GHI: A rough beginning

By John Donnelly

ADDIS ABABA, Ethiopia — The emergency room entrance to Black Lion Hospital, the largest hospital in Ethiopia, was jammed with people. Some shuffled, leaning on canes. Some cradled frail loved ones in their arms. Dr. Solomon Zewdu, the head of the AIDS treatment program, slowly wound his way through the suffering here on the frontlines of the global health battle.

Zewdu is in charge of a large-scale, United States government-funded AIDS program that started under the administration of George W. Bush. He was checking on two projects at the hospital that seem to embody the profound challenges that lie ahead for the next generation of U.S. global health programs which now fall under President Barack Obama’s Global Health Initiative, or GHI. Zewdu questioned if the Obama plan was actually operating.

Seven thousand miles from Washington, Zewdu looked back over his shoulder in the crowded corridor with scores of ill patients sitting on benches or the floor waiting for hours for help and asked, “Have they defined GHI yet?”

That’s a question doctors and public health officials from Guatemala City to Addis Ababa to Kathmandu have been asking for some time, only now with more urgency. It’s been two years since Obama announced he would be putting forth his own global health program in an eight-paragraph statement from the White House, and nearly a year after the administration identified eight countries in which the program would start “learning laboratories.” They are Bangladesh, Ethiopia, Guatemala, Kenya, Malawi, Mali, Nepal and Rwanda.

But so little has happened that even those such as Zewdu, who heads Johns Hopkins University’s AIDS treatment programs here in one of GHI’s eight focus countries, know almost nothing about GHI.

Obama’s low-key announcement and its poorly defined vision for what it seeks to accomplish stand in stark contrast to Bush’s much-trumpeted announcement in a State of the Union address in 2003. Back then, Bush kicked off a forcefully directed and massively funded initiative to fight AIDS around the world, known by its acronym PEPFAR. Obama’s plan sought to be equally ambitious, but more ‘holistic’ in its approach. It was designed to prepare the ground for a new way of improving the health of the poorest people in the world by coordinating efforts to improve the overall health of communities rather than focusing on a more precise target of certain diseases.

This new strategy put Obama’s signature on a main pillar of his administration’s foreign assistance. His pledge was to expand U.S. government focus much more aggressively into other critical global health challenges, such as saving mothers when they give birth or protecting communities from river blindness, instead of the United States continuing to attack one disease at a time, such as AIDS, tuberculosis and malaria, without any coordination.

But the reality so far falls dramatically short of the vision. The administration can point only to a few small programs started under GHI in countries around the world, and those are too new or too small to yield any tangible results. While many health experts argue that it takes time to overhaul assistance to a network of programs, and that ensuring quality is more important than rushing into something, the considerable delays in turning words into action have put the initiative in some fiscal peril. And as a result, supporters fear the GHI’s lofty goals may now be threatened.

Congress and the administration have entered what appears to be a bitter and prolonged period of budget cutting battles, and foreign assistance in general stands to lose billions of dollars a year. No one believes now that GHI will come close to Obama’s target in 2009 of spending $63 billion over six years. If flat funding continues for the next three years — Congress basically flat funded GHI in the FY 2011 appropriation — GHI’s six-year spending total would be no more than $52 billion. But analysts tracking GHI say that flat funding is optimistic and that it would likely be several billion dollars lower than that. It could mean that GHI would receive roughly one-third less in funding than anticipated, say analysts. Funding at that amount would be even less than Congress authorized in 2008 to fund just the fight against AIDS over six years, and Obama’s vision of a more comprehensive battle for global health would be significantly diminished.

What happened to GHI? And what happens next? In a series of reports over the coming months from Washington and in capitals around the world, GlobalPost will examine the behind-the-scenes decisions in the Obama administration as well as what diplomats and health experts are doing now in several countries to try to bring to life this new, but what some say is a stumbling approach in global health.

“The goals and principles of GHI are absolutely correct,” said J. Stephen Morrison, director of the Global Health Policy Center and senior vice president at the Center for Strategic and International Studies, a Washington centrist think-tank, who recently visited two GHI programs in Ethiopia and Kenya. “But GHI is off to a very poor start. It has no new money. And it’s looking for funds in a period of acute budgetary constraints and a divided government.”

Ann Starrs, president of Family Care International and a member of the GHI Initiative Coalition, a group of NGOs that closely track developments in the program, said that professionals working in global health were very enthusiastic about GHI when it was first announced. But now, she said, “the initial price tag of $63 billion has become impossible to achieve. What GHI has become is a set of very worthwhile principles, of people trying to work together across the agencies and provide more integrated services on the ground … but they will be doing it with whatever money they already have in their budgets or whatever little Congress gives them. It is disappointing.”

Lois Quam, who was named GHI’s first director three months ago, acknowledged the slow beginning, saying “there definitely was a period in 2010 when there was a very heavy internal focus of GHI. We have moved beyond that now.”

But she isn’t giving up on the chance to increase GHI’s budget. She said GHI should be especially appealing to lawmakers in a tight budgetary time because its emphasis will be on finding ways to improve health care and also looking for savings at every turn.

“I think the budget situation makes GHI even more important,” Quam said in an interview with GlobalPost in early April.

“If you look at the underlying importance of working closely with countries, to see what works and what doesn’t work, the idea and principle around building more sustainable systems speaks to effectiveness and efficiency,” she added.

Dr. Ezekiel J. “Zeke” Emanuel, an architect of GHI while serving as a top global health aide to Obama, also said he had no doubt that GHI will eventually show its merit.

Asked about the slow start, he said, “I’m an impatient guy. Of course, I’m frustrated. But I’m also realistic. Have we made as much progress as we would like? No. Have we made no progress in the field? That’s absolutely wrong.”

Emanuel, who returned to his former position as chair of the Department of Bioethics Clinical Center at the National Institutes of Health, continued: “How are things now? After two years, are there substantial changes? Yes. But has the problem been completely addressed? No. But that was never a realistic goal. In three or four years, our health programs are going to look different. PEPFAR looks different than how it started.”

An emphasis on getting it right, not speed

In Ethiopia so far, funding — or lack of it — isn’t the driving focus of GHI. Building a better health system is, and to do that many here on the ground believe money may be less of a determining factor than finding a way to effectively coordinate efforts.

In both cases, Zewdu was able to use PEPFAR dollars because he was building on existing AIDS programs, which happened also to help patients with other diseases or conditions. At the Black Lion Hospital, Zewdu checked on two U.S.-taxpayer supported construction projects now under way — each for under $100,000. The first is to consolidate the hospital’s six labs into one, which will allow for far greater efficiency of staff as well as making it easier for patients to access services. The second is to move the pediatric emergency facilities from its current dark, cramped quarters, which have no infection control measures, into a new space that is five to six times larger. The new pediatric emergency room will feature an elevated nurses’ desk that has a 360-degree view of the area and has isolation rooms for children with deadly infectious diseases.

“Where PEPFAR stops and where GHI starts, we don’t know,” he said. “GHI just got started, but these projects define what GHI is about — at least I think they do. So we’re leveraging PEPFAR funds to start building pieces of the health system. In a pediatric emergency room, you don’t want to discriminate for HIV or against HIV patients. You want to treat everyone.”

Zewdu said he wasn’t so worried about whether GHI would have much new funding. He said that PEPFAR was necessarily started as an emergency to save lives as quickly as possible and that meant creating duplicate structures, such as stand-alone treatment centers, which were costly. Now that there’s time to plan new systems, he said, he and others can find savings.

“The beauty of what we’re doing now is it doesn’t take a lot of money,” he said amid the construction of the pediatric emergency room, which still had exposed gray concrete walls and newly cut electrical outlets. “But it does take a lot of effort.” Just that afternoon, Zewdu was going to give a tour of the facilities to an expat couple living in Addis Ababa who wanted to donate wallpaper festooned with large cartoon characters to brighten up the place.

On a plane ride from Addis Ababa to Washington a couple of days later, Ethiopia’s Health Minister Tedros Adhanom Ghebreyesus made the same point. In an interview, he said he wasn’t overly concerned with how much time it has taken to come up with a plan for each country. He said he expected the GHI Ethiopia plan to be finished by mid-May. He and U.S. Ambassador Donald E. Booth co-chair a committee that has been meeting monthly to work out the details.

“I think it will be a really integrated plan, which is really good,” said Dr. Tedros, one of the world’s best-known health ministers who is also chair of the Global Fund to Fight AIDS, Tuberculosis and Malaria. “I don’t think this has taken too long. If you rush in, you often make mistakes.”

Asked if GHI would allow Ethiopia to expand its programs, Tedros said he hoped that would happen but he said he was more concerned to see that the GHI program supports Ethiopia’s health goals.

“We expect more money, obviously,” he said. “But I worry less about the additional money than the quality of the programs. You could give me $300 million without the right approach, but I would prefer if you give me $100 million with the right approach because I can use it in a way that can add value. The value of $100 million used the right way could be more than $300 million used improperly.”

For Tedros and other developing country leaders, the GHI approach already is helping support one of his main goals: allowing the countries to assume more leadership over its health programs. That is a significant shift from years of U.S. foreign assistance policy in which it largely controlled funding for programs deemed best for the country. Now, GHI has promoted intensive talks with country leaders on how to tailor U.S. assistance to country priorities.

But in the meantime, U.S. embassies and developing countries are realizing that GHI isn’t going to have the same trajectory as the Bush administration’s fight against AIDS: No one is expecting large increases in funding anymore.

“GHI for the most part is taking existing funding streams and to get them to work together,” said U.S. Ambassador Booth who gathered his health team at the embassy to discuss the GHI program.

Across the table, Dr. Thomas Kenyon, the former deputy chief of PEPFAR in Washington and now the Centers for Disease Control director in Ethiopia, said that all U.S. officials in the field “were very aware that the budget climate is difficult now. But I don’t think we ever envisioned that the U.S. government would be doing this alone. We’re going to need our partners to help.”

Ambassador Booth, a veteran U.S. diplomat who previously served as ambassador in Zambia and Liberia, said that people should be patient with those directing the new health program. “It’s going to take a while before we will have a full answer for all the partners who ask what are the changes with GHI,” he said. “GHI changes the way we work. We now have a one-health-team approach. And we have no new money in it.”