Better returns on our investments in global health and development

The issue at hand is whether the US should continue its efforts to increase support to local hospitals, governments and faith- and community-based groups in developing countries to promote self-sufficiency so that, over time, countries take over responsibility for the health and well-being of their citizens.
The Bush Administration began a significant push in this direction, in particular within the largest international health initiative in history for a single disease – the President’s Emergency Plan for AIDS Relief (PEPFAR) – and the Millennium Challenge Corporation. The Obama Administration has picked up, evolved and expanded this strategy.  There is remarkable congruence between the speech President Bush gave at his 2008 White House Summit and the speech Secretary Clinton gave in Oslo last week.  Of note, the 43rd President continues to press the same themes with his global health program at the George W. Bush Institute.
The reason for the strong bipartisan agreement is rather simple: it’s the right thing to do for the American taxpayer to save and lift up more lives with the highest return on investment – and that, in turn, is good for our national economy and security.
Local organizations are closer to the ground and create innovative solutions for their health and development challenges. And they do it for far less money than U.S. - and internationally-based organizations. So the American taxpayer gets better outcomes for less money. That’s not an argument to cut spending – because the value for money is so much higher, it’s a strong argument to spend more to fully tackle the massive health and development challenges.
A higher return on investment in health and development pays more than humanitarian dividends. Data show, common sense dictates, and corporate leaders argue that healthy, educated populations in well-governed states expand economic growth around the world and provide new markets for American goods and services. So while a small number of US jobs might be lost in certain development organizations with a shift to local groups, the job growth potential for the US could be significant. In addition, poor, uneducated, unhealthy populations are breeding grounds for fundamentalism – tackling these problems make us more secure.
Finally, the paternalistic era in development is over.  he people of other countries no longer welcome support for programs run from foreign lands. A new approach based in full partnership promotes the image of America and Americans and enhances receptivity to US businesses and American foreign policy.
Those opposed to the bipartisan shift to supporting local organizations point to sporadic corruption scandals.  Corruption on any level is totally unacceptable. The solution is a vigilant, results-based approach – since it is difficult to achieve results if money is stolen and a culture of accountability and responsibility is not enforced.  In addition, beefed up and frequent audits can root out most problems. The Global Fund to Fight AIDS, Tuberculosis and Malaria has begun a revitalization and reform agenda along these lines and other institutions must do the same.  We must also acknowledge that corruption is not limited to local organizations in the developing world.
Another argument is that local organizations cannot manage large programs. In the Bush Administration, PEPFAR required that large US-based HIV treatment programs turn over their activity to local organizations within three years.  Capacity has been built and the transition is being completed under the Obama Administration. There is nothing more complicated than HIV treatment – if those programs can be successfully transitioned, anything can.  The key is to build capacity.
Here is the bridge across the battle lines. America must remain involved – and for health and development diplomacy must be seen to be involved.  And US-based organizations must remain engaged. The only question is the face of US involvement and the role of US-based organizations.  U.S.-based organizations will be needed for the long-term to build the capacity of local organizations to provide services and prevent corruption and for long-term technical support as local groups take over implementation – a role they are playing very effectively for the PEPFAR treatment programs that have been transitioned.  Faith-based organizations, in particular, have a long tradition of building local capacity.
The pace of capacity building and transition will be different in various countries and areas of health and development. Great care is needed to ensure that the quality of services and strict accountability for funds is maintained. And in the near-term, and in some countries with chronically poor governance, the long-term, U.S.-based organizations will be needed for ongoing implementation.
A change in mindset is needed. U.S.-based organizations should begin to shift from being primary implementers of programs to agents of technical support and exchange. Organizations that make this transition will have significant opportunities to grow their business. That shift is the smart strategy for the American taxpayer to ensure the highest return on investment in saving and lifting up lives, and is in our long-term economic and national security interest.  In other words, more than 200 years after his death, we should apply Adam Smith’s notion of enlightened self-interest.
So let’s uphold the strong bipartisan consensus on this issue. It’s the right and the smart thing to do.

Ambassador Dybul, a distinguished scholar at the O’Neill Institute for National and Global Health Law, Georgetown University and Inaugural Global Health Fellow at the George W. Bush Institute formerly served as U.S. Global AIDS Coordinator, 2006-2009.

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