Foreign Relations of the United States, 1977–1980, Volume II, Human Rights and Humanitarian Affairs

315. Issue Paper Prepared by the Task Force on International Health¹

Washington, July 11, 1978

COORDINATION, ORGANIZATION, STAFFING

I. Purpose. The U.S. must strengthen the means by which its several government agencies can relate and join their separate missions and activities in international health. It must do so in a way which supports and is supported by the activities of the U.S. private sector, other donor countries, and multilateral and voluntary organizations. This will require a government-wide policy on international health, interagency coordination at both policy and strategic levels, capacity for development and promotion of new initiatives, and improved intra-agency coordination.

II. Policy. Although many distinct policies exist within and among individual agencies, the absence of a government policy on international health deters the achievement of a fuller humanitarian benefit to global health. In particular, if international health is to profit more from opportunities now available in various U.S. Government departments and agencies, explicit policy detailing the nature of the relation between international health and the various agency missions and activities must be established, understood and implemented by all. That policy must stress U.S. concern for basic health needs at the highest level of government policy-making and complement the President’s human rights policy, demonstrating real and effective concern for the health of people everywhere. It would serve as a model for changes in foreign policy decision making to better support economic and social development and efforts to improve international relations. It would seek to benefit from and improve domestic health activity. It would support and seek support from international economic and commercial policy.

A clearly defined international health policy would also establish more direct guidance for U.S. relationships with multilateral agencies and international financial institutions. The policy must also recognize and complement the unique potential of the U.S. private sector—academia, PVO’s, U.S. private business, and private individuals.

III. Coordinating Mechanisms. Twenty-two agencies engage in international health related activities. A way is needed to relate and strengthen the separate purposes and potential contributions of these agencies to the benefit of overall government goals such as those currently espoused by the President. An explicit policy will be instrumental in creating such procedures. In order to establish a government-wide policy, keep it current, and manage its implementation, the major problem of divided responsibility and authority among the largest agencies will have to be overcome.

There is general agreement among the agencies that coordination can and should be improved. Two levels of interagency coordination are required: a policy level and a strategic program level.

The policy level responsibilities include:

• the planning and evolution of U.S. Government international health policy;

• establishment of the government-wide goals and principles for agencies to use in designing international health programs;

• resolution of any impasse from the strategic level of coordination, especially regarding acceptance and assignment of lead responsibility for different international health activities;

• publication and transmission to the President and Congress of an annual report on international health activities.

Public input should be invited to assist in the performance of all these responsibilities.

Strategic level responsibilities include:

• the planning and evolution of U.S. Government international health strategy;

• interrelation of goals and activities of international health programs throughout government;

• development and promotion of international health initiatives coming from ongoing government programs, international science and health attaches (described in the following paragraphs), the U.S. private sector, foreign countries, or international organizations;

• maintenance of information on relevant governmental and worldwide international health activity.

The key issues to be considered in improving coordination for international health are: structure, lead, and relation to other related coordinating bodies.

Structure. Of the 22 agencies currently involved in international health activities, AID, HEW and State are the most directly involved, followed by ACTION, DoD and Treasury. Broad policy is most easily developed among those agencies most active in international health. Strategy and broad program coordination, however, requires wider involvement of all agencies with related concerns and potentials for contribution. Ad hoc groups, such as the newly formed African Regional Health Strategy Group, can best serve immediate needs.

Other Coordinating Groups. Three existing coordinating groups with health related concerns are: (1) the DCC; (2) the NSC Ad Hoc Population Committee; and (3) Agriculture’s Food Policy Group. The foci and functions of these groups partially involve international health matters. However, there are significant aspects of international health which are not fully covered by any one of them alone or even all three taken together.

Any international health coordinating body will be concerned with improving health in the developing, as well as the developed world. The NSC and Agriculture groups do not address international health concerns broadly. The DCC does not address international health concerns of the United States and the rest of the developed world, nor does its mandate include advancing health science. Good coordination would be made more difficult to achieve, therefore, by parcelling out international health policy and program responsibility to these groups. Whereas population, hunger and perhaps other basic human needs activities might be most appropriately connected to one of the three groups, in the case of international health, it seems more appropriate to consider whether coordination should be separate from these three groups with significant liaison on respectively appropriate matters.

The most difficult question in this regard concerns the newly established role of the AID Administrator as the President’s and the Secretary of State’s principal advisor on development programs and policy,² and as the Executive Branch’s principal spokesperson to the Congress on development assistance. In this role, the Administrator will chair an expanded Development Coordinating Committee³ (DCC). The DCC will deal with issues of bilateral aid, multilateral aid, P.L. 480, aid for certain international organizations, and legislative strategy and tactics. DCC subcommittees have been established on: bilateral aid loans and grants; multilateral aid including IFI and IFAD loans (but a separate National Advisory Council on International Monetary and Financial Policies will be chaired by the Secretary of Treasury and continue to advise him on policy toward the IFI’s); food aid; developmental programs and budgets of international organizations (excluding organizations now backstopped by Treasury); Human Rights and Foreign Assistance; legislative strategy (to be established); and a working group to review strategy for implementing a foundation for International Technological Cooperation.

Lead. State believes the lead should be shared. AID accepts State as the central point of coordination but believes AID should lead for LDC’s and HEW for developed countries. HEW believes it should lead, but underscores the need for a focal point in State and for coordination between HEW and State. Various agencies (and many nongovernment parties) want a significant White House role in the lead.

The answer to who should assume the lead for coordinating U.S. international health policy and programs will depend to a significant extent on the way in which current reorganization and coordination proposals and plans in various areas develop. The new DCC/CDPP⁴ structure will take some time to establish how its concern for development programs and policy will relate to international development assistance in health and to international health activity not primarily related to development. The proposed Foundation for International Technology Cooperation is just now into the earliest planning stage with only very little known of its relation to health. AID responsibilities are currently being considered for reorganization. HEW, DoD and others (EPA, VA, Labor, etc.) are considering strengthening their international health involvements. Congress (Javits and Kennedy) is proposing new roles and structures for the agencies in international health. OMB is moving toward a consolidated budget review for international health. The World Bank is currently reviewing its health sector policy and should be finished doing so early next year. WHO and the U.N. family in general are undergoing significant policy and programmatic reorientation. Until these and other developments take shape, therefore, it would seem appropriate to retain leadership for coordination of international health activity in the White House.

IV. Initiative Development and Promotion. Global health programs, projects and initiatives can and do originate in many ways, in many places, and for many purposes. They serve goals of global health (including health of U.S. citizens), foreign policy, medical diplomacy, developmental and supporting assistance, professional and scientific exchange, and U.S. commerce and finance. At present, it is cumbersome to develop and introduce such initiatives government-wide. Coordination is ad hoc when it takes place. More systematic procedures should help to ensure an integrated, government-wide strategy to implement these initiatives in ways which best exploit government capabilities in concert with U.S. international health and foreign policies.

Development and promotion of such international health initiatives require the capacity to identify needs or opportunities for assistance or collaboration in other countries, to promote these objectives in the U.S. and host country governments, and to design and select appropriate projects and allocate responsibility for implementation among the many U.S. agencies and private sector resources devoted to international health activity.

To some extent, AID personnel perform these functions in developing AID health programs in countries that meet their criteria for assistance. Attaches of the State Department perform similar functions in broader areas related to science, technology, agriculture and commerce; but little or no direct attention is paid to health and basic human needs. Other agencies are similarly involved, e.g., HEW’s research and scientific exchange activity and VA’s technical assistance for hospital construction. But, AID’s coverage of health problems is limited to AID countries and operationally directed to its own programming needs; State’s Attaches are only minimally oriented to health; and the activities of other agencies often miss opportunities for more effective involvement, fuller U.S. participation, or more coordinated activity. Therefore, development and promotion of international health initiatives as described above requires some improvement.

In the future, such initiatives should be routinely developed and promoted through whatever means exist in the government for international health coordination. In addition, Working Group II recommends working within the State Department’s Attache system to the following extent by:

(1) Creating the post of Deputy Science Attache for health in some countries;

(2) Recruiting health scientists to serve as Science Attaches; and

(3) Raising awareness of Science Attaches by:

(a) health orientation at annual or regional meetings of the Science Attaches; and

(b) visits to Science Attaches at their in-country posts.

Furthermore, in the case of international health initiatives with multilateral organizations—especially with WHO, the current staff at HEW, AID and IO is fully deployed and overextended. Most staff work is performed as a part-time responsibility. A study by IO/State⁵ recommends increasing U.S. staff to permit better coordination in Washington and more frequent contacts with WHO headquarters and WHO regional staffs. This is all the more important as WHO is decentralizing its activities to the regions. Working Group II proposes that HEW create Health Attache positions in at least four of the WHO regions. This would work best if HEW would designate an additional three full-time WHO representatives at OIH, and if State would add an additional health officer in IO.

V. Intra-Organizational Coordination. In order to implement such a policy and coordination framework, Departments and agencies will have to establish more clearly their focal points for international health responsibility. In HEW and AID this would require significant intra-organizational coordination among functions (assistance, training, research) and responsibilities (other agency missions and international health). In State, ACTION, DoD, Treasury, Commerce, EPA, etc., this will require identification of organizational points of coordination with international health policy and program activity in their own agency and government-wide.

In the State Department, for example, it would be helpful to formally designate a focal point at which the relationship between international health and international relations would be clarified and strengthened. Because of State’s role as ultimate manager of all U.S. international relations—thus including international health activities involving other countries or their citizens, it would be most useful if this sort of focal point were to serve as State’s point of liaison for all of its activity regarding international health: representation of international health during formulation and conduct of foreign policy and vice versa; development, promotion and management (but not necessarily conduct) of international health initiatives taken primarily to improve U.S. relations with other countries; leadership in major agreements with other countries on transnational health problems with the environment, safety of goods or services in trade, etc.; and neutral broker for the relationship of international health government-wide with U.S. international policies in other areas.

In order to operate such a focal point, State will have to upgrade its organizational capacity and staff in international health. State is currently investigating on their own an appropriate way to improve their ability to meet responsibilities such as those outlined above.

Other agencies may not require as much structure as suggested above. At a minimum, however, some specific delegation of responsibility for international health matters would be appropriate.⁶

1. Source: Carter Library, Staff Office Files, Special Assistant for Health Issues—Peter Bourne Files, Subject Files, Box 35, International Health, 7/11/78–10/5/78. No classification marking. Bourne attached the issue paper, in addition to another issue paper entitled “Legislation” and four draft reports prepared by the working groups: “Report of Working Group II Science and Health Manpower Development,” “Report of Working Group III Multilateral Agencies,” and “Report of Working Group IV International Health Commerce,” to a July 11 memorandum to Benson, Califano’s Special Assistant Peter Bell, Shakow, and Jayne, in preparation for a July 18 Consolidation Group meeting. (Ibid.) No record of this meeting has been found.
2. Within the Department of State, the Under Secretary for Economic Affairs remains the Secretary’s principal advisor for all foreign economic policy. [Footnote in the original.]
3. DCC membership: Agriculture, AID, Commerce, Export-Import Bank, Labor, NSC, OMB, Overseas Private Investment Council, Special Representative for Trade Negotiations, State and Treasury. (Note the absence of HEW, ACTION, DoD and EPA.) [Footnote in the original.]
4. The name DCC may be changed to Council on Development Policies and Programs. [Footnote in the original.]
5. Not found and not further identified.
6. On July 21, The Washington Post reported Bourne’s resignation as Head of the Office of Drug Abuse Policy and Special Assistant for Health Issues, effective July 20. (Fred Barbash and Edward Walsh, “Carter Aid Bourne Resigns Over False Prescription,” The Washington Post, July 21, 1978, p. A–1) In a July 21 memorandum to Lake, Kreisberg, and Garten, Blaney commented, “I am very concerned that with the departure of Peter Bourne and also with the departure of Bill Lowrance in T that development of an international health strategy will fall into disarray.” Blaney suggested that either the Department of State or OMB assume full responsibility for the effort. (National Archives, RG 59, Policy and Planning Staff—Office of the Director, Records of Anthony Lake, 1977–1981, Lot 82D298, Box 7, TL Papers on Specific Mtgs/Appoint. 1978) According to an undated AID “Health Sector Review” discussion paper attached to an August 2 memorandum from Blaney to Lake regarding the UN Water Decade, OMB would now head the initiative. (Ibid.)