This is a joint post with Rachel Silverman.
Since the launch of the Obama administration's $63 billion Global Health Initiative (GHI) in May 2009, we have followed its ups and downs with great enthusiasm (see for example: here, here, and here), trying to better understand its structure and role within the U.S. government's complicated global health architecture. One recurring question we have continually raised has focused on leadership: who, exactly, was to be in charge of this massive undertaking? Who would be accountable for meeting the initiative's eight high-level targets and adhering to its seven guiding principles?
Last December, the State Department's Quadrennial Diplomacy and Development Review (QDDR) appeared to put those questions to rest. According to the 200+ page document, USAID would assume leadership of the GHI by September 2012, contingent upon fulfilling a set of 10 benchmarks to demonstrate its capacity. But upon closer inspection of the GHI over the last year, the QDDR provision only seems to have generated a new set of questions that are more difficult to resolve. While there are no easy answers, the administration should consider these issues as it thinks through the tough decision of pulling the GHI together under one leader and demonstrating success by meeting its targets:
Let's start by eliminating what GHI leadership is not. GHI leadership does not entail budget authority. It would not grant USAID decision-making authority for other agencies within the GHI's purview. It is also our understanding that it won't restructure the current reporting lines within the government, meaning that the heads of other GHI implementing USG agencies will not report to the USAID's Administrator Raj Shah. So, you might ask, what else is there? Not a whole lot. Essentially, the GHI leadership as we see it holds a vague mandate to "coordinate" the GHI agencies. Except that the QDDR specifically exempts PEPFAR (see pages 84 and 217) -- about 70 percent of the GHI's total funding -- from USAID leadership, stating that this program will remain under the Office of the Global AIDS Coordinator (OGAC). And OGAC is already responsible for coordinating USAID and other USG agencies under PEPFAR. So, if USAID coordinates the GHI, you get the picture -- everybody will be coordinating each other!
To sum up: as the GHI leader, USAID will coordinate activities representing about 30 percent of the initiative's total budget, with no authority over funding allocations, decision-making, or the actions of other agency leaders.
If this gives you a headache, you've got company. We tried to map out what the USG GH architecture might look like with USAID as the GHI leader, and OGAC as the PEPFAR coordinator; after several attempts to create a diagram, we gave up. In our effort to identify a practical solution for a way forward, we realized that maybe USAID is being set up for failure; not intentionally, but because the GHI was launched without any clear vision about how it could be operationalized under the current U.S. foreign assistance structure. By burdening USAID with eventual responsibility for the GHI's success but with no authority or leverage to make it happen, the QDDR has inadvertently placed USAID in an impossible situation. Backtrack now and lose face -- it will appear as if the State Department thinks USAID is ill-equipped to lead. But grant USAID nominal "leadership" of the GHI with no real authority, and they're set up for failure.
We know the deadline for the GHI's transition to USAID is still a year away, but the administration has some difficult decisions to make, and quickly. The president's global development legacy is at stake if one of his biggest development initiatives is seen to fail. Here are the options, as we see them, along with their respective trade-offs-constraints, costs, and benefits:
The Bottom Line: Only USAID has the technical capacity to lead the GHI as a development initiative, and it is the natural choice for leadership of the initiative. But beware: by giving USAID responsibility for success without the mandate to meaningfully steer the initiative, USAID is being set up to fail.
We want to hear what you think. What is the best option for the GHI to succeed, knowing that there are tough trade-offs?