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When the U.S. funds global health, other countries do too

- March 21, 2017
Health workers take blood samples for testing at an Ebola screening tent in the local government hospital in Kenema, Sierra Leone in June 2014. (Tommy Trenchard/Reuters)

In President Trump’s proposed budget, there’s a $54 billion bump in military spending. U.S. foreign aid would be cut by 28 percent. Global health spending beyond AIDS, malaria and vaccines will suffer.

This type of foreign aid, according to many U.S. policymakers and military leaders, increases soft power, or the global influence the United States has because it supports basic human rights and humanitarian causes. Emma-Louise Anderson and I show this payoff for the United States among people living with HIV in Zambia and Malawi.

Public health experts say that cuts to U.S. global health funding — which makes up less than 1 percent of the federal budget — threaten the health of U.S. citizens, since pathogens such as Zika, influenza and Ebola can cross borders. For other policymakers and advocates, it is morally unjustifiable to cut health programs that save millions of lives.

Global health programs have a big impact

My research on the politics of health in Africa shows another benefit. U.S.-funded programs interface with domestic politics to create incentives for governments to take action on health issues.

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My book on “Africa and Global Health Governance: Domestic Politics and International Structures” (forthcoming, the Johns Hopkins University Press) details these outcomes. Over a period of a decade, I conducted interviews and focus group discussions with advocates, policymakers, donors and NGOs working in five African countries and the United States. My work included analyzing cross-national health data.

I found that African officials face deep socioeconomic challenges and a lack of resources and tend to view health issues as private. Global health programs — supported by U.S. and other donor countries — helped leaders to prioritize health, particularly when they supported grass-roots health advocates in Africa. Global efforts establish the expectation that governments should promote health. Funding and technical assistance from Western donors, U.N. agencies and NGOs empower national efforts.

Here’s an example: global AIDS programs

Beginning in the late 1990s, global advocates, donor states and U.N. agencies coalesced around an understanding that AIDS treatment and nondiscrimination is a basic human right, and they promoted the norm that people living with HIV must be involved in policymaking. They institutionalized UNAIDS, the agency that coordinates all U.N. activities on AIDS and provides technical assistance to countries.

Donors and governments also established funding mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, which gives nearly $4 billion in grants to combat these three diseases. The United States led these efforts, pushing discussions in U.N. bodies, providing scientific expertise and donating funds.

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In 2015, international funding for AIDS was roughly $7.5 billion. Over the past two decades, the international community helped African states — many of which have a high number of 15- to 49-year-olds living with HIV, the virus that causes AIDS — develop AIDS governance structures. And they promoted local AIDS advocacy.

The result is that today all African countries have national AIDS strategies and commissions. Their leaders speak publicly about AIDS. Almost every country involves people living with HIV in policymaking. Between 2011 and 2015, African countries increased their own AIDS funding by 150 percent, with 32 countries spending more on AIDS in 2014 than in 2010. U.N. policymakers have praised the region for increasing access to AIDS treatment.

It is simplistic to assert that donors alone pushed African countries to act. Instead, donor programs encouraged domestic health programs so that African leaders began to claim this health issue as their own. Over half of African states increased representation on national AIDS institutions to include multiple ministries, civil society organizations, people living with HIV, and faith-based leaders. These AIDS institutions became an important way to foster political alliances and disperse program resources.

Other research shows how these types of inclusive political institutions foster system stability and encourage long-term development.

Throughout Africa, foreign donor support for AIDS advocacy has enabled collaboration between the state and civil society. In both Ghana and Tanzania, for instance, the national AIDS commission helped advocates to coordinate local HIV prevention and advocacy efforts. In Zambia, the committee included church-based health-care providers as part of a broad-based collaboration between government and nongovernment actors.

There’s an added political bonus: increased government legitimacy

In a 2013 survey conducted in 34 African countries, 69 percent of respondents said their governments were doing a fairly good or very good job in combating AIDS. Only 41 percent gave high marks to governments for providing water and sanitation, while 57 percent gave high rankings for improving basic health services. A virtuous cycle emerges: Global AIDS programs, norms and funding help states gain political benefits, which, in turn, lead those states to continue AIDS efforts. The result is lives extended and infections averted.

Other diseases receive less attention

There’s another way to measure the success of international funding for AIDS funding: by contrasting with how African nations address noncommunicable diseases (NCDs). NCDs are chronic, long-term conditions such as cancers, diabetes, and mental health, cardiovascular and respiratory diseases. Increased tobacco and alcohol use, access to processed foods, and urban environments that constrain physical activity have led to the rapid rise of NCDs in low- and middle-income countries. Roughly one in two Africans has hypertension, and cardiovascular disease is the No. 1 killer of Africans over 30 years old.

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Yet African leaders rarely speak publicly about these diseases. NCDs have no autonomous policy institution or funding mechanism at the global level. The low levels of donor activity are echoed in few government activities in African countries. Only one-third have established departments for NCDs; fewer have strategic plans for combating NCDs.

More than one-third of African nations have no policies or institutions for NCDs. The region lags substantially behind Latin America and Southeast Asia. Even though tobacco use is a major risk factor for NCDs, for instance, only half of African governments have implemented taxes on tobacco products.

In the absence of global norms, institutions and funding, as well as bottom-up advocacy pressures, African leaders remain ambivalent about NCDs. Action on NCDs brings few short-term political gains through coalition building, credit-claiming or legitimacy. While population health is a long-term benefit, governments tend to be shortsighted on policies.

On AIDS, in contrast, global assistance — and more crucially, continued U.S. leadership — plays an essential role in incentivizing action on health for poor states with competing development priorities. Global health for all depends on getting these politics right.

Amy S. Patterson is professor of politics at University of the South in Sewanee, Tenn.