This is a joint post with Jenny Ottenhoff and Rachel Silverman.

Happy November 7! The election is over and…things pretty much look the same way they did before.  While I don’t expect the political gridlock in Washington to abate much over the next years, global health fortunately remains one of the few areas of bipartisan consensus in US policy.  When dollar values are taken out of the equation, most policy makers can agree that saving lives of mothers, children and families from preventable, treatable diseases reflects American values and contributes to a safer, healthier world.  Here are five things that should be at the top of the President’s global health agenda for the next four years.

Recommit to PEPFAR with 3.0 Updates – Big decisions will be made on PEPFAR in 2013, whether via reauthorization or renewal of the current legislation.  Either way, President Obama has a unique opportunity to recommit to this essential and historic program, and reshape it to better serve the current state of the epidemic and the USG’s long-term goal of an “AIDS-free generation.” PEPFAR has accomplished much during the past Administration, bringing down treatment costs and leveraging new evaluation results into its programmatic strategy, such as endorsement and use of voluntary male circumcision to help prevent HIV transmission.

Still, there is room for improvement in core parts of PEPFAR’s business model. To start, PEPFAR must assure greater accountability to US taxpayers and program beneficiaries alike by explicitly tying continued funding to program performance, and by publishing funding information, program documents, and results achieved for each of its individual grants. A fundamental component of this transformation is strengthened M&E: PEPFAR should stop relying on self-reported outputs and modeling rather than direct measurement of impact. Instead, robust and independent evaluation strategies are needed, particularly in the program’s priority countries. But to maximize PEPFAR’s impact, it’s not enough to “do things right” by increasing program efficiency; we also need “do the right things” by mainly funding interventions that have been subject to impact evaluation and shown to generate cost-effective impact on the disease. That means more of what works (ART, male circumcision, PMTCT, and targeted prevention programs to high-risk groups) and less of what doesn’t, or at least has no robust evidence of effectiveness (many OVC interventions, voluntary testing and counseling, and behavior change programs for abstinence/fidelity – I’m looking at you!). PEPFAR can still innovate with experimental programs, but any unproven intervention should be subjected to robust, independent impact evaluation. Such evidence-based priority-setting of scarce resources may seem harsh, but it is an ethical imperative given limited resources: every dollar spent on an ambiguous or ineffective program is a dollar not spent doing something we know will save lives.

…And Think Sustainability – Although US leadership in global health is based on American generosity and values, the USG is not a charity and shouldn’t act like one. Ultimately, the role of American global health policy must be to empower low- and middle-income country governments to finance key public health services for their own populations, avoiding permanent structural and fiscal dependency on US aid programs. In practice, this means that the United States should create incentives for governments to self-finance and arrange provision (public or private) of these key services, and not fund the services directly. PEPFAR and PMI cannot continue to purchase products and services directly with no end in sight, as if running health facilities from a distance via mainly US contractors. Instead, COD Aid and budget support conditional on independently-verified health impact are the way forward. This does not mean less money, it means money structured differently — money that is directly linked to health results and establishes an exit trajectory as countries become wealthier.

Open Government through Open Data – Better aid data and greater transparency in US global health programs is arguably the most politically and fiscally viable area for significant progress in the next four years.   During his first term, President Obama’s administration made strides towards greater transparency in foreign assistance.  Perhaps most notably, the President’s Emergency Plan for AIDS Relief (PEPFAR) released a preliminary report on the pilot of its Expenditure Analysis Initiative, an important move towards evidence-based decision making and greater transparency by the United States’ largest global health program.  More broadly, the United States joined the International Aid Transparency Initiative (IATI) and launched the Foreign Assistance Dashboard, which aims to capture foreign aid spending information from twenty federal agencies that provide some form of foreign aid, including for health.  While progress has been slow – the PEPFAR expenditure analysis report is far from comprehensive, the United States hasn’t actually reported anything to IATI, and only three agencies have reported data to the Dashboard – these are significant steps in the right direction to be built upon during President Obama’s second term.  More and better data will allow analysts to understand the distribution of US global health resources across countries, intervention strategies, and implementers, and to oversee the effectiveness, efficiency, and appropriate use of American tax dollars.

Secure our Borders (against Superbugs) & Improve Health Security for All– Infectious disease knows no border and the way in which the United States engages and responds to disease outbreaks has global implications. Novel emerging disease outbreaks (think H1N1 and SARS) are rapidly expanding worldwide – threatening lives and global health investments – but still they receive very little political and budgetary attention in the United States.  President Obama’s Global Health Initiative made no mention of emerging diseases and over the past five years the United States has cut the budget for global disease surveillance and outbreak response. The CDC’s  Global Disease Detection (GDD) program, tasked with investigating and tracking disease outbreaks, received just $41.6 million in 2012 (and the President’s 2013 request adds only $58,000) and currently just one million is budgeted for the program’s Operations Center which sends deployments to investigate novel diseases.  The United States is also moving slowly on the implementation of the World Health Organizations international health regulations (IHR)– which provide a framework for the international response to a global epidemic – and should further commit to full engagement and compliance with the IHR requirements early on in the President’s next term.

Drug-resistant epidemics (think MRSA and other ‘superbugs’) are also on the rise.  In the United States, we’ve seen increasing numbers of serious infections caused by these so-called ‘superbugs’ – including one deadly outbreak this year at Bethesda’s NIH hospital that killed seven.  In the developing world, millions of children die annually from drug resistant disease strains, and since 2006 donors have spent more than $1.5 billion on advanced drugs to treat resistant diseases. Unless more action is taken, the stage is set for both the death toll and the dollar cost to rise.  America’s laudable efforts to increase access to drugs in the developing world must be accompanied by measures to protect and sustain their effectiveness.   A good first step: build health security into the global health agenda and ensure that we are able to track the effectiveness of medicines provided through US global health programs by strengthening the key components of health systems – including testing and surveillance capabilities – that can better detect and deter the emergence and spread of drug resistance (see other recommendations from the CGD Drug Resistance Working Group.)

Strengthen Engagement with Global Health Partnerships – CGD’s health aid effectiveness index, QuODA Health, shows that, compared to bilateral donors, global health partnerships like GAVI and the Global Fund allocate their aid more efficiently, reduce the burden on recipients through increased coordination, and foster institutions by allocating more to countries with national health plans.  Still, the United States provides only 7 percent of its health aid through multilateral channels such as the Global Fund, GAVI, PAHO, WHO, and UNICEF. As the United States consolidates its global health portfolio, it could benefit from channeling more of its limited funds to the global health partnerships.  At the same time, the United States could push for value for money reforms at these institutions, such as more accurate performance data and strengthened performance based financing that would improve the efficiency and impact of US contributions. But strengthening multilateral engagement and cleaning up shop here at home go hand and hand; the United States should harmonize its own bilateral efforts on expenditure reporting and performance management with those of multilateral global health institutions. It’s also time to coordinate more closely at the program level to maximize impact, and to meet the shared ethical commitment to sustain people on life saving treatment even in the context of declining resources.

Given rising concern about US fiscal deficits, I’ve focused here on things that cost little or nothing in budget terms.  But all will require political will and the attention of senior policymakers, both of which are scarcer than dollars these days.  So a bonus recommendation (plea?) for President Obama as he heads into his second term – take the lead!  Maintaining support for current programs, particularly in hard economic times, and getting the greatest reputational benefit from them requires visible White House leadership. We’ll be watching for the President to highlight the importance of investing in global health early and often.