Guest Blog: GHI May Unravel PEPFAR's Success

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Last week, the Kaiser Family Foundation held a forum on the Obama Administration’s Global Health Initiative, sparking fresh debate over this significant shift in U.S. global health policy. In response to the presentations made by top U.S. government officials at that event, Shepherd Smith, a well-known AIDS advocate and program coordinator with considerable knowledge about the history and politics of PEPFAR, wrote this commentary about the Administration’s proposal for a six-year $63 billion GHI.

First and foremost, there is no one in the global HIV/AIDS community–clinicians, advocates, implementers, etc.—who disagrees conceptually with the intent of the Global Health Initiative (GHI).  In fact, the PEPFAR reauthorization legislation, known as the Lantos-Hyde Act, makes foundational the need to deal with a broad range of opportunistic infections, to strengthen healthcare systems, to train more healthcare workers, and to tackle a host of other activities in a more comprehensive manner than just addressing HIV, TB, and malaria. How and where that is done—and at what cost–is the issue at hand.

The announcement of the GHI in May of 2009 shed little detail on what this new $63 billion program might look like, leading many to believe little thought had gone into the initiative.  Nearly a year later, we are beginning to see the outlines of this plan. Clearly, it is a work in progress that needs further discussion and a broader airing. We now know, for example, that the $63  billion is not really new money, but rather the $48 billion authorized over five years in the Lantos-Hyde Act, with a sixth year tacked on at the end.  There is, perhaps, over that six-year period possibly two or three billion dollars of “new” money. So what does that mean for the core PEPFAR program? And how can a new global initiative be successful with so few new dollars?

PEPFAR concentrated on the countries hardest hit by HIV/AIDS, while this new initiative appears designed to be inclusive of all the developing nations in the world.  In order to gain the resources to do this without any significant additional funding, there has to be some deconstruction of the highly successful PEPFAR program. Furthermore, building an entirely new GHI program, which still has not been entirely fleshed out, will take time and some trial-and-error efforts before we get it right.  That takes a lot of energy and a lot of money.  By lessening the emphasis on the core PEPFAR focus to develop a global program with limited funding may well result in the failure of not just one initiative, but both. This then is a high-risk venture.

It would be helpful to publish any risk analysis that has been done on GHI in respect to its impact on PEPFAR if future funding is flat-lined or reduced. For example, the HIV-positive patients now in care under PEPFAR fully expect to be put on antiretroviral therapy once their CD4 count falls below two hundred.  Is this still a realistic expectation? And if not, how is that explained to host countries and to those who will suffer and die if they don’t get access to treatment?

The credibility of the United States is at stake in this significant and sudden program change.  We have made commitments and established excellent working relationships with the countries that have benefited from PEPFAR.  If we don’t meet those commitments, there will be legitimate criticisms of the U.S.  Many of these countries have very limited resources and will now be asked to shift funding and emphasis. They will have to wonder if a subsequent administration will require them to change everything yet again.   

One particular concern is how GHI will interact with the faith community, which delivers 30 % to 70 % of all health care needs in developing countries, according to World Health Organization estimates. The short GHI narrative nearly overlooks the important role the faith community plays, as well as services other NGOs provide. If failures arise in the core PEPFAR program that negate the commitments these faith entities have made to their patients and congregants, then they will naturally shy away from future participation in U.S. government sponsored health programs.  This aspect alone should cause us to be certain the commitments we made under PEPFAR are met–before moving forward with the GHI.  Already, there have been media reports that some clinics in PEPFAR countries are being forced to turn away new patients seeking HIV treatment because of flat funding.  If such scenarios continue, there will be needless suffering that will not cast a positive light on the GHI.

Another concern is the Administration’s statement, in the GHI consultation document, that “the GHI Fund is expected to increase in FY 2012 and beyond.” That may be wishful thinking of the highest order at this particular time in our nation’s history. It’s almost as if those writing this haven’t watched the news in several years. The American people are saying we need to stop or reduce federal spending, and that needs to be factored into the funding equation for this new program. If spending goes down instead of up, there needs to be a contingency plan for the core PEPFAR program, which so much of this seems to be dependent on for success.

The uncertainty now building around both PEPFAR and GHI is not healthy, and it can only be resolved through Congressional hearings that promote a greater understanding of the issues surrounding this significant shift in policy. Without a strong bipartisan political commitment to this initiative (as there was to the reauthorization of PEPFAR), there is serious potential for failure of not just GHI, but PEPFAR as well. The GHI’s success is dependent on an increase in funding, which at this point may or may not happen. Without that guarantee, we may do more harm than good in embarking down this new road.

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