International Development Assistance for Health: Ten Priorities for the Next President

As the fall elections near, the presidential candidates and many influential organizations are proposing fundamental reform of the health care system. However, apart from the reauthorization of the President's Emergency Plan for AIDS Relief (PEPFAR), which both candidates sponsored, senators McCain and Obama have barely uttered a word about presidential leadership to improve the health of the world's poorest people. (Obama does have a credible policy, but he rarely promotes it.¹) But America has an important interest in international development assistance for health, and for more reasons than are commonly recognized. I offer ten priorities for the next president's agenda.

Is America Truly Generous?

Americans think of themselves as a generous people with a humanitarian commitment. In many ways, we are just that—witness the outpouring of concern in the aftermath of highly visible disasters such as the South Asia tsunami and the earthquake in China. Wealthy private philanthropists also contribute substantially to global health assistance. The United States donates more official development assistance (ODA) in absolute terms than any other country—$21.8 billion in 2007—and its proportion of ODA devoted to health (5.6 percent) is higher than many "Group of Eight" countries.² America is also the clear leader on HIV/AIDS, and it is the only country projected to meet the 2005 G8 Gleneagles commitment to double aid to sub Saharan Africa by 2010.

Nonetheless, the self-image of America as moral and generous does not stand up to scrutiny. In 1975, America and other developed countries pledged to give 0.7 percent of gross national income per annum to ODA. Yet the United States devotes only 0.16 percent of GNI to ODA, placing us last among G8 countries, excluding Russia. By contrast, peer countries such as France and the United Kingdom devote roughly 0.5 percent to ODA, and Norway devotes 0.9 percent—three to four times more than the United States.³

Moreover, U.S. aid is spent ineffectively. Nearly 70 percent of America's global aid budget for health is devoted to AIDS, primarily because of PEPFAR, badly neglecting critical areas of global health such as health systems and maternal/ child health. The One Campaign, a nonpartisan organization that advocates for the elimination of global poverty, ranks the United States as tied with Italy for last on the effectiveness of its aid, as measured against a set of ten critical indicators.⁴ Worse yet, apart from PEPFAR, the vast preponderance of ODA is devoted to countries that have strategic military value to the United States, such as Afghanistan, Egypt, Iraq, Israel, and Pakistan.⁵

Health Diplomacy

The World Health Organization projects that if rich countries increased international aid even modestly, tens of millions of lives would be saved every year. Why should rich countries care?

The traditional foreign policy answer has been that international health assistance is in a country's national interests. In a globalized world, infectious diseases readily spread across national boundaries. Beyond narrow self-interest, there are broader, "enlightened" interests in global health because epidemic disease dampens tourism, trade, and commerce, as demonstrated by SARS, mad cow disease, and avian influenza. These are the traditional foreign policy responses, but if assistance is always tied to self-interest, then funding will always be skewed toward what the rich want to deliver, rather than toward the larger, systemic problems of the poor.

The WHO now urges countries to think of "global health diplomacy" as a justification for enhanced assistance. Although the term is poorly defined, it means that health should become an instrument of foreign, trade, and security policy. It envisages that a country uses development assistance as a way of promoting its values and image in the world and demonstrating its commitment to the common good. The global health diplomacy approach has implications not only for the level and kind of assistance that a country offers. It also involves collaborative relationships among key partners, such as international organizations, states, nongovernmental organizations, and the private sector. It is reflected in a country's sensitivity to the priorities of poor countries...