Health Diplomacy Bulletin 20

Issue No. 20
Meeting the Challenges to Global Health:
From China to Africa to Capitol Hill 
  • China pushes ahead with development strategy in Africa, holding its third summit for African government chiefs in Beijing. First Lady Peng hosts first spouses in an HIV/AIDS forum.
  • A key USAID official warns that China is having a negative influence in development, and the U.S. must pay heed.
  • The Senate is close to responding to House bill on PEPFAR reauthorization.
  • MenStar, a DREAMS-style initiative for men, brings together government, corporate, and foundation resources.
  • The shift to more indigenous control of PEPFAR programs won’t be easy, but it’s a powerful goal.
China Ratchets Up Support for
Global Health in Africa 
As the U.S. leadership continues to send mixed signals about its commitment to development in Africa, China recently rolled out the red carpet to welcome the continent’s heads of state last week to Beijing, placing increased emphasis on health.
Chinese President Xi Jinping and First Lady Peng Liyuan hosted 40 African heads of state and First Ladies for the third Forum on Chinese-African Cooperation (FOCAC) from Sept. 3 to 5. It was the third such summit since 2006 and focused largely on Xi’s announcement of $60 billion in new infrastructure financing over the next three years for Africa.
By contrast, the only U.S. Cabinet-level delegation to Africa since the beginning of the Trump Administration was the ill-starred trip in February of former Secretary of State Rex Tillerson, who was fired two days in. First Lady Melania Trump recently announced that she will visit Africa, solo, next month. Meanwhile, the Administration’s budgets regularly propose large cuts for global-health programs.
Xi’s wife Peng, who was last year’s winner of the UNAIDS Award for Outstanding Achievement, led a meeting of Africa first spouses focused on joint efforts to fight HIV/AIDS. The First Lady of Burkina Faso, Sika Bella Kabore, delivered remarks on behalf of the Organization of African First Ladies Against HIV/AIDS and encouraged more resources to be directed toward public health. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, and Peter Sands, the new executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, also attended.
China has gone from being a recipient of Global Fund dollars, to managing its own program, to becoming a contributor of $800 million. This total pales in comparison to the $1.35 billion annual commitment of the U.S. to the Global Fund. America’s bilateral commitment to fighting global AIDS through PEPFAR is $6.5 billion annually. Yet, while China historically focused its soft-power diplomacy efforts on infrastructure, it is now ramping up its support of global health in Africa.
In his speech to open the summit, President Xi said:
We will launch a health care initiative. China has decided to upgrade 50 medical and health aid programs for Africa, particularly flagship projects such as the headquarters of the African Center for Disease Control and Prevention and China-Africa Friendship Hospitals…. Cooperation programs will be launched on the prevention and control of emerging and re-emerging communicable diseases, schistosomiasis, HIV/AIDS and malaria. China will train more medical specialists for Africa and continue to send medical teams that better meet Africa’s needs.
More mobile medical services will be provided to patients for the treatment of cataract, heart disease and dental defects. And targeted health care services will be provided to women and children of vulnerable groups in Africa.
China’s health initiative is part of its overall strategy of projecting power on the continent through economic diplomacy, with major investments being explored in every country. China also put its first foreign military base in Djibouti, and has diplomatic missions in 52 African countries to 49 for theU.S. Chinese infrastructure has been criticized as “neocolonial” and detrimental to advancing job skills for indigenous workers. Still, last week’s attendees at the Beijing summit had nothing but praise for their Chinese partners.
Botswana’s new president, Mokgweetsi Masisi, declared, “To China, her president and citizens, we admire and hold you in very high regard! Keep the innovation, friendliness and international outlook as bright as the Chinese spirit!” South Africa’s President Cyril Ramaphosa stated, “In the values that it promotes, in the manner that it operates, and in the impact that it has on African countries, FOCAC refutes the view that a new colonialism is taking hold in Africa, as our detractors would have us believe.”
An Update on PEPFAR Reauthorization Prospects before Midterm Elections
Meanwhile, as China forges ahead, the U.S. Congress still has not made an official, long-term, unequivocal commitment to the most effective global health program of the century: the President’s Emergency Plan for AIDS Relief (PEPFAR).
While the House of Representatives introduced an initial, “skinny” reauthorization of the PEPFAR legislation last month, Senate counterparts still have not followed suit. Specific Senators have committed to the Administration that they will have co-sponsors soon, but no official announcement has been made.
Sen. Johnny Isakson (R-Ga) Tweeted on Aug. 23 that he was meeting with Ambassador Birx to discuss the “upcoming reauthorization of this life-saving program.” Isakson is a key player in global health. He chairs the Senate Foreign Relations subcommittee on USAID Management, International Operations, and Bilateral Development and sits on the subcommittee on Africa and Global Health.
Most HIV/AIDS advocates who were hesitant about the merits of a reauthorization were worried about what the more extreme wings of both political parties would add to the bill, which replaces an authorization that expires at the end of this month. As the 2018 reauthorization currently stands, it is a simple update with no dollar amounts listed, leaving those decisions entirely to the appropriators.
Key global health organizations are on board. Recently, dozens of them – including amfAR, Save the Children, the Global Health Council, and Friends of the Global Fight – sent a letter endorsing the reauthorization bill.
With Boost From U.K., U.S., and Global Partners,
PEPFAR Puts New Focus on Young African Men
What the U.S. has — and China can’t match — is the true, effective public-private partnership. Recognizing that girls and young women account for 74% of new HIV infections among adolescents in sub-Saharan Africa, PEPFAR launched a program to target them called DREAMS, which stands for “Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women.” Private-sector partners in DREAMS include the Bill & Melinda Gates Foundation, Girl Effect, ViiV Healthcare, Gilead Sciences, and Johnson & Johnson.
Relatively quickly, DREAMS has scored successes. According to a PEPFAR Fact Sheet:
In the 10 African countries (63 districts) implementing PEPFAR’s DREAMS partnership, the majority (65 percent) of the highest-HIV-burden communities or districts achieved a 25-40 percent or greater decline in new HIV diagnoses among young women, and new diagnoses declined in nearly all DREAMS intervention districts.
Now, PEPFAR has launched a new program aimed at young men, called the Menstar Coalition, with strong support from both the U.S. and U.K. private sectors, as well as from international organizations. Partners include the Global Fund, Unitaid, the Elton John AIDS Foundation, the Children’s Investment Fund Foundation, and again Gilead Sciences, and Johnson & Johnson. Sir Elton John and the Duke of Sussex made the announcement July 24 at the International AIDS Conference in Amsterdam. The founding partners have made a commitment of $1.2 billion, with $800 million to be spent in the next year.
“We’re missing half of the men between the ages of 15 and 35,” Birx said in an interview in edition No. 18 of this newsletter. “They’re not virally suppressed because they’re not coming into the clinics, and they’re not seen.”
MenStar is starting an HIV self-testing program in Kenya in 2019 specifically appealing to men. The overall immediate objection is to bring an additional one million men into testing in the next year and to “support over 90% of men in this age group to be virally suppressed to effectively interrupt HIV transmission.”
PEPFAR’s Shift to Local Implementers:
No Piece of Cake
In July, Deborah Birx, the physician and retired Army colonel who has served as U.S. Global AIDS Coordinator since 2014, announced a new goal of having 70% of PEPFAR funding go to indigenous implementers of the program within the next 30 months. Birx’s inspiration came from the successful shift of the Centers for Disease Control (CDC), where was previously director of the Division of Global HIV/AIDS, to having local implementers provide 65% of its work. Birx’s motivation in the new PEPFAR policy is largely budgetary: local partners can free up more resources currently spent on higher-cost international contractors.
One of the challenges Birx noted even at the time of the announcement was the additional management required to make the transition at CDC from 90 major partners to the 600 local partners that eventually became the focus of the agency’s funding. Birx estimated that, for PEPFAR, some 6,000 local partners would be needed for full implementation.
In a piece on its website Aug. 9 headlined, “PEPFAR’s New Targets for Local Implementation: Commendable in Theory, Complicated in Practice,” the Center for Global Development (CGD) commented on the difficulties of reaching Birx’s bold goal. The authors, Sarah Rose and Rachel Silverman, noted that USAID also struggled with its 2010 goal of moving towards “Local Solutions” with 30% of programs being implemented by locals. In the end, USAID was only able to move only 19% of their resources to indigenous partners.
Rose and Silverman agree that local partnership is a good and worthy goal — and one PEFAR should continue pursuing. Most PEPFAR focus countries have the advantage of decades spent building infrastructure to fight AIDS. Birx’s policy shift is also in synch both with her own background in management and budgeting and with the Trump Administration’s emphasis on spending development money efficiently.
In Our Next Issue
The 73rd session of the United Nations General Assembly takes place this week in New York. We’ll be reporting in our next issue on global health discussions, always a focus of intense interest at UNGA.