social responsibility has resulted in greater financial and technical investments in global health research and programming by corporations. Between 2001 and 2003, the pharmaceutical industry increased its global health spend - ing nearly threefold, from $564 million to $1.4 billion (PhRMA, 2003, 2004). Increasingly, other industries are also becoming engaged in this field. Two recent cases are ExxonMobil’s establishment of the Africa Health Initiative in 2000 to fund and support activities related to the prevention, control, and treatment of malaria (ExxonMobil, 2008) and Procter & Gamble’s initiative to provide safe drinking water to more than a million African children (Procter & Gamble Company, 2006). The Global Business Coalition on HIV/AIDS, Tuberculosis, and Malaria (GBC)—a nonprofit comprised entirely of businesses—applies its resources in partnership with other nongovernmental organizations, multilaterals, and governments (GBC, 2009). New Business Models for Profit and for Global Health Driven by the idea that society’s most pressing social problems can be solved by innovative solutions using a sustainable business model, some businesses are combining profit with a social mission. The Grameen Danone Foods Social 5 Interestingly,the value of corporate citizenship to companies remains debatable: a meta-analysis of 167 studies over 35 years found a positive but weak link between social and financial performance (Margolis et al., 2007).

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 THE U.S. COMMITMENT TO GLOBAL HEALTH Business Enterprise in Bangladesh, for example, is a collaborative effort to bring nutrient-rich and affordable yogurt to low-income populations in Bangladesh, while also promoting a sustainable and socially conscious business model (Gra - meen Trust, 2006). InnoCentive is a web-based platform that connects seekers faced with scien - tific challenges (such as governments, corporations, and foundations) to solvers (such as scientists, technologists, and businessmen). InnoCentive, with its net - work of 170,000 solvers from around the globe, helps to lower the transaction costs of product development. For example, InnoCentive brought together a seeker—the Global Alliance for TB—with a solver—a young man from India whose mother contracted TB when he was a child—to overcome a cost barrier in the product development process that would have prohibited the use of the TB drug in low- and middle-income countries (Bingham, 2009). Global Health on the Academic Agenda On American university campuses, the study of global health has flourished, with a globally oriented student body demanding a curriculum that reflects its interests and career aspirations. Unprecedented energy and enthusiasm for this field can be seen among students, as well as among medical residents and fac- ulty. For example, data from the Association of American Medical Colleges (AAMC) show that the percentage of U.S. senior medical students participating in global health experiences increased from 8 percent in 1986 to 28 percent in 2008 (AAMC, 1986, 2008) and two-thirds of U.S. medical schools now provide courses in global health. Universities are increasingly interested in global health efforts because the resulting initiatives are socially beneficial and foster institutional growth and development. Both learners and institutions gain from a greater awareness of global health issues that help them better understand issues in their own institu - tions and communities, which are becoming more global as the population con - tinues to diversify (Kanter, 2008). University global health programs range in scope from individual courses to comprehensive, multidisciplinary, multiprofessional initiatives that often include patient care, research, and education components. This interest is evident in uni - versity curriculums and in the many research alliances focused on global health initiatives spanning universities and research institutes. The larger initiatives include alliances with schools of public policy, engineering, law, environment, theology, and business, as well as partnerships with non-U.S. institutions (Kanter, 2008). FUTURE COMMITMENTS TO GLOBAL HEALTH Progress toward global health requires collaboration between many part- ners—donors, recipient country governments, and implementing agencies—to

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 INTRODUCTION develop, finance, and deliver essential and cost-effective health interventions. The United States can, however, lead by setting an example of meaningful finan- cial commitments, technical excellence, and respectful partnership. By building on past achievements, continuing successful partnerships, and leveraging new commitments to global health, the United States has the opportunity to move the world closer to the ultimate goal of improved health for all. The committee finds that progress in health over the last half-century can mostly be attributed to the creation, dissemination, and adoption of interventions to improve health. Simple and cost-effective interventions can help save lives in countries around the world during all phases of economic development. Imme - diate health gains, especially for the most disadvantaged populations, are there - fore possible but will require investments in sustainable and equitable systems to deliver cost-effective interventions (and develop future interventions). Such investments should be made alongside the efforts by governments and civil soci- ety to monitor the social determinants of health within their countries to tackle inequity and improve daily living conditions. This report focuses specifically on how the United States and the interna - tional community can work with the governmental and nongovernmental sectors in low- and middle-income countries to improve their healthcare sectors and so advance global health. The committee examined many ways in which the United States, including its governmental and the nongovernmental sectors, could con - tribute to these advances. The committee focused on areas in which the United States can draw on its comparative advantage, such as research, technology, or resources, to capitalize on the growing interest in its universities, foundations, and commercial entities to address significant bottlenecks in improving global health. The committee 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 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 an example of engaging in respectful partnerships. REFERENCES AAMC (Association of American Medical Colleges). 1986. Medical student graduation question- naire: Summary report for all schools. Washington, DC: Association of American Medical Colleges. ———. 2008. GQ program evaluation survey: All schools summary report. Washington, DC: As- sociation of American Medical Colleges. Barr, D. A. 2007. Ethics in public health research: A research protocol to evaluate the effectiveness of public-private partnerships as a means to improve health and welfare systems worldwide. American Journal of Public Health 97(1):19-25.

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