309. Letter From the Director of the Office of Management and Budget (McIntyre) and the President’s Special Assistant for Health Issues (Bourne) to Secretary of State Vance1

Dear Mr. Secretary:

The President has approved the broad concept of an international health initiative as outlined in Peter Bourne’s memo of January 9th.2 The President’s State of the Union Message promises to “present a strategy this year for working directly with other nations and through international organizations to raise the standards of health and nutri [Page 1040] tion around the world”.3 Such an initiative, which should be an important component of the recent U.S. commitment to major increases in foreign aid through 1982, requires decisions now to develop the foundation for specific actions and programs later.

We have initiated a process to devise and implement a world health strategy. Our approach will be two-fold: first, to identify and highlight the many activities already in process and, second, to focus current U.S. Government activities in international health within a coordinated framework of priorities and goals so as to work more effectively with related U.S. Government activities, with private organizations, with other nations, and with the several international and multilateral organizations.

With regard to international health programs in the developing countries, the strategy developed should be fully coordinated with the studies of foreign aid organization and program reform currently underway.

Building on the considerable amount of work already done by the agencies in developing the strategy, the first step has been taken by Peter Bourne’s staff in preparing a report on international health. The next step is to develop a broad policy statement encompassing the humanitarian goals and identifying specific areas of Presidential interest. To this end, enclosed is a draft statement of strategy including general objectives and several proposed initiatives which were developed during the initial review of U.S. international health programs. This draft will be the basis for developing the broad policy statement. Before proceeding further, however, we need each agency’s views of the overall initiative and how it feels it can best contribute to the effort. Comments should address both the merits and problems associated with the proposed initiatives. While detailed analysis will be addressed later in the process, we seek your initial assessments as to the programmatic and budgetary implications of the proposals. Your preliminary analysis will help us to assess the likely cost-effectiveness of the several possibilities and determine which merit priority attention.

The development of the broad policy statement should be completed by April 1, 1978, in the form of a decision memorandum to the President. We have established the following schedule:

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March 3 —Receipt of agency comments on the enclosed draft.
March 10 —Circulate draft decision memorandum to the agencies for comment.
March 22 —Receipt of agency comments on the draft decision memorandum.
March 27 —Circulate revised draft decision memorandum.
March 29 —Cabinet-level review, if necessary.
April 1 —Decision memorandum to the President on the initial strategy.
April —A statement of general direction and emphasis will be included in the OMB Spring Planning Review. As necessary, designate lead agencies for further program development and establish coordinating committees to develop Response Memoranda on specific issues.

To meet this schedule, we request that you forward your comments to Peter Bourne by March 3 on the proposed strategy and key issues contained in the enclosed draft memorandum, with emphasis on options available to the United States and recommendations regarding implementation or needed further analysis.

  • James T. McIntyre, Jr.
  • Peter G. Bourne, M.D.4


Draft Statement of Strategy5



I. Background

In mid-1977, Peter Bourne, Special Assistant to the President for Health Affairs, began a review of international health to determine the nature and status of the United States’ programs in this area. In October 1977, a draft report was published titled “Foundations for a New U.S. [Page 1042] International Health Policy: Assessment of Problems, Programs, Resources and Opportunities.”6 This draft report was circulated to the involved Departments and agencies for their comment. On January 9th, Dr. Bourne recommended a program called “New Directions in International Health” be initiated as the first response to the President’s promise to implement a global basic human needs strategy.

At present, U.S. Government international health programs are scattered among 22 agencies with various responsibilities and authorities, operating relatively independently of each other. Both domestic and international issues are involved in international health matters, which highlights the need for a flexible and responsive management structure. The Federal agencies involved in international health spent $528 million in FY 1976, under more than 100 separate legislative mandates; yet there is no government-wide coordinating mechanism to establish overall policy, goals or programmatic priorities. A central focal point is essential to achieving the full potential of current knowledge and resources and is likely to be as important to basic health needs as are new scientific discoveries.

What is needed is the allocation of U.S. resources on the basis of an assessment of real global health needs taking into account health problems which cause most damage to human potential, and most severely compromise economic development, and vice versa. Priorities must be set, working with the World Health Organization and the involved countries, and programs developed for action against the remaining major crippling or fatal diseases. Criteria must be developed for resource decisions, taking into account cultural differences, country or area priorities and levels of training and systems capacity for continuing to carry out the program at the local level.7

International health has in the past been exclusively thought of as an aspect of foreign aid primarily through development assistance. However, commercial, diplomatic, and environmental avenues are also ways to approach international health problems.

Presidential endorsement and higher priority on U.S. involvement in world health matters is fundamental to a new strategy. Potential Presidential initiatives which are suggested involve impaired vision and blindness, rural water supply systems, establishment of an International Health Services Corps and other measures and changes in policy which would enhance the effectiveness of our international health program.

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II. Statement of Strategy

The basic strategy will be to highlight and focus U.S. Government activities in international health so as to work more effectively with other nations, private voluntary organizations, and international organizations, within a broad, coordinated set of program priorities and goals. Presidential participation will encourage the active involvement of all Departments within the U.S. Government and of nations around the world. International health will become an integral aspect of U.S. foreign policy. The strategy will aim at increasing awareness of world health problems and support for both ongoing and new efforts to improve world health and nutrition.8 It will focus on long-range planning and local capabilities for continuing health programs.

Another aim of the strategy will be to develop a mechanism for ensuring that both current programs and new directions are complementary, and provide the appropriate programmatic basis for the Presidential “New Directions in International Health” initiative.

General Objectives

Broad goals that this strategy will promote are:

—Working toward the elimination of the major infectious diseases.

—Providing access to a basic minimum level of health care for people everywhere, especially the poorest one billion.

—Emphasizing the delivery of community-based primary health care training to health personnel as near as possible to the point where they deliver services.

—Encouraging special initiatives to deal with the generic problems of ill health, malnutrition, and lack of clean water supplies, with a priority on prevention aspects of these problems.

Action Plan

The general approach to developing a world health initiative includes:

—A Presidential statement, at an appropriate opportunity, indicating a personal interest in raising the level of public and private activities aimed at improving health around the world. Emphasis would be on program development, capitalizing on current U.S. programs, and striving for increased partnership with other donor countries, as well as with receiving countries, in making basic improvements consistent with the general objectives above. Better coordination of “human needs” activities would be a central theme.

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—A number of potential initiatives are identified in the following section of this paper. Based on comments and recommendations received from the involved agencies, these initiatives will be announced or assigned for further action as appropriate.

Further action could include assigning higher priority to an ongoing effort, assignment of the appropriate Department for preparation of an implementation plan or establishment of an interagency committee to develop a recommended approach. The most important opportunity for inclusion in the Administration’s planning is through the OMB Spring Planning Review. Therefore, it is important that general guidance with a sense of relative priorities be available to OMB by early April. This schedule does not require immediate specific programmatic recommendations or that potential organizational questions be resolved during the first phase of this review.

—The remainder of the year would be planned to accomplish the necessary studies, and to seek opportunities to encourage efforts to improve world health and to strengthen coordinative activities, including within the U.S. Government, with and between international organizations, and with private sector organizations.

Proposed Initiatives

The initial review of international health, conducted by Peter Bourne’s staff, and comments received from the relevant agencies led to selection of areas where improvements may be made in the U.S. approach to international health. Outlined below, these potential initiatives are discussed in more detail in the following section.

1. Expand U.S. involvement with health-oriented activities of international organizations.

2. Encourage and facilitate private sector involvement to complement international health programs.

3. Expand capacity for knowledge development and use.

—Upgrading the Fogarty International Center.

—U.S. Global Health Consortia.

—Foreign Research and Training Centers.

4. International health manpower.

—Presidential Scholars in Global Health.

—Global Health Cadre.

—International Health Services Corps.

5. Presidential priorities in prevention.

—World Blindness.

—World Water Supply.

6. Coordination of U.S. Government activities in world health.

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III. Proposed Initiatives—For Comment

In addition to commenting on the general concept of the described International Health initiative, the Departments and agencies are asked to provide comments on each of the attached draft papers.9

  1. Source: Carter Library, Staff Office Files, Special Assistant for Health Issues—Peter Bourne Files, White House Office File on International Health, Box 52, Chron 1–3/78. No classification marking.
  2. See Document 306.
  3. The President’s January 19 address on the State of the Union, delivered before a joint session of Congress, is printed in Public Papers: Carter, 1978, Book I, pp. 90–98. The longer, printed version of the State of the Union message is ibid., pp. 98–123. Carter presented his international health proposal in conjunction with several domestic health initiatives, including a reorganization of HEW, a child immunization campaign, and a national health insurance program. An excerpt of Carter’s State of the Union address is scheduled for publication in Foreign Relations, 1977–1980, volume I, Foundations of Foreign Policy.
  4. Printed from an unsigned copy.
  5. No classification marking. Prepared on February 15.
  6. See footnote 2, Document 299.
  7. An unknown hand underlined this paragraph, beginning with the word “assessment.”
  8. An unknown hand underlined this sentence, beginning with the word “increasing.”
  9. Attached but not printed are six undated draft papers on the topics of expanding U.S. involvement with the health-related activities of international organizations, encouraging private sector involvement to complement international health programs, providing for the analysis of international health needs, international health manpower, Presidential priorities in prevention of blindness and improvement in potable water supplies, and coordination of U.S. Government activities in world health.