COMMENTARY: A New Strategic Consensus on Foreign Assistance Must Begin with Global Health

A Commentary by CEDPA President Carol Peasley

Feb. 13, 2009 — For the past week, CEDPA has been abuzz with the energy of 25 seasoned women leaders from around the world. These courageous and determined women are here for CEDPA’s Alumni Coaching workshop, part of the innovative CEDPA Alumni Coaching Program. Each of these coaches will be paired with a recent graduate of CEDPA’s many leadership programs. The coaches, experts in their field, provide guidance and insight to help the graduate sustain their personal and professional growth and performance.

During the week, I spoke with many of these remarkable women, but one particular conversation stood out. This conversation was with a woman who heads an NGO in an important South Asian country. She and her group have a long history of supporting reproductive health and neo-natal health; they have a significant network of community-based service providers. But, donor resources are increasingly difficult to obtain, either because the resources are now going to disease- or issue-specific initiatives or because they are going into “funding baskets” that, in turn, give government complete control over how they are used. In this particular Asian country, the government does not like to see its performance compared to that of the private community-based networks, so it allocates almost nothing to them.

In my October Commentary, I spoke about the importance of Foreign Aid Reform. This remains a hot topic, and all of us in the U.S.-based international development community eagerly await the Obama Administration’s appointments for leadership positions in USAID and other agencies. We also eagerly await decisions on possible structural and organizational changes.

In the meantime, we know that many interested parties are advocating for new foreign assistance authorizing legislation – and that the House Foreign Affairs Committee is itself taking the lead to craft a new Foreign Assistance Act (FAA). While all of us working in the development field hope to see new legislation to replace the oft-amended FAA of 1961, it may be even more important in the short-term to develop a consensus on foreign assistance priorities and a new strategic development framework. Without this initial consensus among the Executive and Legislative branches and all interested parties, the new FAA could too easily become another “Christmas tree” with too many baubles and bangles.

The conversation with my colleague gave me a concrete understanding of what I conceptually already knew. While a new strategic development framework is needed in general, it is especially urgent to resolve a host of critical issues in supporting Global Health. Prior Administrations and the Congress have dramatically increased funding for Global Health in recent years, but almost all of these increases have been in “stovepipes” such as HIV/AIDS, malaria, polio, tuberculosis, avian flu, etc. These new “stovepipes” have been added to the population and maternal/child health “stovepipes” from earlier years. The result is a mish-mash of vertical programs that have had a number of unanticipated negative effects, including weakened health systems, losses of health workers or at least compartmentalization of them, distorted resource allocations, and disempowered countries that are no longer able to direct resources to their highest priority needs.

While my colleague has creatively adapted to the new world of “stovepipes” and has figured out ways to achieve multiple objectives with HIV/AIDS resources, it is a fact that growing numbers of women in her community are not receiving adequate help in preventing or spacing their pregnancies, or in giving birth. My example involves only one relatively small geographic area, but we know that this experience has been repeated around the world. Is it in fact one explanation for why the Millennium Development Goal for Maternal Health has not improved at all over the past eight years? Are mothers bearing the major brunt for the dysfunctional way in Global Health assistance is provided?

The Global Health Council and the Center for Global Development have eloquently argued for the need to bring coherence to the Global Health assistance agenda. While I cannot match their technical expertise or eloquence, I can add my voice to the debate. We must bring the “stovepipes” together and prepare a true Global Health strategy. This strategy must recognize and protect the importance of the various special issues and “stovepipes,” but it must simultaneously promote integration and a more holistic look at the health sector in individual developing countries. While aiming to achieve real impact on people’s lives, this strategy must also aim to strengthen and use local infrastructure. It is not enough – and not appropriate – for international NGOs to be directly providing services. We must simultaneously build local capacity – if not, none of the results will be sustainable.

A new Global Health strategy must also look at how U.S. assistance to the sector is delivered, most especially the degree to which the U.S. provides its assistance bilaterally or through multilateral mechanisms such as the Global Fund to Fight AIDS, Malaria, and Tuberculosis. Several prominent Washington think tanks argue that more U.S. assistance should go through the multilaterals. There are strong reasons for this position, including the fact that it gives a more prominent voice for the local countries in setting priorities. But, we must look at this question carefully and decide in the context of our bilateral capacities and interests. There are pros and cons – all must be examined strategically.

Lastly, as the new Administration proceeds in developing a Global Health strategy, it needs to reach out to a broad range of actors. The Congress must participate in the deliberations. Multilateral organizations must participate. Developing countries must participate. In addition, since international NGOs and other technical assistance providers play an important role in delivering services – and most importantly in building local capacity – they too must be brought explicitly into the strategy development process. Then, if we all work together, keep aid effectiveness at the center of our deliberations and learn from the past, we will see the kinds of changes that will improve lives and build long-term, sustainable solutions.

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