“I think health systems can be quite sexy,” said Dr. Rajiv Shah, the USAID Administrator, during an event at the Center for Strategic and International Studies yesterday. He made the statement as an off-the-cuff remark when comparing new efforts to scale up health system strengthening (HSS) rather than focusing on vertical, disease specific projects. And I certainly agree: health systems are quite sexy.
The theme of the event was global health policy, with an emphasis on the Global Health Initiative, a $63 billion commitment funneled through USAID, the CDC, and PEPFAR (at the State Department) to improve health outcomes overseas. Specific goals include reducing the number of maternal deaths, prevention of millions of new HIV infections, reduction of under-five mortality, and to eliminate some neglected tropical diseases. Shah noted that $63 billion was double the amount spent on global health projects over the past six years, and has the potential to make a significant impact if spent wisely.
I have not had the opportunity to see Shah speak before, and I was impressed by his candid, humble, and thoughtful attitude; he was even more eloquent in the question and answer session than in the speech itself, and presented himself as the kind of boss/colleague/authority figure who you not only would respect, but would also want to be friends with. The former USAID Administrator, Henrietta Holsman Fore, introduced Shah, giving him glowing accolades and highlighting the strong, positive relationship the two of them have, something of an anomaly in an city often dominated by differences in politics rather than coming together for the common good.
While Shah made a number of interesting points throughout his presentation, highlighting programs he witnessed on different trips to the USAID Mission and USAID sponsored projects in Senegal, Kenya, Bangladesh, Sudan, and other countries and outlining the core tenants of the GHI, a few recurring themes throughout the speech and the question and answer that gave me great hope for USAID under the leadership of this remarkable physician.
In the past, he observed, many USAID sponsored clinics were “organized around disease specific interventions, and not the patient.” As HIV swept through many African nations, like Kenya, space allocated for oral rehydration therapy (a cheap way to save a child’s life when he or she is suffering from diarrhea) was transformed into space for voluntary counseling and testing. Some clinics could provide prevention of mother-to-child transmission services, but lacked the course of drugs necessary to treat a case of malaria. And when funding ran out, there were gaps when services were unavailable. These vertical programs (“silos”) have been ineffective in getting to the root of many of the problems and issues in countries where under-five and maternal mortality are staggering; instead of building local capacity and enabling capable members of the community to treat the patient, they treated the disease.
“The GHI is not for building health systems for the sake of building systems,” Shah reminded the audience. The initiative emphasizes the involvement of community members, scale up of community health workers to bridge that last mile between a health facility and a woman with a dying child, faith-based organizations, government, and other stakeholders. In addition, he sees the project as a way to “create conditions that will reduce the need for future aid,” an end-goal I support wholeheartedly.
This will require the buy-in of many stakeholders, rather than a movement led by one or a few individuals. Instead of mirroring the strategy of the child survival movement in the 1980’s, which saw massive gains in vaccination rates and reductions in child mortality under the stewardship of James P. Grant at UNICEF, only to be lost when the leaders of the movement moved on, Shah is looking for individuals and groups at all levels to work together to achieve mortality reductions.
Talk is cheap, though, and while I have great faith that Shah’s enthusiasm, passion, and the respect he both commands from others and gives in return will all serve him well in his post, I will continue to follow where the GHI goes as it is implemented, and what results we see. “I think of development not as charity, but as a strategic investment to buy outcomes,” Shah said. Perhaps having a visionary leader who looks at global health challenges through both the lenses of medicine and business will be the key to achieving the successes we have been striving for since the 1960’s.
[As an aside: a question from the audience on how to convince Americans spending so much money on global health projects in a time when the government is operating on a massive deficit, our national debt is mounting, and many Americans themselves are struggling has been swimming circles in my mind since yesterday, and prompted me to do a bit more digging for information. I’ll be posting on that topic later this week.]