Global Health Priorities: Building on U.S. Global Health Engagement

Over the past two decades, the United States has been a leader in global health. This has been a bipartisan effort through successive Congresses and multiple administrations. U.S. funding, along with political will from partner countries and engaged stakeholders and community leadership, has led to achievements many thought impossible a few decades ago. But there is more work to be done, particularly given the challenges created by COVID-19.

Thirty-eight million people around the world were living with HIV in 2019, with approximately 25.4 million accessing antiretroviral therapy (ART), 17.2 million due to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Sub-Saharan Africa remains the region most affected by HIV but has seen tremendous progress. Global rates of new infection have fallen by 23% since 2010, including by 38% in Eastern and Southern Africa and 25% in Central and West Africa, although several populations remain disproportionately affected. Over the past decades, progress has also been made on preventing transmission of HIV from mother to baby during pregnancy or breastfeeding, decreasing maternal mortality, improving under-5 survival, and declining cases and deaths from malaria and tuberculosis.

While progress should be celebrated, Congress and the administration cannot lose sight of what is at stake, especially considering the ground already lost or at risk of being relinquished as a result of the COVID-19 pandemic. The world was already off track to reach the global goal of ending AIDS as a public health threat by 2030, and setbacks in other health, economic, and development indicators as a result of COVID-19 are being seen.

The health and well-being of people around the world matters to Americans. Our investments abroad signal our respect for human dignity. Moreover, U.S. investments in global health have strengthened democracies, reinvigorated economies, and encouraged friendlier and more-productive diplomatic relations, according to a report from the Bipartisan Policy Center. All of these things benefit Americans. Furthermore, as the United States has pulled inward, influence has been ceded to actors with more sinister motives.

The following recommendations are key to U.S. leadership in global health acceleration, integration, and expansion, while guarding against and responding to effects of COVID-19.

Congress should continue to fully support and fund PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, keeping in mind implications of COVID-19

PEPFAR has been successful in accelerating the number of people living with HIV (PLHIV) receiving treatment with flat funding since 2009. U.S. participation in the Global Fund to Fight AIDS, Tuberculosis, and Malaria contributes to the overall pool of funding to fight infectious disease and galvanizes support from other countries. In 2019, Congress approved a nearly 16% uptick in support to the Global Fund, the first increase in six years.

However, the assistance PEPFAR and the Global Fund have provided for the COVID-19 response across sub-Saharan Africa has had implications for their programs and budgets. The Global Fund has reported its COVID-19 efforts are quickly running out of money, and PEPFAR teams have worked to continue services while also supporting countries’ COVID-19 responses.

Congress should commission analyses to understand how COVID-19 is affecting U.S.-funded global health programs and quickly act on the findings to make necessary adjustments in appropriations. That will ensure that the programs are fully supported in line with the realities of the pandemic. Furthermore, as PEPFAR outlines its action plan for 2021-2025, Congress must also look to the future. Additional funding will likely be necessary for a comprehensive strategy to combat HIV and support holistic health systems and services.

PEPFAR and U.S.-funded global health programs must remain data focused to increase efficiency and effectiveness and reach all communities

PEPFAR uses a granular data review to direct resources where they will be most impactful. This approach has allowed PEPFAR to maintain efficiency, effectiveness, and accountability and should be continued across PEPFAR and all U.S.-funded global health programs.

Disaggregated data has also helped PEPFAR understand where it needs to change strategy or increase focus, and robust evaluations should continue. Adding qualitative methods to ongoing program monitoring and evaluation also provides context to the numbers and helps identify creative solutions to serious issues. PEPFAR has started to implement feedback mechanisms to hear from clients and civil society organizations. These efforts should continue to best serve PLHIV and communities at risk of HIV as well as be adopted by other U.S. global health programs.

Congress should invest in a global COVID-19 response, and the Biden administration should prioritize health security

Disease does not respect borders, and COVID-19 is undeniable proof of this. Congress must understand that, to protect Americans, it behooves the United States to invest on a global level and work with international coordinating bodies to carry forward an equitable global response.

Proven mechanisms exist through which to channel resources. U.S. programs such as PEPFAR support partner countries’ pandemic responses and have invested in healthcare infrastructure, trained a large cadre of healthcare workers, and helped establish basic public health practices such as contact tracing. The Global Fund and Gavi, the Vaccine Alliance are also well-positioned to play critical roles in therapeutic, diagnostic, and vaccine procurement and dissemination for COVID-19 while continuing to fulfill their mandates. The World Health Organization plays a critical role in collating data, setting priorities, and issuing guidance.

While the world is building back and moving forward, it will be critical for the United States to consider how it prepares for the next infectious disease outbreak and responds to other public health emergencies. Robust health systems that can detect, track, and contain disease are paramount for global health security. COVID-19 shined a spotlight on the weaknesses of our systems. Horizontal investments in health should be a priority to ensure future disease outbreaks are dealt with effectively. The United States’ health security is only assured if global health security and systems are strong.

The administration should ensure global health programs provide quality services that are community led and community focused

Leadership requires inclusion and humility. While the United States has been the leading supporter of global health programs, the incoming administration has an opportunity to evolve U.S. leadership through “a consistent, courageous, and creative effort” to be more intentional by including communities served by U.S. global health programs at decision-making tables.

Increased emphasis has been placed on ensuring communities are at the center of public-health efforts. PEPFAR’s annual Country Operational Planning process, and particularly the annual multistakeholder meetings, provide an excellent example of a path toward meaningful inclusion of diverse communities. Acknowledging and tapping into the power of communities will make for more acceptable and sustainable programs and better protect human rights in public health.

Beyond democratizing decision-making, implementing agencies should continue their efforts to fund local organizations.

Programs must also maintain assurances of quality and accessibility of services. Working with communities and partnering with local experts to oversee programs leads to better outcomes for clients.

Policymakers should continue to support integrated approaches to health care and enhance coordination with other U.S.-supported programs

Most U.S.-funded health programs were designed to address a single disease or specific health indicator, but it is becoming more apparent that maintaining a vertical approach to public health is not going to be sustainable.

PLHIV are 15 to 22 times more likely to contract TB, and women living with HIV (WLHIV) are up to six times more likely to develop cervical cancer. With global increases in noncommunicable diseases, gaps in women’s healthcare, and considerations for supporting PLHIV through aging, U.S. global health programs will require latitude to provide comprehensive care.

Through Go Further, a partnership between PEPFAR, the Bush Institute, UNAIDS, and Merck, PEPFAR has added cervical cancer screening and same-day treatment of precancerous lesions into HIV clinics and offers the service to WLHIV while they are attending the clinic for routine HIV services. Integrating services decreases inefficiencies and additional burdens on clients to seek care within a disconnected health system. Go Further is an example of how U.S. efforts can be improved and expanded for more fully integrated healthcare that is responsive to complex realities people face and more aligned with partner countries’ public health priorities.

In addition to integrating healthcare, there is opportunity for health programs to collaborate with other U.S. supported social and community programs that contribute to individual and societal well-being. For example, DREAMS is another PEPFAR-led partnership that has taken a holistic approach to addressing HIV among adolescent girls and young women. DREAMS has achieved at least a 25% reduction in new HIV incidence among adolescent girls and young women in most of the districts where it operates. But in addition to decreased HIV incidence, DREAMS has also empowered adolescent girls and young women with formal education, vocational and business training, accurate information and services for health care, and opportunities that increase their choices and bolster their potential to contribute to their families, communities, and countries. Collaboration between health and other U.S.-supported programs, such as for education, economic opportunity, water, sanitation and hygiene (WASH), or agriculture development, has the potential to multiply impact.

The administration and congress should reinforce PEPFAR’s role in global health diplomacy through the state department

PEPFAR has the ability to wield diplomatic influence, maintain relationships with multiple stakeholders, and retain oversight of a coordinated HIV response. Because it is situated in the State Department and run by an ambassador-at-large, it can work effectively with partner governments on accountability, transparency, and impact. A supportive policy structure is critical to achieving the best outcomes for PLHIV or at risk of HIV, making PEPFAR’s ability to negotiate with governments critically important. For example, PEPFAR has been working with government partners to introduce better treatments and protect PLHIV – especially key populations – from discrimination and human rights abuses. Moreover, PEPFAR works with each country to ensure the long-term sustainability of HIV/ AIDS programs by encouraging governments to assume increasing responsibility for them.

The U.S. government must strengthen partnerships with the private sector, other donors, and international coordinating bodies

The U.S. government has contributed generously to global health programs. Over the past 18 years, more than $90 billion has been earmarked for PEPFAR and the Global Fund alone. But while the United States commits more than any other country, all U.S. foreign aid for health and development is less than 1% of the total budget and a smaller proportion of its gross national product than comparable counterparts, according to the Brookings Institution. As the United States continues to fully and reasonably fund global health programs, there are opportunities for partnership with the private sector and other donors.

Private sector and philanthropic partners are able to take risks and make investments that the U.S. government cannot – including in cutting-edge research – and they bring competencies from other disciplines that make program delivery more efficient and effective. Public-private partnerships should be encouraged and expanded.

The United States must also maintain relationships with international coordinating bodies. In the global HIV response, UNAIDS plays a significant role in global goal and target setting, data collection and analysis, engaging civil society and communities, and developing policy agendas. The WHO is influential in setting the public health priorities of countries the United States partners with as well as directing global guidance, policy, and standards. As the administration reengages, the United States should urge reform of the WHO toward transparency, accountability, and clarity and effectiveness of its mandate. When the United States disengages, other actors fill the void. U.S. interests will be best served through cooperation with WHO, while also holding it to democratic standards.

The United States’ unrelenting commitment to global health remains important – even more so as the world deals with the COVID-19 pandemic and its aftermath. Congress and the administration should set an agenda that builds on the commitments the U.S. government has made, particularly over the past 18 years – one that goes even further to consider new realities for global health.