International finance providers, pharmaceutical companies, medtech innovators and NGOs need to look at how to work with the new US administration on global health and development. We have a pretty good idea of what it is likely to do. The plans will worry some multilateral organisations and service providers, but they also offer important opportunities.
The next US Administration, “should focus on updating the Global Health Bureau’s portfolio, emphasizing a comprehensive approach to supporting women, children, and families; building host-country institutional capacity; increasing awards to local and faith-based partners … and improving USAID’s ability to coordinate with local partners.” Guess where that text comes from?
It’s not from a worthy think tank or the Harris / Waltz platform; it’s from Project 2025 (with a few giveaway words removed), the Heritage Foundation’s plan for the next “conservative Administration”. That is the document demonised by Democrats throughout the campaign, but widely thought to be a roadmap for many on the Trump team.
I’m generally to the left of centre, so I’m always going to have trouble with attacks on “climate fanaticism” or “woke gender extremism”. The document is also occasionally silly in claiming, for example, that Engender Health (on whose board I served), is allowed to spend Federal money “without oversight”… if only. Its position on safe abortion is particularly disingenuous because, putting aside any consideration of issues of morality and autonomy, criminalising abortion normally increases the number of abortions and always leads to more deaths among women, particularly vulnerable women. That, though, is another post for another day.
Overall, however, Project 2025’s chapter on USAID is populist but not nuts. Unlike a lot of pontificating about development, it’s coherent and readable. A lot of what it has to say about development assistance in general and global health in particular, rings true, sometimes painfully so. It shows a real commitment to lifting people out of poverty and into better health, however much I dislike some of the specifics. Here are a few excerpts
“Many USAID-funded global health activities remain rooted in patterns that began decades ago and measure improvements in terms of inputs— money spent—instead of outcomes achieved. From the 1950s to 1970s, the major recognized threats to human health were infectious diseases such as polio and smallpox, and USAID funded programs ‘in’ a country, not ‘with’ a country. Maternal and child health, food, water, and sanitation programs were often intermittent. USAID consistently financed population control, contraception, and abortion as essential to ‘development.’ Most programs focused on one disease or condition but had little integration with other global health activities. Chronic diseases were ignored.” I can’t find much to quibble with if we delete the bit about abortion and “population control” (USAID always stressed the need for consent, albeit that it had a high tolerance for programmes that verged on the coercive in a few friendly régimes).
“The continued high rate of maternal and infant mortality is a persistent global tragedy. Contrary to current publicity, this problem is not solved by abortion. Families genuinely cherish children. The next leadership at USAID must focus attention on women and children’s health (including unborn children) as well as health risks across life spans, including childhood infections, cervical cancer, adolescent risks, and family stability, by utilizing a coordinated approach. The Bureau should implement a ‘Request for Application for Resilient Families’ that harvests collaborative funds from siloed programs and makes individuals and the family, not diseases or conditions, the true focus of intervention.” I haven’t seen much of that “current publicity” but, otherwise… well, yes.
“Millions of people are alive today because of the American people’s investment in PEPFAR and PMI. The training, laboratory, clinical intervention, health education, data collection, and organizational platforms of these programs became the bedrock for responding to the COVID pandemic. It is time for these programs to become part of an integrated, strong, and sustainable network of health care and public health in developing countries. A smooth transition to national ownership and funding, however, will require better coordination of USAID’s own stovepiped programs with PEPFAR and PMI.” Exactly!
“The Bureau’s Center for Innovation and Impact (CII) should be empowered to expand networks of private and faith-based health organizations that can develop projects using development-impact bonds, capital funds, and innovative technologies… More flexible and agile CII funding will spur innovation within the Bureau and help to enhance countries’ self-reliance in the provision of health care.” I’m jumping up and down applauding.
“Over the past decade, the U.S. government has expended $14 billion in aid to Syria where the bloody regime of Bashar al-Assad—a close ally of Iran and Russia—skims nearly half of foreign aid through inflated official exchange rates, the diversion of food baskets to its military units, and procurement arrangements with compromised local contractors … humanitarian aid is sustaining war economies, creating financial incentives for warring parties to continue fighting, discouraging governments from reforming, and propping up malign regimes.” I’m not a Syria or USAID expert and parts of this may be wrong, but it doesn’t sound impossible given what I’ve seen elsewhere with non-US funding
“[In Africa, a] failure to generate wealth has provided opportunities for China to step in and become the continent’s leader in trade, loans, and investment. As a result, Beijing controls most of the continent’s strategic minerals that are critical to advanced technology. Moreover, USAID is criticized by Africans for exporting cultural values that are anathema to their traditional norms, further abetting Chinese continental supremacy.” The last sentence is, I suspect, a dig at trying to limit support for régimes that persecute LGBTQ people, often at the urging of US and Saudi fundamentalists. However, the first bit has an element of truth.
This is a highly selective set of quotes – there is a lot to dislike in Project 2025 – but I’m trying to make a point. We shouldn’t despair if it becomes the blueprint for the second Trump Administration’s development assistance and global health work. I will disagree with a lot of it, but I have disagreed with some of every development assistance policy by every government (what on earth are European governments thinking when they fund activists against the pharmaceutical industry, for example). However, there’s no plan to dismantle USAID and walk away from involvement in alleviating poverty and there are some exciting opportunities for change that will empower community organisations and for exciting public-private partnerships. There’s even a solid, grounded appreciation of all that the Bush-era programmes against HIV and malaria have accomplished and can yet do.
Read the full text of the Project 2025 chapter for yourself here https://static.project2025.org/2025_MandateForLeadership_CHAPTER-09.pdf
Original Article: https://www.linkedin.com/pulse/second-trump-administration-global-health-mark-chataway-3rvhe/