AMERICA’S VITAL INTEREST IN GLOBAL HEALTH: PROTECTING OUR PEOPLE, ENHANCING OUR ECONOMY, AND ADVANCING OUR INTERNATIONAL INTERESTS (1997)
The 1997 report presaged an international movement around the turn of the millennium toward promoting health, developing new interventions and strategies for treating diseases, ensuring global health security, and reducing inequities in health and in access to health care.1 The report called for phasing out the distinction between domestic and international health issues and implementing cooperative efforts to deal with cross-border health threats, contending that “the direct interests of the American people are best served when the United States acts decisively to promote health around the world” (IOM, 1997). The recommendations made in the 1997 Institute of Medicine (IOM) report clustered around three broad ways that the United States would benefit from entering the global health arena—protecting the American people, enhancing the American economy, and advancing American international interests. These themes are presented in the report under the guiding principle that the United States should as-
1 Programs and organizations launched include Médecins Sans Frontières’ Campaign for Access to Essential Medicines (1999); World Health Organization’s Global Outbreak Alert and Response Network (2000); the Bill & Melinda Gates Foundation (2000); Stop Tuberculosis Partnership (now housed by UNOPS) (2000); Gavi, the Vaccine Alliance (2000); the United Nations’ Millennium Development Goals (2000); and the Global Fund to Fight AIDS, Tuberculosis and Malaria (2002).
sume a global health leadership role and lead from its strengths, particularly in the areas of medical science and technology.
Within the theme of “protecting our people” are recommendations in the areas of health surveillance, information sharing, research, and collaboration. The board advised the U.S. government, in partnership with the corporate sector, to facilitate the development of a global network to carry out biomedical surveillance for existing and emerging infectious diseases and to serve as an early warning system for global health threats, such as potential attacks with chemical or biological agents. This network was to be bolstered by efforts to more broadly share information among countries about efficient and equitable health care financing and delivery, to invest in further international collaborative health research and new product development, and to conduct research about the prevention of violence.
To enhance the U.S. economy, the committee recommended that the U.S. government incentivize biopharmaceutical industries to research and develop products aimed primarily at populations in low- and middle-income countries (LMICs),2 with a view to strengthen the U.S. industry and improve the population health and economic prosperity of other countries. Furthermore, the committee advised the United States to broaden the scope of its investments in global health research and development toward preventing and controlling the greatest international health burdens and threats: infectious diseases, noncommunicable diseases (NCDs), substance abuse, injuries, and violence.
To advance the international interests of the United States, the committee advised the U.S. government to parlay partnerships and cost sharing with international governments and donors into increased investment in biomedical research and development linked to global health.
To build health workforce capacity, the report called for continued long-term federal investment to build on the U.S. strength in educating and training health providers, researchers, and policy makers toward establishing a sound global health infrastructure for preventing, detecting, and treating disease and other public health threats of international scope. In the areas of global leadership and the U.S. global health strategy, the committee recommended creating a governmental Interagency Task Force on Global Health to anticipate global health needs and coordinate responses, with the U.S. Department of Health and Human Services (HHS) taking a lead role in strategizing, setting priorities, and liaising among agencies and with other sectors (academia, nongovernmental organizations [NGOs], industries, and international agencies). The report also directed the government to expand
2 Suggested incentives include allowing multi-tiered pricing of drugs and vaccines, protecting intellectual property rights, extending patents to encourage product development, and creating public–private partnerships to develop essential products for poor populations.
its sphere of international influence by paying its dues to the United Nations (UN) system and promoting the system’s reform, as well as forming international, multisectoral, and multilateral health-focused partnerships to drive research, leverage expertise, and capitalize on limited resources.
THE U.S. COMMITMENT TO GLOBAL HEALTH (2009)
The Committee on U.S. Commitment to Global Health in 2009 noted that in the years since the 1997 IOM report discussed above, the United States vital self-interest in promoting global health and health security had been borne out and even heightened in the wake of burgeoning globalization and urbanization and cross-border health threats of infectious disease (such as the 2009 H1N1 influenza epidemic), as well as unhealthy consumer goods and the high prevalence of modifiable risk factors that are linked to chronic diseases and most premature deaths worldwide. The committee expanded on the definition of global health in the 1997 report by appending the “goal of improving health for all people by reducing avoidable disease, disabilities, and deaths” (IOM, 2009). The report’s recommendations concentrate on ways the United States can lead by example in international collaborative efforts to develop, finance, and deliver essential, cost-effective health interventions to improve health on a worldwide scale, but with a particular focus on LMICs. The recommendations fall into four categories: increasing U.S. financial commitments to global health; scaling up existing health interventions; partnering to invest in people, institutions, and capacity building; and sharing knowledge to address health problems in LMICs.
The interim period between the two reports saw a marked increase in both the funding and priority afforded to global health, despite the relatively low level of overall overseas development assistance extended by the United States compared with other high-income countries. The committee urged the U.S. government to meet existing international aid commitments by investing $15 billion annually in global health by 2012,3 with $13 billion of that directed to the health-related Millennium Development Goals and $2 billion toward NCDs and injuries. Related recommendations include designing a coordinated funding approach for global health research that leverages the HHS budget for research subsidies and the foreign affairs budget for innovative funding mechanisms to procure drugs and diagnostics; prioritizing donor aid; and providing support for developing sound country-led national health plans with appropriate monitoring, evaluation, and review.
3 This would double U.S. annual commitments to global health between 2008 ($7.51 billion) and 2012.
To improve coordination across the U.S. government, the committee recommended creating a White House Interagency Committee on Global Health, chaired by a senior official designated by the president, to be tasked with leading, planning, prioritizing, and coordinating the budgeting for major U.S. government global health programs and activities. This was done through the launch of the Global Health Initiative (GHI) in 2009 by President Obama. However, with an initiative spanning so many agencies and health areas, its success depended on strong authority and budget given to the GHI organizers. Unfortunately, they received neither, and GHI had little more than a web presence coordinating priority area global health programs.
To achieve significant health gains by scaling up existing interventions, the committee recommended that the U.S. public and private sector lead through global partnerships to prepare for the emerging health challenges of the 21st century (e.g., infectious pandemic threats, NCDs, climate change, globalization, and urbanization), and to strengthen neglected health systems by leveraging disease-specific programs. The U.S. government’s global health programs and other health organizations operating in low-income countries were advised to focus on strengthening and supporting national health systems by aligning sustained assistance with the priorities of each national health sector’s human resource plans.
To generate and share knowledge about how to most effectively address the health problems that disproportionately affect LMICs, the committee recommended that the U.S. research sector collaborate with global partners to leverage its scientific and technical capabilities to study the basic mechanisms of those diseases, to examine new interventions for infectious diseases, to reduce health system bottlenecks, and to rigorously evaluate programmatic efforts. To empower researchers in LMICs to improve their populations’ health, the report advised establishing global networks to disseminate and expedite sharing knowledge through improved access to scientific publications (e.g., in public digital libraries), research data, materials, and patented interventions.
To promote institutional capacity building, the U.S. government and private sector were advised to foster long-term reciprocally beneficial global partnerships with institutions (academia, research institutes, and health systems) in LMICs to further enable and financially support local problem solving and policy making.4 At the time of the report the health workforce predicament in LMICs was of crisis proportions; thus, the committee rec-
4 Specifically, 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.
ommended exploring opportunities to support country-led health-sector workforce plans and explore potential opportunities to leverage the U.S. workforce (e.g., through a global health service corps).
The committee made several recommendations about how the United States could set the example of engaging in respectful partnerships and assume the role of international leader in global health. The committee advised that enabling countries to maintain ownership and accountability for their populations’ health, as well as ensuring long-term sustainability, will require donors to support local capacity building and the development of outcome-oriented country-driven agreements to coalesce all partners (public and private sector) around a national health plan, a single monitoring and evaluation framework, and a unified review process. To that end, funding support should be proportionately greater for technically and financially sound country-led health plans coupled with transparent, agreed-upon implementation strategies.
The report advised the U.S. government to act as a global health leader by paying its fair share of the World Health Organization (WHO) budget and providing technical expertise to WHO as needed, but it also called for requesting a rigorous external review of WHO aimed at maximizing its effectiveness. The U.S. president was urged to highlight health as a pillar of U.S. foreign policy, given that acting in the global interest with priorities based on effectively attaining sustained health gains (rather than short-term strategic or tactical domestic benefits) will reap longer-term economic, diplomatic, and security rewards.5
KEY AREAS OF RECOMMENDATION AND ADVANCEMENTS TO DATE
Despite the change in the global health landscape between the two IOM reports, certain key areas of recommendation remained consistent: sharing information, health research collaboration, health workforce capacity, U.S. global health strategy, and the role of the United States as a global leader in this domain. The 1997 report made recommendations in the areas of surveillance, medical research and development, and violence research that were not prominent in the 2009 report, while the latter report provided explicit recommendations in the areas of institutional capacity building as well as financing and donor goals. Progress to date toward in each of those 10 areas is summarized in this section.
5 The committee also suggested that the U.S. president convene world leaders for a summit meeting at the UN General Assembly General Debate and the 2009 G20 meeting to announce the commitment to the overall global health funding recommended in the report ($15 billion per annum) as well as highlighting the importance of improving food and water security.
In the area of information sharing, global knowledge networks have been supported across sectors through WHO, the World Bank, academic research centers, and NGOs. Other efforts to cooperatively and innovatively address complex global development challenges include the Global Knowledge Initiative (2009) and the U.S. Agency for International Development’s (USAID’s) Higher Education Solutions Network (2012),6 although the latter is focused more generally on development.
Progress in health research collaboration includes the Partnerships for Enhanced Engagement in Research (2011), a competitive program that offers awards to scientists from LMICs (and partners them with U.S. government-funded researchers) to support research and capacity building; the program is administered by USAID but leverages funding across the U.S. government (USAID, 2016). Other USAID efforts include its Evaluation Policy (2011) (USAID, 2011) as well as the Global Development Lab (2014), which aims to strengthen the evidence base and leverage science and technology to improve development results, with a focus on ending extreme poverty by 2030 (USAID, 2017). The National Institute of Allergy and Infectious Diseases funded eight tropical research medicine centers in 2012 to support research on neglected tropical diseases in endemic areas.
Progress in health workforce capacity is evident on multiple fronts. The Medical Education Partnership Initiative was launched in 2010 by The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Health Resources and Services Administration, and the National Institutes of Health (NIH) to address the severe shortage of skilled health workers, despite the resources mobilized by PEPFAR and others.7 The Nursing Education Partnership Initiative (PEPFAR, n.d.) also supports PEPFAR by aiming to train at least 140,000 new health care professionals and paraprofessionals in the partner countries of the Democratic Republic of Congo, Ethiopia, Lesotho, Malawi, and Zambia. However, these programs concluded in 2015, and thus far have not been renewed. The U.S. Centers for Disease Control and Prevention (CDC)’s Division of Global Health Protection has delivered field epidemiology training programs since 1980 (currently in 70 countries) (CDC, 2016a), as well as a new initiative called Improving Public
6 The Global Knowledge Initiative is an NGO that seeks to surmount global development challenges through collaborative innovation and knowledge sharing by connecting innovative stakeholders with resources, expertise, and financing. See more at http://globalknowledgeinitiative.org (accessed April 17, 2017). The USAID Higher Education Solutions Network is a partnership between USAID and seven universities designed to foster cooperative scientific innovation. See more at https://www.usaid.gov/hesn (accessed April 17, 2017).
7 MEPI addressed these shortages by improving the quality of graduates, promoting retention of graduates where they are most needed, improving capacity for regionally relevant research, building communities of practice within Africa and globally, and ensuring sustainability (NIH, 2017).
Health Management for Action (CDC, 2016c), which trains public health managers. The Global Health Service Partnership, established in 2012, is a public–private partnership between Seed Global Health, the Peace Corps, PEPFAR, and the Global Health Service Corps to send doctors and nurses to LMICs facing health care provider shortages as medical educators (Peace Corps, n.d.; Seed Global Health, 2017).
Efforts related to the U.S. global health strategy include the GHI (2008), a presidential initiative that was launched with great fanfare, but did not receive anticipated funding, attributable at least in part to a lack of clear leadership or hierarchy. The Global Health Security Agenda (2014) (GHSA, n.d.) is a partnership that seeks to build country-level capacity to address the threat of infectious disease and maintain global health security through implementation of the International Health Regulations (2005). Currently, the President’s National Security Council serves the coordinating role in calling for interagency policy committees as needed for specific topics or initiatives.
Progress toward the United States assuming a global leadership role as requested through multilateral engagement in health is less apparent. As of 2015, the United States was assessed at 28 percent of the UN peacekeeping budget and 22 percent of the regular budget (UN, 2016, 2017), and 22 percent of the overall WHO budget (WHO, 2015). However, a significant proportion of this funding still is unpaid (WHO, 2017). The 2009 G20 meeting included food security but not water; however, at the 2009 G8 summit President Obama announced plans for increased investment in global food security.8
In surveillance, a focus of the 1997 report’s recommendations, progress at the global level includes the International Health Regulations (established in 2005) and the CDC Country Partnerships for Integrated Disease Surveillance and Response Implementation, which seeks to make surveillance and laboratory data more usable by public health managers and other decision makers in improving detection and response to health problems in African countries (CDC, 2017). The Global Outbreak Alert and Response Network (WHO, n.d.) (2000) is a collaboration to guide technical expertise on the ground during disease outbreaks that pose an international threat.9
8 For example, Feed the Future (2012), is a whole-of-government approach led by USAID to address extreme poverty, undernutrition, and hunger. See more at https://www.feedthefuture.gov/about (accessed April 17, 2017).
9 In addition to these sources of surveillance data, there are informal sources, including the International Society for Infectious Diseases–Program for Monitoring Emerging Diseases (ISID, 2014), the Global Public Health Intelligence Network via Health Canada (Government of Canada, 2016), the CDC Global Disease Detection Operations Center (CDC, 2016b), and HealthMap (HealthMap, n.d.).
The 2016 publication The Neglected Dimension of Global Security recommended that WHO should generate a high-priority “watch list” of outbreaks to be released to national focal points on a daily basis and on a weekly basis to the public. However, the commission noted that reporting by countries will need to be incentivized by International Health Regulations toward a broader aim of fostering transparency in information sharing (GHRF Commission, 2016). At the national level, Homeland Security Presidential Directive 10 (2004) addresses biodefense for the 21st century (Bush, 2004). However, according to a 2016 Blue Ribbon Study Panel on Biodefense, the U.S. Department of Homeland Security (DHS) National Biosurveillance Integration Center (DHS, 2016) has been unable to meet its mandate of “integrating and analyzing data relating to human health, animal, plant, food, and environmental monitoring systems” (Blue Ribbon Study Panel on Biodefense, 2015). Thus, while much progress has been made since 1997 in surveillance at national and global levels, the 2009 H1N1 outbreak and the 2014–2015 Ebola outbreak illustrate that there is still a long way to go before countries are able to rapidly detect and report disease outbreak.
In the area of medical research and development, another focus of the 1997 report, the Office of the Assistant Secretary for Preparedness and Response established the Biomedical Advanced Research and Development Authority in 2006 through the Pandemic and All-Hazards Preparedness Act,10 which incentivizes cost sharing through Centers of Innovation for Advanced Development and Manufacturing partnerships between the U.S. government and the private sector for collaboration, development, cost sharing, and ensuring surge capacity for vaccine manufacturing (ASPR, 2007). The U.S. Food and Drug Administration’s (FDA’s) Priority Review Voucher program (2007) spurs development by allowing for expedited FDA review of certain types of new drugs (i.e. neglected diseases, medical countermeasures, and rare pediatric diseases), which can translate into millions in dollars of profits (Gaffney et al., 2016). The U.S. Patent and Trademark Office’s Patents for Humanity program awards patents to innovators striving to address global humanitarian challenges (USPTO, 2016). In addition to these programs, the U.S. supports key public–private partnerships—product development partnerships—that are instrumental in incentivizing the innovation of diagnostics drugs that target poverty-related diseases.
To advance violence research as recommended in the 1997 report, the U.S. Department of State and USAID have funded sexual- and gender-based violence prevention and response projects (2012).11 CDC, the United
10 H.R. 307, 113th Congress.
11 Pursuant to Section 7061 of the Conference Report accompanying the U.S. Department of State, Foreign Operations, and Related Programs Appropriations Act, 2012 (Div. I, Public Law 112-74).
Nations Population Fund, and the Office of the United Nations High Commissioner for Refugees have conducted population-based studies in Liberia, East Timor, and Uganda to examine violence against women, and NIH has funded research grants addressing partner violence in the context of human immunodeficiency virus (HIV) programming.
Institutional capacity building, as well as donor goals and financing, were areas of recommendation for the 2009 IOM report. To the former, the CDC Global Disease Detection Program works in 50 countries through 10 centers to develop six core capacities12 formulated to achieve compliance with International Health Regulations (CDC, 2016b). The Health Systems 20/20 Project (2008–2012) was USAID’s global health flagship project designed to strengthen health systems though integrative approaches to addressing financing, governance, operational, and capacity-system constraints (USAID, 2013). The USAID Collaborative Support for Health program in Liberia seeks to strengthen the health system’s resilience in emergency contexts (MSH, 2017).
With respect to donor goals and financing, funding did increase slightly after 2008 but not to the extent recommended in the IOM report; it hovered around $9 billion annually from 2009 to 2016 (Salaam-Blyther, 2013).13 There has been an ideological shift toward country ownership reflected in the change in terminology from aid to partnership and a new emphasis on government-to-government funding, which will become clear in the 2017 committee report recommendations as well.
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13 Appropriated U.S. funding for global health between 2009 and 2016 fluctuated: $8.46 billion in 2009, $9.016 billion in 2010, $8.86 billion in 2011 (Salaam-Blyther, 2013), $9.8 billion in 2012, $9.6 billion in 2013, $10.2 billion in 2014, $10.2 billion in 2015, and 10.2 billion in 2016 (Valentine et al., 2016).
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