On March 23, the House Appropriations Subcommittee on State, Foreign Operations, and Related Programs held a hearing on global health and HIV/AIDS programs at the State Department and U.S. Agency for International Development (USAID).
Chair Nita Lowey (D-NY) said, “This committee has made global health a key priority, providing over $30 billion over the past five years, with impressive results: HIV/AIDS programs directly supported 2.4 million people on treatment; malaria programs have protected 19 million families with bed nets; and 19 million women have accessed voluntary family planning services. Despite expanded services, the development of parallel systems or ‘stovepipes of excellence’ present challenges with integration and efficiency. It makes no sense for a woman to travel east of her village for pre-natal visits, west to get her daughter vaccinated, and north for an HIV/AIDS test. I’m pleased the budget request purposes to better coordinate our efforts, particularly given the strong foundation within our HIV/AIDS programs.” However, Rep. Lowey also raised several questions regarding the strategies for maternal and child health and nutrition programs, saying, “In FY2008, USAID developed a comprehensive strategy, at the direction of this subcommittee, to expand child survival programs focusing resources in 30 countries. What results were attained with these additional resources? What lessons learned will be applied to the GHI [Global Health Initiative]? Do we expect improved results with an integrated model under the GHI? I have championed expanded access to voluntary family planning for many years. We still find ourselves unable to meet the demand in much of the developing world. Under the GHI, how will U.S. government resources ensure access to those most in need of these services? What efforts will be made to integrate family planning with other services for mothers, including child survival and malaria programs? Other donors have prioritized family planning, and I am interested to hear how you will coordinate with them so the expanded U.S. effort fully complements their programs.”
“I want to be on record that the goals of the president’s Global Health Initiative are impressive, important, and worthy of support,” said Ranking Member Kay Granger (R-TX). She continued, “These goals include achieving better health for women and children in the developing world and providing a long-term plan for delivery of health services led by the countries themselves. Funding for global health programs has increased significantly since the start of the Bush administration to last year’s enacted level from $1.8 billion to $7.8 billion. This three-fold increase in funding has allowed for a rapid scale up of our health interventions overseas. Now is the time to begin examining the path forward because this level of increase cannot be sustained while our own country faces such a dire fiscal situation.” Rep. Granger continued, “I applaud the administration for looking at how to shift the global health debate to sustainability…We have a long way to go to achieve these goals, but I commend the administration for starting the dialogue. In practice I see a number of challenges, in particular to faith-based organizations that I hope to address today during my question time. Additionally, I don’t understand why a presidential initiative of this size is not being formalized through authorization legislation. Instead, the administration has put this subcommittee in a difficult position by requesting a number of significant funding increases for several programs maternal and child health, nutrition, family planning, and neglected tropical diseases but, there is no legislative recommendation for laying out the concrete steps necessary to determine how these dollars might be spent differently. How can we be assured that the Global Health Initiative will not just add another layer of bureaucracy to these crucial programs?”
Ambassador Eric Goosby, United States Global AIDS Coordinator at the State Department, discussed the successes of the President’s Emergency Plan for AIDS Relief (PEPFAR) and how the program will serve as a foundation for the newly established Global Health Initiative, saying, “In fact, PEPFAR is the cornerstone of the president’s Global Health Initiative, which commits $63 billion over six years to support partner countries in improving and expanding access to health services…In addition to this funding commitment, GHI is about new emphasis on integration, coordination, building capacity, and creating the conditions for long-term sustainability. I want to stress that this new initiative will not change PEPFAR’s emphasis on prevention, care, and treatment of HIV/AIDS, but will allow us to ensure that communities affected by HIV have access to a comprehensive set of health services to address the range of health needs they face.”
After detailing the president’s FY2011 budget request for the GHI, Mr. Goosby explained that “According to UNAIDS, 33.4 million people are living with HIV worldwide, and approximately 2.7 million new infections occurred in 2008. For every two people who start treatment, five more are infected. Women and girls continue to face a disproportionate impact of new infections. The World Health Organization (WHO) reports that AIDS is the leading cause of death worldwide for women in their reproductive years (ages 15-44) and these women who die often leave behind children who are then themselves at higher risk for adverse health outcomes.” Among the improvements detailed by Mr. Goosby, he noted, “I would particularly like to note a marked increase in the results achieved by programs for prevention of mother-to-child transmission (PMTCT). In FY2009, PEPFAR-supported programs provided services to millions of women, allowing nearly 100,000 babies of HIV-positive mothers to be born HIV-free, adding to the almost 240,000 infant infections averted during the previous years of the program. Our PEPFAR country teams deserve great credit for this significant boost in PMTCT efforts.”
In discussing the “renewed focus on prevention,” Mr. Goosby said, “A successful prevention program requires a combination of mutually reinforcing interventions tailored to the needs of different target populations. In recent years, several low-prevalence countries have had some success in containing their epidemics, concentrated in most-at-risk populations. However, only a few high-prevalence countries have significantly reduced HIV prevalence. Increased attention is critical for hyperendemic countries, while simultaneously continuing to respond to countries with both concentrated and generalized epidemics…At the country level, multiple epidemics exist within diverse populations and social networks, including concentrated epidemics within larger generalized epidemics. Identifying and targeting interventions to match these needs is difficult, especially when such epidemics involve groups that are often marginalized and discriminated against. Stigmatized populations are frequently hidden and hard to reach with services. PEPFAR will support efforts to address the prevention, care, and treatment needs of most-at-risk populations. In addition, the disease’s disproportionate impact on women and girls means that our prevention programs must focus on interventions behavioral, biomedical, and structural that will keep women and girls safe from infection. And an essential part of meeting the needs of women and girls involves working with men and boys to change attitudes around gender.”
Gloria Steele, senior deputy assistant administrator for Global Health at USAID, explained that $900 million in the president’s FY2011 budget request for global health would be allocated to maternal and child health (MCH) programs, including nutrition programs, in order “[t]o scale up and deliver health interventions that have the potential to substantially reduce maternal and under-five mortality.” She said, “Allocations to countries are based on magnitude and severity of maternal and under-five mortality, and operational factors including country commitment that predict program success. Every year, 8.8 million children die in the developing world; approximately two-thirds of these deaths are from preventable disease and malnutrition. In addition, 530,000 mothers die every year from complications related to pregnancy or childbirth, and for every woman who dies, 20 more suffer injury, infection, or disease. MCH activities will be integrated with family planning programs in all countries; with PEPFAR’s investments in strengthening prevention of mother-to-child transmission in countries with generalized HIV epidemics and follow-up of HIV-positive mothers and HIV-exposed and infected children; with safe blood programs; and with PMI’s [President’s Malaria Initiative] investments in bed net provision and treatment of pregnant women, infants, and children. By developing and implementing high-impact, evidence-based interventions, delivered at low cost, USAID’s maternal health programs have helped reduce maternal mortality in 15 countries by nine to 48 percent since the late 1980s. In eleven of these countries, newborn mortality also decreased by 16 to 42 percent. With USAID support, counties as diverse as Nepal, Cambodia, Ethiopia, Madagascar, Tanzania, and Afghanistan have reduced under-five mortality by 25 percent in five to seven years.”
Ms. Steele added, “In the past year, USAD introduced a number of new high-impact interventions including: post-partum hemorrhage prevention and management and active management of the third stage of labor (AMSTL) in 16 of the 30 priority countries, to address the major cause of maternal mortality; a package of essential newborn care preventive interventions that can be used in home births as well as facilities in 19 countries – USAID-supported research has shown that this package of preventive newborn care can reduce neonatal mortality by about one-third; zinc for treatment of child diarrhea in ten countries; and point-of-use drinking water disinfection for prevention of child diarrhea in ten countries. Our MCH program will scale up efforts to combat maternal mortality and apply a women-focused ‘dual-track’ approach, rapidly expanding coverage of existing life-saving interventions that can be provided now (such as prevention and management of post-partum hemorrhage, the leading cause of maternal mortality in the developing world; family planning; anemia reduction; and clean delivery), with simultaneous investment in building the longer-term human resource and system capability required to provide comprehensive obstetric care.”
Ms. Steele also noted that “In countries with high mortality rates and weak health systems, reducing mortality requires bringing a basic set of high impact services as close as possible to the people who need those services. For this reason, USAID’s Maternal and Child Health programs have pioneered, and FY2011 funding will strengthen and expand community-based approaches, such as treatment of child pneumonia and newborn sepsis, misoprostol to prevent post-partum hemorrhage in home deliveries, and behavior change programs to promote breastfeeding. These approaches are often delivered through partnerships with NGOs [nongovernmental organizations], but need to be taken to scale as components of national health sector programs.”
