How to Not Botch the United States’ Next Move in the Fight Against Ebola

If there can be a faint silver lining to the Ebola epidemic, it’s that it demonstrates how unknown, underestimated, or ignored weaknesses in poor countries’ health systems and in the existing global health-security regime (such as it is) constitute a threat. The dearth of health system capacity in poor countries is no longer just a humanitarian and development concern, but a national security concern for the United States as well. The extent of the problem is illustrated best by the response Ebola necessitated: a U.S.-led contingency operation, cobbled together on the fly and building capacity on the ground from scratch.

Being a contingency, the Ebola response is funded from a special account that for the time being avoids direct competition between it and established global health programs, such as those for HIV/AIDS and malaria. But as Ebola-as-a-contingency fades and the long-term health-security requirements persist, direct competition for funding with established health programs is a very real possibility. In a regular budget environment the two would be funded largely through the same foreign operations account.

This funding competition also invites confusion among different program requirements. Both development and health-security in some respect aim to strengthen health systems in poor countries, and USAID plays a leading role in both. But while HIV/AIDS or malaria programming can be helpful for health-security, and vice-versa, they are not the same. Conflating their specific requirements or looking for a “two for the price of one” solution will compromise both.

The White House surely knows this potential conflict is just around the corner, as their Fiscal Year 2016 budget process begins and a possible return to sequestration looms. The conflict for money between the two priorities is avoidable, but it will require the president to show leadership early to arrest the compulsion in Washington to fudge numbers and rob Peter to pay Paul. He can begin with these three basic points:

1) Create guarantees against cannibalization: Our HIV/AIDS and malaria programs are true game-changers upon which millions of people depend daily for life and health. They are programmatically demanding and intensely focused. Their continued ability to save millions of lives cannot depend on assumed, coincidental benefits with health-security. Likewise, health-security is a national security requirement that cannot be pursued effectively on another program’s dime. More to the point, while some shared goals will bring mutual benefits, if we want both, we’ll have to plan and pay for both.

2) Define our objectives: Although Ebola has made the need clear, health systems strengthening, the term that has come to define U.S. goals on this front, is an impractically broad concept under which all sorts of agendas – both appropriate and inappropriate – will seek a piece of the funding pie. The administration must be very clear about exactly what it aims to achieve and how, or risk an outcome that is, in the aggregate, ineffective. Programs must be based on specific targets and unambiguous definitions of success, with the rigor and standards for performance on par with what we demanded of our HIV/AIDS and malaria programs.

3) Think beyond government: The development world tends to view its business in terms of public institutions, and with some distrust of the private sector and especially of profit motive. But a public sector-only approach in this case would be wrong for three reasons. First, the U.S. government and the development finance institutions we fund have powerful tools to facilitate and incentivize the private sector to help build health systems. Whether motivated by corporate citizenship or profit, private investment in health systems holds enormous potential that would be shortsighted to leave untapped. Second, in Africa especially, healthcare is provided and funded significantly through the private sector, especially through out-of-pocket spending. This fact has as much to do with the appalling state of healthcare on the continent as anything, but it is unrealistic to bypass the markets and systems where people go for healthcare. Third, global health partnerships such as the Global Fund and the Gavi Alliance constituted a small revolution in development a decade ago, where the private sector, private foundations, and non-governmental groups participate along with governments in the governance, accountability, and financing of programs. These partnerships have not been without their challenges, but the model has proven effective, especially when the U.N.-based system isn’t up to the job. With U.S. leadership, the global partnership model holds real potential for health-security as well.

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