301. Memorandum From the Deputy Director of the Policy Planning Staff (Kreisberg) to the Deputy Under Secretary of State for Security Assistance, Science, and Technology (Nye)1


  • Draft Presidential Decision Document on International Health Initiatives

The problems associated with the draft decision memorandum to the President2 reflect many of the same difficulties the Department had with regard to the larger International Health Report.3 These problems include:

Lack of Priority Setting: The decision document does not address itself to the very thorny but key problem of where specifically we should direct our resources in the area of international health. Should we do more in the area of infant immunization, tropical disease research, nutritional assistance, population or basic health services? What should be the relative mix in our assistance program between bilateral and multilateral programs or one form of health assistance vs. other forms?

Lack of Specificity and Clarity: In many of the recommendations there is a lack of specificity with respect to who should undertake a certain action, how much a particular action would cost and what the benefits might be in return for resources employed and the role of the various agencies in supporting the initiatives. Also the report does not [Page 995] really set forth an international health strategy which was initially the purpose of the entire exercise. The President in reading this decision paper does not, in fact, receive any analysis priorities, or basic strategy, i.e., a meaningful context in which to make decisions about initiatives and additional resource allocation.

Lack of Analysis of the Interrelationship of WHO and Related Programs to Those of Donor Countries, LDCs and Our Own Ongoing and Planned Health Activities: The decision memo does not relate existing and planned international health programs to those of the USG. There is no reference to programs by others or ourselves to deal with specific health problems.

Inaccurate Characterizations: In a number of cases the report characterizes ongoing policies, programs and views of USG agencies in ways which do not fully or accurately reflect the existing situation. In particular, a statement that international health activities address only agency specific missions is unsound. Nor does the report recognize that AID health and other programs in fact are increasingly focussed on the poor and the provision of basic health care. This has been the case over the last year.

Lack of Interrelationship/Coordination: The recommendations tend to be placed in isolation from associated strategies and programs in related areas. There is no recognition of ongoing policies and studies such as those dealing with AID development assistance. We may indeed want to increase AID funding for health programs proportionately to increased overall assistance levels, but no case has been made for this recommendation.

Creation of Overly Complex and Burdensome International Health Bureaucracy and Coordinating Mechanisms: The recommendations to establish a three-tier international health bureaucracy headed by Dr. Bourne does not seem the most efficient approach to developing and coordinating an international health strategy. A simpler structure, coordinated and staffed in the Department of State or alternatively within the White House as part of the NSC system may be more time and cost effective.

Funding Recommendations

Finally, the memorandum puts a total cost of $50 million the first year rising to $76 million five years annually from now on the overall recommendations. Unfortunately the paper nowhere indicates how much improvement in the health and well being of the very poor will be achieved by these increased figures. For example, would we not be better off in taking this money and pledging it directly to poorer LDC basic health care programs aimed directly at such diseases as schistosomiasis, malaria, or the typical childhood diseases. I suspect that the [Page 996] money expended on some of these programs more directly than that proposed in the Bourne recommendations would have a greater impact on basic health needs than the recommendations set forth in the draft memorandum. A troublesome factor in the entire recommendations and the larger report is the absence of any analysis and recommendations directed at global diseases themselves and what we might be able to buy by increasing our funding for dealing with them directly. Much of the funds recommended will go to already wealthy American or foreign professionals and relatively little will find their way to the provision of on-the-ground health care which could change significantly the present dismal LDC health situation.

With respect to the specific recommendations contained in the report, our comments are attached.4

  1. Source: National Archives, RG 59, Policy and Planning Staff—Office of the Director, Records of Anthony Lake, 1977–1981, Lot 82D298, Box 3, TL 11/16–11/30/77. Limited Official Use.
  2. Under cover of a November 16 memorandum to Maynes, Lake, Mink, Saunders, Katz, Holbrooke, Atherton, Vest, Moose, and Todman, Nye transmitted a copy of a November 9 draft decision memorandum from Bourne to the President concerning international health initiatives. Nye requested that the bureaus submit comments to T by November 21 in order for T to coordinate the Department’s suggested changes to the decision memorandum. (National Archives, RG 59, Office of the Under Secretary of State for Security Assistance, Science, and Technology, Lot 80D72, Box 1, HEALTH—Peter Bourne) An undated memorandum from Lannon Walker to Nye, a November 22 memorandum from Brewster to Nye, and a November 22 memorandum from Hormats to Nye, all outlining specific bureau concerns with the draft, are all ibid. Bourne also sent the draft decision memorandum to Brzezinski, Eizenstat, McIntyre, Watson, Harold Brown, Kreps, and Sam Brown under a November 17 covering memorandum, in which he indicated that he had distributed copies of the draft decision memorandum at the November 16 White House meeting (see footnote 13, Document 299). Bourne asked the recipients to provide comments on the draft decision memorandum by November 25. (Carter Library, Staff Office Files, Special Assistant for Health Issues—Peter Bourne Files, Subject Files, Box 35, International Health, 11/2/77–11/30/77)
  3. See footnote 2, Document 299.
  4. Attached but not printed is a 3-page paper entitled “Comments on Specific Recommendations.”