Global Health System Strengthening: Issues for Congress

February 6, 2015 Global Health System Strengthening: Issues for Congress 5. Service delivery. The management and Introduction The ongoing West Africa Ebola outbreak has generated interest among some Members of Congress in strengthening the domestic health systems of developing countries. The Ebola epidemic revealed not only the threat that weak health systems in developing countries pose to the world, but also elucidated gaps in international frameworks for responding to global health crises. Consensus is emerging that health system strengthening is important for international security, though debate abounds regarding the appropriate approach for achieving this goal and the role the United States might play in such efforts, especially in relation to other U.S. global health assistance priorities. Overview In 2013, the 28 donor countries in the Development Cooperation Directorate (DAC) of the Organization for Economic Cooperation and Development (OECD) provided more than $13 billion for improving global health. The United States, a DAC member, provided more than half of these funds. As a leading donor for global health, the United States remains an influential stakeholder in the global health arena, and the manner in which it provides its health aid affects how recipient countries and other stakeholders implement their health plans. Over the past 15 years, U.S. funding for global health has more than quadrupled, due in large part to funding for the President’s Emergency Plan for AIDS Relief (PEPFAR). Other “vertical” programs (efforts that address a particular health issue), such as the President’s Malaria Initiative (PMI), have also contributed to increased U.S. global health spending. Increased U.S. funding for multilateral health programs has also been aimed primarily at vertical programs. In 2012, roughly 65% of U.S. contributions to the World Health Organization (WHO) were provided through voluntary contributions designated to support specific initiatives like Gavi, a multilateral effort to broaden global access to vaccines. While vertical programs have contributed to significant declines in infectious disease deaths, the Ebola outbreak has demonstrated deficiencies in this approach and has prompted calls for investing “diagonally” in both vertical and “horizontal” health systems-based programs. According to WHO, there are six components of a health system: 1. Human resources. The people who provide health care and support health delivery. 2. Governance and leadership. Policies, strategies, and plans that countries employ to guide health programs. 3. Financing. Mechanisms used to fund health efforts and allocate resources. 4. Commodities. Goods that are used to provide health care. delivery of health care. 6. Information. The collection, analysis, and dissemination of health statistics for planning and allocating health resources. Supporters of health system strengthening argue that systems-based funding is cost-efficient because it can reduce redundancies, boost country ownership, and could ultimately eliminate the need for funding vertical programs. U.S. Policy The United States is increasingly incorporating elements of health system strengthening into bilateral health assistance, though not in a comprehensive or fully integrated fashion. PEPFAR, for example, provides training for health workers, but the training is focused on HIV/AIDS care. PMI is improving the supply chain mechanisms for the delivery of malaria-related commodities, but broader supply chain deficiencies may persist within the health systems of recipient countries. The Neglected Tropical Diseases (NTD) Program has expanded access to NTD treatments in remote areas, though access to other basic health interventions (like vaccinations) may remain limited in these areas. The multilateral Global Health Security Agenda, which the United States supports, aims to improve developing countries’ capacity to detect, prevent, and respond to pandemics, but is primarily focused on infectious diseases and vaccines. It remains to be seen whether incremental implementation of systems-based strategies within vertical programs will advance “resilience” in health systems. Resilient health systems are those capable of addressing unanticipated shocks, like disease outbreaks, without interrupting delivery of basic health services (as has occurred during the Ebola outbreak). Early in his Administration, President Obama announced the Global Health Initiative (GHI) to strengthen health systems, improve the coordination and integration of U.S. bilateral global health programs, and expand results-based funding. Other stated goals of GHI were to • increase the impact of U.S. global health investments, • advance country ownership of health aid, and • enhance program monitoring and evaluation and research and innovation. As part of GHI, the U.S. Agency for International Development (USAID), Department of State, and Department of Health and Human Services (HHS) jointly planned how U.S. global health aid would be spent and aligned this strategy with the national health plans of 28 priority recipient countries. Despite having developed country health plans, some question whether GHI is being carried out, as the prior coordinating mechanism for the www.crs.gov | 7-5700 Global Health System Strengthening: Issues for Congress initiative has lapsed and a new GHI Coordinator was not identified. Issues for Congressional Consideration Through legislation and oversight activities, Congress has played an important role in shaping U.S. global health programs. After President Bush announced PEPFAR in 2003, Congress enacted the Leadership Act (P.L. 108-25), which, among other things, established the Office of the Global AIDS Coordinator at the Department of State. Until that point, each implementing agency was independently planning and developing its own HIV/AIDS plan. The Lantos Hyde Act (P.L. 110-293), among other things, authorized the establishment of a Malaria Coordinator at USAID to oversee the planning and implementation of PMI and directed the Administration to establish PEPFAR partnership frameworks for accelerating country ownership and cost sharing. Presidential health initiatives like PEPFAR and PMI have endured across administrations, in large part, because they have quantifiable targets that were authorized in statute and receive annual appropriations. As Congress considers calls for strengthening weak health systems and bolstering global health security, several questions may arise, including: • Appropriate funds for health system strengthening? In foreign aid appropriations, Congress specifies that the bulk of health aid funding be spent on vertical programs. This phenomenon has created a tension between those who seek to protect advancements made under vertical programs and those who want to add broader systemsbased strategies. Those in Congress who may want to support health system strengthening efforts without reducing spending on vertical programs may consider providing additional funds specifically for health system strengthening. Such provisions, however, may be subject to larger debates about foreign aid funding levels. • Authorize the creation of a Global Health Coordinator? During the George W. Bush Administration, Congress authorized the establishment of coordinators for various health programs, such as PEPFAR. This legislative action has mandated agencies to work collaboratively and has unified implementing partners around achieving a particular goal. This model could be emulated for health system strengthening with the establishment of a Global Health Coordinator who would oversee the development of a U.S. health systems strategy. Such a strategy might include targets for strengthening health systems, indicators for measuring and monitoring progress, and a budget for achieving the goals. Critics of establishing a Global 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 term of the law. On the other hand, issues that slowed implementation of GHI may persist and could complicate operationalization of the initiative. • Establish pilot health system countries? The United States is implementing health programs in over 100 countries. The structure and vitality of health systems vary per country, as does U.S. engagement. This variance might complicate efforts to develop a single U.S. government health system strengthening strategy. Congress might consider authorizing the establishment of pilot countries where a health systems plan could be developed and implemented. Standardizing or expanding the strategy might be complicated, however, by varying conditions on the ground. • Consider legislative constraints to implementing health system strengthening strategies? There is some debate about whether appropriations for vertical programs could be used for broader health system efforts. In March 2013, the Government Accountability Office (GAO) released a report indicating that roughly 21% of PEPFAR funds in FY2012 were spent on capacity-building projects under the “other” budgetary category. The report noted that it was unclear what portions of these funds were spent on care, treatment, and prevention activities. PEPFAR Coordinator Deborah Birx asserted at her confirmation hearing that she would ensure 50% of all PEPFAR resources, including those funded through other accounts, be spent on care and treatment activities, as mandated in the Leadership Act. Some global health advocates expressed concern that budgetary reforms aimed at adhering to the law would imperil improvements in health systems made through PEPFAR. Those in Congress who wish to provide greater flexibility to the executive branch to pursue systems-based approaches might consider legislative provisions that would clarify the extent to which agencies can support broader health system efforts through vertical programs. • Explore Pool Funds for Health? In many countries, U.S. spending on health programs exceeds national health budgets and these countries’ capacity to manage large-scale development and health programs is limited. USAID has proposed a Pool Funding mechanism, through which donors would provide funds directly to a third party to incrementally release funds to the host government as program targets are met. In Pool Funding documents, USAID has asserted that the mechanism can help to build local financial management capacity, reduce human resource burdens on recipient countries by aligning U.S. health policy with those of host governments, reduce transaction costs, and improve efficiency. Interested Members may wish to authorize broader use of the Pool Fund for Health. Tiaji Salaam-Blyther, tsalaam@crs.loc.gov, 7-7677 www.crs.gov | 7-5700 IF10124