The New State Department Office of Global Health Diplomacy: A Second Chance to Get Things Right

Former Secretary of State Hillary Clinton, in one of her final acts as secretary, created the Office of Global Health Diplomacy (OGHD) and appointed Dr. Eric Goosby to head the new office. Goosby now combines his new duties with his existing role as head of the Office of the Global AIDS Coordinator, based at the State Department, where he is responsible for management of the $6 billion President’s Emergency Plan for AIDS Relief (PEPFAR). In early 2013, Ambassador Leslie Rowe, a respected career diplomat, also joined the Office.

In her tenure, Clinton made the secretary's office the lead high-level force responsible for advancing U.S. policy on global health and this has been reaffirmed by the creation of the OGHD. There is a broad expectation that Secretary John Kerry, who entered office already deeply conversant with the global health agenda and U.S. achievements, will carry Clinton's legacy forward. It was smart to arrange for the OGHD to be headed by someone who is both as widely known and admired as Dr. Goosby and who already carries considerable authority in overseeing U.S. HIV/AIDS programs and policies (and the single largest global health budget). This improves the odds that the OGHD can be truly impactful in ensuring the continuity of the high-level State Department leadership of health diplomacy.

No less important, the OGHD offers the Obama administration a second chance, after costly stumbles in the first term, to get its global health policy right, especially in improving cross-agency coherence of U.S. international health programs and sharpening the vision for U.S. leadership in global health.

With much fanfare, the White House launched the Global Health Initiative (GHI) in early 2009 to lead efforts to integrate HIV/AIDS programs with maternal health, family planning, and ending preventable childhood deaths; to elevate women, girls, and gender equality to be a central lens guiding health investments; to empower ambassadors to be the CEO in-country of global health execution; and to give priority to transitioning partner countries to take greater ownership of their nations' health, financially, politically and managerially.

GHI ultimately foundered because it lacked the ingredients for success: a clear mandate, true authority, accountable leadership, budgetary clout, and consistent high-level backing. Worse yet, in sharp contrast to the Bush era, U.S. resources available for global health became flat, reflective of the extended recession and budgetary turmoil during Obama’s first term. As the U.S. policy agenda widened under GHI, competition for scarce dollars did not ease but intensified.

Despite the best efforts of its first and only executive director Lois Quam, GHI was never able to achieve a new unity of effort and transcend the scramble for resources and turf between USAID and the Office of the Global AIDS Coordinator and CDC. Indeed, at times GHI succumbed to the very forces it was tasked with mitigating. At the same time, U.S. ambassadors in key countries like South Africa, Kenya, and Ethiopia lacked the budget flexibility, ability to win cooperation from truculent U.S. personnel (whose career advancement was determined at their home headquarters), and sufficient leverage with partner countries to do what was now asked of them. Global health budgets, heavily concentrated in HIV/AIDS and malaria, continued to be centrally apportioned from Washington, D.C.

GHI was never able to acquire an effective leadership voice. This vacuum allowed U.S. objectives and initiatives to proliferate without clear prioritization, and weakened U.S. capacity to respond to growing demands for strong diplomatic engagement with key partner governments. For example, in fighting HIV/AIDS, the United States continues to face several partner governments that have initiated regressive policies criminalizing homosexuality and other difficult-to-reach populations vulnerable to HIV infection, reducing the potential impact of U.S. funding. In Nigeria, Pakistan, and Afghanistan, global progress to eradicate polio continues to be endangered by political dynamics and worsening insecurity, requiring sustained and dexterous diplomatic engagement by the United States. In 2011, the CIA’s use of a fake vaccinator in its efforts to verify Osama Bin Laden’s presence in Abbottabad brought U.S. security interests into a sharp and costly collision with public health stakes that still awaits resolution.

Buffeted from multiple directions, GHI quietly expired in mid-2012. In the second Obama term, the OGHD has the opportunity to try again, to advance GHI's lofty and critical goals.

There will be considerable skepticism that OGHD will be able to escape GHI's fate. Many question what changes are needed to make a successful outcome likely, especially if U.S. funding for global health and development declines and interagency turf battles persist. There are three answers to that question:

First, diplomatic success can only be achieved if Ambassador Goosby has reliable, robust assets

He requires regular and direct access to Secretary Kerry, an explicit mandate from the secretary defining OGHD’s specific charge, and visible empowerment to carry the secretary's mantle and deliver the secretary’s direct input at critical moments. In Goosby’s dealings with partner governments, his reach needs to reliably extend to the heads of state and ministers of finance and foreign affairs—well above the ministers of health—who will be essential to moving any shared diplomatic agenda forward.

He needs budget and managerial clout. Without the capacity to shift accounts, he cannot nimbly support ambassadors who need greater budget flexibility in negotiations with partner countries over transition plans.

He needs managerial influence to improve the global health skills of U.S. diplomats and to empower them to reward well-performing staff (and more effectively manage recalcitrant staff).

Second, Ambassador Goosby needs a compelling, intelligible game plan

He needs to pick his spots very carefully, avoid a dilution of effort, work really smartly with others, be both realistic and ambitious, and deliver credible concrete proof of OGHD’s value in a relatively short period. Options include: 

• Work assiduously with U.S. ambassadors to accelerate progress in a select number of key transitions, such as South Africa, Kenya, and Ethiopia. The aim should be to demonstrate that mutually agreed transition plans are indeed translating into results in that these governments are making higher commitments to their health sectors and assuming lead responsibilities at the same time that the U.S. role is able to shift to expert technical support in areas of highest need and where the U.S. comparative advantage is strongest.
• Focus on severely under-performing countries with huge disease burdens where there is a possibility that a concentrated U.S. push might reap returns in the health sector.
• Step up energies in confronting a country which continues to toy with regressive policies, perhaps in concert with other major donor countries and international organizations like UNAIDS.
• Push for fiscal viability, performance, and commitment of key multilateral partners. The World Bank has exceptional convening powers, expertise in building health systems, and financing capacities yet these are underutilized in strengthening health approaches in both low income countries and emerging economies. This is the year of the Global Fund replenishment, the World Bank’s IDA replenishment, and Dr. Jim Kim’s pivotal first year at the helm of the Bank. 2014 is the year of the GAVI Alliance replenishment. The OGHD has the opportunity to shape outcomes with each of these if empowered and focused to do so.

Third, Ambassador Goosby needs to use the OGHD bully pulpit to sharpen the vision for the future of U.S. global health policy

There is considerable confusion about U.S. priorities across infectious diseases, maternal and reproductive, and child survival; it is not clear how U.S. diplomacy is able to handle a swiftly widening global agenda that encompasses polio, non-communicable diseases, climate change, and the global development agenda post-2015 when the current Millennium Development Goals (MDGs) run their 15 year course, among other issues. Through speeches, writings, editorials, and special high-level gatherings, OGHD can make a very significant intellectual and conceptual contribution, if empowered and focused to do so.

J. Stephen Morrison is senior vice president and director of the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

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