Rethinking US Global Health Funding: Welcome, and Long Overdue ⋆ Brownstone Institute
The global health world is struggling. For the past two and a half decades, it has been based on a model of ever-growing funding, channelled from the taxpayers and investors of wealthy countries, through intermediary organizations mostly staffed from the same countries to recipient nations who have far lower income and limited health infrastructure. This model has saved lives, yet it has also built dependency both from the health systems of recipient countries and from the army of salaried bureaucrats and non-government organizations, which have prospered from its largesse. The United States government’s abrupt defunding of the world’s largest aid agency, USAID, and its cut in support to the World Health Organization and GAVI (The Vaccine Alliance) have sent shockwaves through the global health world.
Most response is highly negative. Former USAID administrator Samantha Power recently told CNN that the gutting of USAID, resulting in cutting “life-saving programs,” could cause millions of deaths globally. The message was clear – the West African Ebola outbreak was resolved thanks to USAID help, thus protecting Americans from Ebola. Further, potentially millions of children would die from malaria because USAID is not saving them. The compere seems clear that a halving of child mortality in recent years is due to foreign money, particularly that of USAID and Mr Bill Gates, while 25 million lives have been saved from HIV by US government funding.
A recent Opinion in the science journal PLOS Global Public Health reflects the same sentiment. Ooms et al. call ‘upon the international community to protect the global responses to HIV, TB and malaria’ in the face of recent funding cuts by the United States (US). The authors argue that other countries must make up the shortfall, particularly for the 2027- 2029 replenishment cycle of the Global Fund to Fight AIDS, Malaria and Tuberculosis (GFATM), since the GFATM is highly dependent on US funding. To support this rallying call, the authors argue that HIV/AIDS, malaria, and tuberculosis are ‘global health security threats’ that require continued collective action. ‘Undermining such collective action,’ they argue, ‘makes the world less safe for everyone.’
HIV/AIDS, malaria, and tuberculosis remain the three biggest communicable diseases, killing millions of people annually with significant socioeconomic impacts, and there is no doubt that Western money has, and is, reducing their harm. Moreover, aid policy priorities should be fastened to the greatest disease burdens, such as these. They also need to be promoting locally owned, contextualised, effective, efficient, and equitable responses. Promoting the building of local and national capacity and sustainability.
This is where the concern lies. If, as is claimed, withdrawal of support now will have such rapid and devastating impacts, then for decades while commodities have been purchased and delivered, capacity to manage disease burden at a local and national level has clearly not been built. The model, while good at patching holes, remains extremely fragile. Simply seeking to direct the same money into more of the same, after more than two decades of doing the same, indicates a failed international health model. Perpetual dependency is inequitable. As we argue below, claims of gains in health security of the donor nation(s) are also based on shaky ground.
Health Security from What?Ooms et al. argue, and Samantha Power implies, that inaction on outbreak detection and suppression of HIV/AIDS, malaria, and tuberculosis ‘makes the world less safe for everyone.’ This statement mirrors another popular phrase within the global pandemic prevention, preparedness, and response (PPPR) lexicon; namely that ‘no one is safe until everyone is safe.’ Statements such as these are purposefully highly securitised and emotive, cultivating collective interest via a direct appeal for one’s self-preservation.
Yet, such claims are often inaccurate and overblown.
First, in the case of the GFATM, 71% of its funding portfolio is directed to Sub-Saharan Africa (as is most USAID support for these diseases), which accounts for 95% of all deaths from malaria, 70% of all deaths from HIV/AIDS, and 33% of all deaths from tuberculosis. Although the effects of the three diseases represent security risks as determinants of political instability, economic underperformance, and societal cohesion, they remain relatively geographically confined. Moreover, despite impacts of climate on vector range, temperate countries and wealthier tropical countries continue to progress in reducing malaria burden while other regions continue to fail. This is because the three diseases are primarily associated with poverty and health system dysfunction. Thus, they represent geopolitical security interests and moral imperatives for donor countries rather than major direct threats to their health security.
Second, the widely stated assumption is that more donor money means better outcomes. Whilst this may be a short-term truth, 25 years of putting large resources into global health institutions has not generated corresponding health outcomes, with some outcomes worsening over recent years. Rather than funding more of the same, this should be an opportunity to reconsider the entire, vertical disease- and commodity- based health model on which USAID’s programs and GFATM are predominantly based. Should we just look for more funds, including as Ooms et al. suggest, draining funds from low-income countries to be cycled through centralized Western-based institutions like GFATM, or consider new models that prioritize health systems and underlying economic and health resilience?
Third, the argument for an increased investment in aid-giving agencies under conditions of increasing scarcity overlooks the numerically larger threat to global health financing; the diversion of unprecedented funds to the growing pandemic agenda. According to the WHO and the World Bank, the financial request for PPPR is $31.1 billion annually, with annual investments of $26.4 billion required of low- and middle-income countries (LMICs) and an estimated $10.5 in additional overseas development assistance (ODA). The World Bank suggests a further $10.5 to $11.5 billion a year for One Health.
As argued elsewhere, mobilizing even a fraction of these resources to PPPR is not commensurate with known risk, representing significant opportunity costs through diversion of funds away from AIDS, malaria, and tuberculosis. In context, this constitutes a disproportionate distribution where the estimated annual $10.5 billion ODA costs for PPPR represents over 25% of 2022 ODA total spend on all global health programmes, while tuberculosis, which kills 1.3 million people per year, would receive just over 3% of ODA.
Health Security for Whom?A common argument against the securitisation of health is that it is underpinned by an ontology that understands threats as being exclusively from the ‘Global South,’ from which developed countries need to remain vigilant. However, an argument could be made that the health security of the Global South is actually undermined by Northern-led aid and the agencies that direct it.
The argument is threefold. First, despite 25 years of increasing investment, global health equity within its portfolio remains underwhelming. Second, GFATM investment has poorly facilitated national ownership, self-reliance, and capacity building, arguably perpetuating aid dependency. Third, and relatedly, though some institutions such as GFATM were originally intended to become redundant, with a mandate to improve country-level capacities as a ‘bridge fund,’ there are few signs of such redundancy. They actually continued to expand their staffing and portfolio.
ConclusionWe agree that the international community should continue to support less-resourced members, prioritizing the highest burden of infectious diseases. However, we disagree that this should consist of perpetual and increasing payments to centralized agencies such as GFATM, GAVI, and the Pandemic Fund, or donor bureaucracies like USAID. There are wider questions that must be asked on how global health policy is designed and implemented, particularly the balance between addressing underlying health drivers and economic sufficiency versus commodity-based vertical programs, and in defining what constitutes success.
Currently, global health is poised to spend billions on pandemic threats of unknown severity based on underdeveloped evidence, and questionable political processes. It has delivered poorly on its ‘golden era’ promises of national ownership, aid effectiveness, and health system strengthening. Ultimately, health security is weakened by continued aid dependency and its modular approach. In this regard, more is not better, but simply more of the same. The US reassessment of national priorities and approach should prompt a much broader rethink.
Garrett W. Brown
David Bell
Blagovesta Tacheva
Jean Merlin von Agris