America First Global Health Guidance Launches Fee-for-Service Coup Against CDC

Bonus: it comes with a menu.

The Department of State is turning the US Centers for Disease Control and Prevention’s global HIV program into a disempowered, McKinsey consulting firm-esque entity that will receive resources at the whim of politically appointed Department of State leadership. Released to government staff yesterday, the new “Guidance for U.S. Government Operations Under the America First Global Health Strategy” (I’ve included JPGS of the whole thing at the end of the document) lays out a plan for placing every aspect of global health foreign assistance funding and decision making in Department of State control, including the public health agendas and activities of the CDC, the nation’s bulwark against infectious disease threats.

Historically, CDC received roughly USD two billion a year from the State Department, via a transfer of foreign assistance funds from the State Department-held Global Health Programs account. The new guidance swaps in a fee-for-service model, in which CDC’s global health program will receive payments based on technical assistance services that countries select and prioritize, along with a minimum package of services required by almost all countries receiving funding under the America First Global Health Strategy.

By setting the minimum package, insisting on the fee-for-service model (an approach State Department advisor Brad Smith has been promoting for months now), and effectively ending predictable funding for CDC, the Department of State is positioning itself to influence, if not set, US global health security strategy at a scientific and public health level for which it has neither the expertise nor the statutory mandate.

The Department of State’s mandate for handling global health foreign assistance comes from the President’s Emergency Plan for AIDS Relief, or PEPFAR program, which established, in its authorizing law, the program’s unique structure. Back in 2003, the Department of State was put at the center of PEPFAR in part because it was not a program implementer—and so could be trusted to dispense money to agencies with the relevant expertise including, at that time, CDC, USAID, and the Department of Defense.

Now that State is refashioning itself as the home of US foreign aid, there is a glaring conflict of interest in its having the ability, by virtue of its control over the Global Health Program budget, to determine agency funding levels. This risk is made vividly real in the newly-released Guidance and Management and Programmatic Services Schedule fee schedule. Taken together, these documents underfund the CDC global HIV program and, in so doing, and undermine the scientific and public health functions of American global health security.

The love child of a dim sum menu and the Delta SkyMiles Loyalty Program Overview, the Schedule itemizes a range of different services that countries can buy from CDC with tiered pricing determined by some combination of the size of the country, the complexity of the system and/or “the level of support needed from CDC.”

Alt text: A sepia-tinted screen shot of a photo of a computer screen with one page of the fee-for-service schedule on it. There’s a list of numbered items (29-34) down the left hand column that included things like ‘vaccination in public health emergencies,’ ‘malaria prevention and control,’ and others. There’s an explanation of the “Tier” system at the bottom. Hey honey, what looks good to you? Do you want to get support for the National TB control program and Infection Prevention and Control? Oh, you know what, we probably shouldn’t. It’s been a slow month for paid stack subscribers, and I think we’re Tier 3. Let’s just go for malaria elimination and hope our health workers remember their IPC training from last year. And I think I’ll try the soup dumplings to start.

Countries that receive more than $125,000,000 under the America First Global Health Strategy will be required to purchase a minimum package of services from CDC that includes award and agreement management services (services #1 and #2) surveillance planning (service #3), population health and biomarker surveys (service #9), laboratory quality management (service #15), health data quality assessment (service #23) and the Field Epidemiology Training Program (service #25)—if this is part of the country’s MoU.

For Tier 1 countries, the minimum package (plus FTEP) nets CDC about $3.2 million. It’s just over $10 million in Tier 3 countries. Each of these sums must cover both country-level and headquarters operating expenses, previously budgeted separately.

Each of these sums is also an incredibly small percentage of CDC’s most recent operating budget in most countries where AFGHS is being implemented. In Uganda, for example, CDC’s PEPFAR program budget alone was more than USD$ 146 million in FY2022.

The AFGHS architects will say that the minimum package is a floor, not a ceiling, and that CDC could make more money if countries select more of its services. But here’s the thing: global health security, national health systems and disease responses, country HIV programs and American health security are not well served by menu-based planning in which budget constraints, political priorities, stigma, discrimination, ignorance and fear can dictate choices about what’s paid for and what isn’t.

They are served by robust institutions with appropriate resources and expertise. The CDC has been gutted, brutalized, scaled back, shot at and stacked with non-scientists this year. And through it all, the global health program that provided more than two thirds of PEPFAR’s antiretroviral treatment has kept on keeping on. It is a last bastion of functionality and full-service programming when USAID-funded programs were closed over night.

The Department of State wants this to change. The fee menu describes CDC as “the preferred global staffing service provider for the implementation of the AFGHS.”

Every word in that sentence makes America less secure and its aid less effective. Preferred clearly leaves the door open for other entities to take on tasks in the menu; staffing service provider for the implementation of the AFGHS relegates an autonomous Federal agency to actualizing a global health strategy that was written by people with no global health security experience at all.

It also suggests the authors don’t understand or don’t care about the CDC’s model of working with countries.

At this moment—and for years prior to the advent of the President’s Emergency Plan for AIDS Relief—the CDC worked with countries around the world through close partnerships with governments, centered on embedded technical expertise. For example, CDC might fund a scientist with expertise in malaria control to sit in the same office as, and work alongside the government representative in, a country’s ministry of health mosquito-borne disease unit. These partnerships were flexible and based on local, evolving context.

In this example, the malaria technical expert wouldn’t be restricted to development of the malaria control guidelines. If she saw an uptick in new cases, or a set of clinical reports suggesting that chikangunya or some other mosquito-borne illness was rising, she could pivot what she was working on. If the cases were in a camp for internally displaced persons that the government didn’t want to call attention to, she could, often, figure out a way to mobilize a public health response anyway.

Frequently, she was a scientist from the region or the country whose health ministry she was supporting. The systems and standard operating procedures she and her government counterparts developed for one disease could be readily adapted and used for others. She was not a consultant dispatched by a staffing provider. She was not tied to a pamphlet-length American plan.

Let’s turn back to the under-funding question for a moment. If Uganda were a Tier 3 country that bought just the minimum package of services, CDC would see a 14-fold decrease in its budget compared to FY2023. There would be at minimum 92.9% less funding for the CDC in country; and since the new fees have to cover headquarters expenses, it would actually be even less. A cut of this type means the end of CDC presence of any meaningful scale or scope in a country that’s had recent outbreaks of Marburg and Ebola virus, and hundreds of cases of a “mystery” disease.¹

But wait! Emily - we’ve gotcha now!² None of those diseases are HIV! Comparing PEPFAR budgets to the fee-for-service budget may be exactly what GHSD wants me to do. Because that figure is very high and it includes grants to implementing partners that Secretary Rubio, Mr. Lewin and Mr. Smith think are waste-y, fraud-y and abuse-y.³

But I’m not walking into a trap. I’m walking right up to a design quirk in US global health funding and programming that the Department of State has no business exploiting.

The quirk is the President’s Emergency Plan for AIDS Relief, the largest disease-specific initiative in US and world history. For the last 22 years, US funding for HIV has dominated our global health investment,⁴ and foreign aid for HIV has been the primary source of funding for CDC’s global health program.

This is the quirk in the system that we have to get familiar with, so that we can prevent it from being exploited. Most of CDC’s global health presence has rested on and been subsidized by PEPFAR dollars. This isn’t a shameful secret. This is the way it should be if you do HIV work properly.

PEPFAR dollars supported CDC country-based and headquarter activities that built laboratory, training, surveillance and human resource capacity that served country’s HIV programs. Because HIV programs are embedded within health systems, these investments also supported other activities—including infectious disease outbreak tracking and response, laboratory capacity that helps diagnose COVID-19, Ebola, Marburg, Hanta and to identify drug resistant strains of HIV, tuberculosis and other diseases.

The architects of AFGHS rail against the earmark that set aside such a large proportion of US foreign assistance specifically for HIV in a way that suggests they do not understand what CDC PEPFAR money has supported. They say that would like to see this earmark dispensed with so that the funds can be used to support a wider array of activities, including those aligned with country priorities.

This critique isn’t new and their vision for a diversified funding approach isn’t original. Many other folks have wanted US bilateral foreign assistance for global health to move away from a vertical disease-specific model—from ethicists to country governments to groups working on other issues including mental health, neglected diseases, and non-communicable diseases.

However, I cannot think of a single advocate for a revised approach to public health foreign assistance who has said: dispense with the earmark and give all of the control over the money to politicized foreign policy officials who know nothing about disease surveillance, outbreak response, or government to government collaboration.

Secretary of State Henry Kissinger thought that slowing population control was in America’s security interests and he wrote a memo arguing for US support for contraceptives and family planning overseas. Kissinger was entitled to his opinion. Contraception and abortion are healthcare. But if, as Secretary of State, he’d controlled the CDC budget and strategy, he could have operationalized his agenda, prioritizing injectable contraceptives instead of smallpox jabs, and eradication would never have happened.

Historically, the Department of State has been responsible for global health diplomacy—an important field centered on the government-to-government and global arrangements that support health in an interconnected world. The US government’s foreign policy shop has not exercised control over budgets, staffing, agendas and activities related to public health, epidemiology, disease surveillance and outbreak response. Multiple laws establish that the Department of Health and Human Services, CDC, the Administration for Strategic Preparedness and Response (ASPR), and other government entities are the scientific leads.

The new guidance changes the status quo not by rewriting laws but by establishing State Department control over funding. Whether it’s choking off funding for the supply chain contract, CDC or Department of Defense, control of the Global Health Programs budget is a primary tactic for the State Department’s expansionist agenda. The Guidance and companion fee schedule are an absurd, dangerous over-reach. Congress and anyone else who cares about avoiding Ebola on the subway or Hanta virus at Hardee’s should take notice and action.

Fortunately, there is a remedy. Congress gives the State Department its Global Health Program money, and Congress can, and must, use its legislative powers to direct State to transfer a minimum portion of the GHP budget to CDC. This wording can go into House and Senate appropriations bills; there is also a clear need for new legislation that establishes the roles, mandates and responsibilities of the government agencies and departments involved in foreign assistance for global health now that the Department of State has a conflict of interest it clearly will not manage on its own.

1. https://www.timesnownews.com/health/hundreds-sick-in-uganda-with-bizarre-dancing-disease-which-leaves-victims-shaking-uncontrollably-article-116399091

https://www.independent.co.ug/marburg-5-ugandan-districts-on-high-risk-of-outbreak/

https://www.cdc.gov/han/php/notices/han00521.html

2. In which I briefly indulge in the fantasy that any one ever from Department of State would engage with a query from me.

3. These grants are anathema unless and until the Department of State is running them (I promise I’ll get to the sole source procurement story line just as soon as the Department of State stops releasing its blueprints for world domination.) Indeed, the new guidance lays out its plan for taking over all current mechanisms, except when there is a lifesaving imperative that requires that the CDC or another agency to continue implementation.

4. https://www.kff.org/global-health-policy/breaking-down-the-u-s-global-health-budget-by-program-area/#113f80b3-617d-4275-afbb-25b19d875c65