Global Health System Strengthening: Issues for Congress
February 6, 2015
Global Health System Strengthening: Issues for Congress
Introduction
5. Service delivery. The management and
The ongoing West Africa Ebola outbreak has generated
delivery of health care.
interest among some Members of Congress in strengthening
6. Information. The collection, analysis, and
the domestic health systems of developing countries. The
dissemination of health statistics for planning
Ebola epidemic revealed not only the threat that weak
and allocating health resources.
health systems in developing countries pose to the world,
Supporters of health system strengthening argue that
but also elucidated gaps in international frameworks for
systems-based funding is cost-efficient because it can
responding to global health crises. Consensus is emerging
reduce redundancies, boost country ownership, and could
that health system strengthening is important for
ultimately eliminate the need for funding vertical programs.
international security, though debate abounds regarding the
appropriate approach for achieving this goal and the role
U.S. Policy
the United States might play in such efforts, especially in
The United States is increasingly incorporating elements of
relation to other U.S. global health assistance priorities.
health system strengthening into bilateral health assistance,
Overview
though not in a comprehensive or fully integrated fashion.
PEPFAR, for example, provides training for health workers,
In 2013, the 28 donor countries in the Development
but the training is focused on HIV/AIDS care. PMI is
Cooperation Directorate (DAC) of the Organization for
improving the supply chain mechanisms for the delivery of
Economic Cooperation and Development (OECD) provided
malaria-related commodities, but broader supply chain
more than $13 billion for improving global health. The
deficiencies may persist within the health systems of
United States, a DAC member, provided more than half of
recipient countries. The Neglected Tropical Diseases
these funds. As a leading donor for global health, the
(NTD) Program has expanded access to NTD treatments in
United States remains an influential stakeholder in the
remote areas, though access to other basic health
global health arena, and the manner in which it provides its
interventions (like vaccinations) may remain limited in
health aid affects how recipient countries and other
these areas. The multilateral Global Health Security
stakeholders implement their health plans.
Agenda, which the United States supports, aims to improve
Over the past 15 years, U.S. funding for global health has
developing countries’ capacity to detect, prevent, and
more than quadrupled, due in large part to funding for the
respond to pandemics, but is primarily focused on
President’s Emergency Plan for AIDS Relief (PEPFAR).
infectious diseases and vaccines.
Other “vertical” programs (efforts that address a particular
health issue), such as the President’s Malaria Initiative
It remains to be seen whether incremental implementation
of systems-based strategies within vertical programs will
(PMI), have also contributed to increased U.S. global health
advance “resilience” in health systems. Resilient health
spending. Increased U.S. funding for multilateral health
systems are those capable of addressing unanticipated
programs has also been aimed primarily at vertical
shocks, like disease outbreaks, without interrupting delivery
programs. In 2012, roughly 65% of U.S. contributions to
of basic health services (as has occurred during the Ebola
the World Health Organization (WHO) were provided
outbreak).
through voluntary contributions designated to support
specific initiatives like Gavi, a multilateral effort to broaden
Early in his Administration, President Obama announced
global access to vaccines. While vertical programs have
the Global Health Initiative (GHI) to strengthen health
contributed to significant declines in infectious disease
systems, improve the coordination and integration of U.S.
deaths, the Ebola outbreak has demonstrated deficiencies in
bilateral global health programs, and expand results-based
this approach and has prompted calls for investing
funding. Other stated goals of GHI were to
“diagonally” in both vertical and “horizontal” health
increase the impact of U.S. global health investments,
systems-based programs. According to WHO, there are six
components of a health system:
advance country ownership of health aid, and
1. Human resources. The people who provide
enhance program monitoring and evaluation and
health care and support health delivery.
research and innovation.
2. Governance and leadership. Policies,
As part of GHI, the U.S. Agency for International
strategies, and plans that countries employ to
Development (USAID), Department of State, and
guide health programs.
Department of Health and Human Services (HHS) jointly
3. Financing. Mechanisms used to fund health
planned how U.S. global health aid would be spent and
efforts and allocate resources.
aligned this strategy with the national health plans of 28
priority recipient countries. Despite having developed
4. Commodities. Goods that are used to provide
country health plans, some question whether GHI is being
health care.
https://crsreports.congress.gov
Global Health System Strengthening: Issues for Congress
carried out, as the prior coordinating mechanism for the
term of the law. On the other hand, issues that slowed
initiative has lapsed and a new GHI Coordinator was not
implementation of GHI may persist and could
identified.
complicate operationalization of the initiative.
Issues for Congressional Consideration
Establish pilot health system countries? The United
States is implementing health programs in over 100
Through legislation and oversight activities, Congress has
countries. The structure and vitality of health systems
played an important role in shaping U.S. global health
vary per country, as does U.S. engagement. This
programs. After President Bush announced PEPFAR in
variance might complicate efforts to develop a single
2003, Congress enacted the Leadership Act (P.L. 108-25),
U.S. government health system strengthening strategy.
which, among other things, established the Office of the
Congress might consider authorizing the establishment
Global AIDS Coordinator at the Department of State. Until
of pilot countries where a health systems plan could be
that point, each implementing agency was independently
developed and implemented. Standardizing or
planning and developing its own HIV/AIDS plan. The
expanding the strategy might be complicated, however,
Lantos Hyde Act (P.L. 110-293), among other things,
by varying conditions on the ground.
authorized the establishment of a Malaria Coordinator at
USAID to oversee the planning and implementation of PMI
Consider legislative constraints to implementing
and directed the Administration to establish PEPFAR
health system strengthening strategies? There is some
partnership frameworks for accelerating country ownership
debate about whether appropriations for vertical
and cost sharing.
programs could be used for broader health system
efforts. In March 2013, the Government Accountability
Presidential health initiatives like PEPFAR and PMI have
Office (GAO) released a report indicating that roughly
endured across administrations, in large part, because they
21% of PEPFAR funds in FY2012 were spent on
have quantifiable targets that were authorized in statute and
capacity-building projects under the “other” budgetary
receive annual appropriations. As Congress considers calls
category. The report noted that it was unclear what
for strengthening weak health systems and bolstering global
portions of these funds were spent on care, treatment,
health security, several questions may arise, including:
and prevention activities. PEPFAR Coordinator
Deborah Birx asserted at her confirmation hearing that
Appropriate funds for health system strengthening?
she would ensure 50% of all PEPFAR resources,
In foreign aid appropriations, Congress specifies that the
including those funded through other accounts, be spent
bulk of health aid funding be spent on vertical programs.
on care and treatment activities, as mandated in the
This phenomenon has created a tension between those
Leadership Act. Some global health advocates expressed
who seek to protect advancements made under vertical
concern that budgetary reforms aimed at adhering to the
programs and those who want to add broader systems-
law would imperil improvements in health systems
based strategies. Those in Congress who may want to
made through PEPFAR. Those in Congress who wish to
support health system strengthening efforts without
provide greater flexibility to the executive branch to
reducing spending on vertical programs may consider
pursue systems-based approaches might consider
providing additional funds specifically for health system
legislative provisions that would clarify the extent to
strengthening. Such provisions, however, may be
which agencies can support broader health system
subject to larger debates about foreign aid funding
efforts through vertical programs.
levels.
Explore Pool Funds for Health? In many countries,
Authorize the creation of a Global Health
U.S. spending on health programs exceeds national
Coordinator? During the George W. Bush
health budgets and these countries’ capacity to manage
Administration, Congress authorized the establishment
large-scale development and health programs is limited.
of coordinators for various health programs, such as
USAID has proposed a Pool Funding mechanism,
PEPFAR. This legislative action has mandated agencies
through which donors would provide funds directly to a
to work collaboratively and has unified implementing
third party to incrementally release funds to the host
partners around achieving a particular goal. This model
government as program targets are met. In Pool Funding
could be emulated for health system strengthening with
documents, USAID has asserted that the mechanism can
the establishment of a Global Health Coordinator who
help to build local financial management capacity,
would oversee the development of a U.S. health systems
reduce human resource burdens on recipient countries
strategy. Such a strategy might include targets for
by aligning U.S. health policy with those of host
strengthening health systems, indicators for measuring
governments, reduce transaction costs, and improve
and monitoring progress, and a budget for achieving the
efficiency. Interested Members may wish to authorize
goals. Critics of establishing a Global Health
broader use of the Pool Fund for Health.
Coordinator might argue that this approach adds
bureaucracy and could exacerbate interagency tensions.
Authorize the Global Health Initiative? While
planning GHI implementation, USAID developed
country-specific health plans that offered a framework
for improving cost efficiency, integration, and
collaboration across agencies and health programs. The
initiative lacks a congressional mandate, which would
require U.S. agencies to carry out the framework for the
https://crsreports.congress.gov
Global Health System Strengthening: Issues for Congress
Tiaji Salaam-Blyther, Specialist in Global Health
IF10124
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