Center for Global Development, Washington, DC
ADMINISTRATOR SAMANTHA POWER: Thank you. Thank you so much, I was in some suspense there as to where that was going. And I’m sitting next to my Chief of Staff Dennis Vega. I was going to blame him if we had dashed expectations but you know, we are getting there and I have the privilege of being two years into my job. I have assembled a tremendous team, and of course, what predated the political appointees’ arrivals at USAID, is such a remarkable workforce with such dedication and rigor. And so, I think we’re on a track, we have a lot more that we are aiming to get a lot more done.
I do want to talk about – for a second – about one of the tremendous leaders we have at USAID and that is Atul Gawande. I see a lot of nodding out there, I don’t know how many of you got into the field of global health or work on issues related to health because you may have read something that Atul wrote a long time ago or more recently. But we just couldn’t feel more privileged, at USAID, and I speak for people not only here at headquarters but out in the Missions, to have Atul as part of our team – such a thought leader, such a visionary, such a curious person, as well. Notwithstanding all of the ideas that he’s put out there – in fact, probably – the way he’s able to put out so many ideas is just going around and asking such thoughtful questions and really listening. And really trying to understand what stands in the way of the kinds of results that we all seek. So, Atul, thank you for coming to USAID. Thank you for being such a great partner, to me personally. Can’t wait to discuss some of the issues that I will be laying out here in this speech with you and engage with the audience.
And President [Masood] Ahmed in addition to being relieved at how you ended your introduction, I would just say, also, thank you for forgiving us from trying to recruit from this amazing institution, some of your very best. But, even those we haven’t managed to lure, we continue to learn from. So many of us, at USAID, have little interruptions in our calendar where we are tuning into some event you are doing or we are taking home with us some briefing paper or some reflection you have on these cross cutting issues. So, you know, if we are able to really make a dent and enhance our impact in the world, it would be in large measure because we learn from you and the team you’ve assembled here. And all of the great research and scholarship, as well, that you incentivize well beyond these walls. So, this is a great partnership and I feel, again, really really lucky to be among you.
So, for decades CGD has led a brilliant project called Millions Saved, that analyzes the impact of various global health interventions. The central, unassailable finding from that research is that – as they put it – global health works, it just works. And the people at CGD have vital insights about how to make global health keep working – even in the face of daunting new challenges. So I am really, really looking forward to our discussion today.
I want to start us off today with a thought experiment. Imagine, instead of coming out every day, the newspaper came out only once a century. Imagine what the headline might be today – would it be “The allies win World War II – Hitler defeated? Man lands on the moon? DNA is discovered?”
Well, the science writer Steven Johnson suggests another headline: that over the past century, human life expectancy doubled. Think about that. Human life expectancy doubled. At the start of the last century, the average human life expectancy was in the mid-thirties. Today, it is more than seventy.
Think again about how incredible that is. At the beginning of the 20th century, about one in three children died before they made it to their fifth birthday. Turn to your left right now, turn to your right – one of you wouldn’t have made it past the age of five. Nearly every family had to endure the unthinkable agony of losing a child.
That is until we began one of the greatest stories of progress of our time. And the story as you well know starts with a series of remarkable scientific innovations. Scientists discover antibiotics that make diseases that were once a death sentence, like tuberculosis, manageable and treatable. They develop safer methods for helping women and babies survive the risks of childbirth. They craft vaccines that protect people from deadly illnesses, helping to stop the spread of diseases right in their tracks.
But initially, these innovations are only available in the rich world – so, by 1970, life expectancy in some of the richest countries is already nearly 70, while in the poorest, it has barely budged.
But then, over the next 50 years, we see exceptional coordination – across governments around the world and across the aisle right here in Washington, DC – and in so doing we see the gap between rich and poor nations closing, we see these innovations reaching billions of people. Now, these efforts, to be clear, haven’t been perfect and nor have the results – today, life expectancy remains about 18 years higher in rich countries than in poor ones.
But overall, progress has been extraordinary. Because of that global effort to extend humanity’s greatest lifesaving innovations to the furthest reaches of the planet, in the last thirty years alone, maternal mortality fell by 40 percent, child mortality fell by 60 percent – and the world’s average life expectancy climbed up to the mid-seventies. The story really of the century.
As Johnson, himself, put the headline: “Humanity gives itself an extra life.” Humanity gives itself an extra life.
Today, however, the world faces a question: Will that incredible story of progress end with us?
Because if you look at the graph of human life expectancy, you see it going up, up, up for decades – until the year 2020, when suddenly, the line looks like it’s falling off a cliff. Average global life expectancy stops its upward climb and falls, instead, by two years – the biggest drop since China’s Great Famine claimed an estimated 30 million lives in the late 1950s.
We all know, of course, what happened, President Ahmed alluded to it, in the year 2020, we’ve all lived it. COVID ravaged communities around the world – COVID overwhelmed health clinics, disrupted routine treatments and preventative care, and killed millions.
Now, COVID-19 is very close to becoming a manageable endemic disease and last week, President Biden signed legislation ending the national COVID-19 emergency. So it is tempting to think that this trend line will just jump right back up to where it was heading before the pandemic.
But the sad fact is it will not.
COVID didn’t just attack individual immune systems; it attacked our societal immune system – weakening health systems around the world and making it unlikely that we will simply recover our upward march once the pandemic is over.
Our weakened health systems are facing growing stresses. An increase in conflict – to rates that we haven’t seen since the Cold War – is disrupting the treatment and prevention of all diseases. Our changing climate is driving an increase in health conditions like malaria and heat stress. And the global food crisis is upping rates of malnutrition – which is a contributing factor in nearly half of childhood deaths.
So now, we see some of humanity’s worst killers back at large. After the largest backsliding in childhood vaccinations in three decades, children are dying in their beds from measles – an entirely preventable disease – as global cases spike by a frightening 80 percent. Health clinics are once again becoming overwhelmed with cholera patients as outbreaks emerge in the wake of climate-driven disasters tainting the water in 30 countries – including some that hadn’t seen a cholera outbreak in decades. And after the pandemic disrupted polio vaccination efforts, wild polio – once gone from the African continent – has returned, setting back the global effort to eradicate the disease.
But today’s leaders have the power to get this progress back on track.
To do so, we will need to take on the underlying challenges that are straining our health systems – helping communities adapt to a changing climate and transition to clean energy to prevent further destruction; building food systems to withstand disasters like drought and floods; and of course preventing conflicts and fostering stability. I feel so privileged to work at USAID because USAID is investing on all of these vital fronts. And one can’t talk about health without, again, putting it in that larger context.
But in the health space specifically – what I am here to talk about today – we must build resilience by uniting in pursuit of three foundational goals.
First, we must finish the fight against the disease that caused the downturn in life expectancy in the first place – by turning COVID into a manageable illness everywhere.
Second, we need to build up our health security defenses against new outbreaks and future pandemic threats – since the same risk factors that caused COVID to spread across the planet remain very much with us.
And finally, we will need to rebuild the resilience of our health systems by investing in the people who form the backbone of these systems: our always essential primary health workers.
So first, make and keep COVID a manageable disease
After so many years of COVID dominating our conversations, and our days, and our fears, many people are frankly just tired of hearing about it.
But that sense of COVID fatigue means that many have also missed some inspiring developments.
In 2021, President Biden committed to making the United States the “arsenal of vaccines” for the world. And, working with the global vaccine distribution alliance COVAX, U.S. government agencies have worked tirelessly to fulfill that vision. USAID managed the donation of more than 680 million COVID-19 vaccines to more than 100 countries, helping to end the worldwide shortage of doses.
And we launched Global VAX, an initiative to help overcome barriers to delivery of vaccines across those countries. Local leaders worked to strengthen distribution infrastructure, they worked to recruit and train health care workers so as to get shots into arms, and companies used their global supply chains to provide cold storage for vaccines and to keep them from going bad.
And these partnerships have led to some incredible success stories. In just the first five months after the start of the U.S. government’s partnership with the country of Tanzania, for example, on its vaccination campaign, which started in June 2022, COVID-19 vaccination coverage jumped from 15 percent – and that’s what got all the headlines, and the headlines haven’t really changed – to 94 percent of the eligible population.
In Zambia, while few again in this country were watching, coverage jumped from four percent in 2022 to over 75 percent of the eligible population in just one year.
In the countries that received vaccines through COVAX, COVID vaccines saved 7.5 million lives in the first year alone.
With each passing day, however, there is a greater risk of running into the central irony that has gotten in the way of fighting so many outbreaks in the past: The desire to “move on” from the pandemic causes us to stop taking the very actions that allow us to move on from the pandemic.
Even now, every week, thousands still die from COVID – and hundreds of thousands of new cases are confirmed. In order to keep COVID from continuing to strain our health systems and cause needless suffering around the planet, nations need to be equipped with the oral antiviral medications, the rapid tests, and the vaccines that they need to make COVID a manageable endemic disease.
Antivirals can have an astonishing 90 percent effectiveness in preventing hospitalization and death – and they provide a critical backstop if a variant emerges that evades current vaccines. Organizations like the Global Fund can help supply these life-saving treatments around the world, as they have successfully done with so many other essential medications.
So, as we speak, USAID in collaboration with the Global Fund and other partners, is in the midst of making the first oral COVID antivirals available in ten low-income countries. We are also working with these countries on plans to procure generic versions of these antivirals as they start to become available, which of course will make it easier for countries to afford antivirals without assistance.
At the same time, USAID will keep supporting countries to meet their COVID vaccine coverage goals, focusing specifically on those who are hardest to reach, and those who are highest at risk of severe illness and death.
We’ve moved past the stage where COVID is the world’s top priority, the crisis that colors every other. And thank goodness for that.
But truly learning to live with this disease requires transitioning COVID prevention and treatment into routine care – and getting all people access to the extraordinary innovations that turn COVID into a manageable endemic disease.
Second, we have to build up our defenses against biological threats
Getting and keeping COVID under control really is just the beginning. We have to build the world’s capacity to prevent, detect, and respond to all infectious disease outbreaks – whether they’re caused by new COVID variants, existing threats, or emerging pathogens.
Disease outbreaks are urgent national security risks, and governments around the world need to treat them that way – building up our collective defenses, again, against biological threats.
The COVID-19 pandemic, as President Ahmed has pointed out, is not a “black swan.” The risk factors that help new pathogens emerge and spread quickly have grown – and they are still growing. As humans destroy forests and other habitats to feed and house a growing population, and as conflict and climate disasters like wildfires and prolonged droughts push animals and humans out of their existing homes, wildlife and people are coming into closer contact with one another – making it easier, as we all know, for diseases to jump from animals to humans. And in an increasingly globalized world, these pathogens can quickly spread across communities, countries, and continents.
All told, Gavi projects that the annual probability of an extreme pandemic will increase threefold in the coming decades – putting the odds of a pandemic of similar severity to COVID happening during our lifetimes at nearly 40 percent.
How do we prevent this? First, again, with innovation. Scientists have identified the most likely pandemic risks, and they are already working on the vaccines and other tools needed to stop them. The United States government is investing in these efforts. For instance, we have made a 150 million dollar commitment to the Coalition for Epidemic Preparedness Innovations to help develop the next generation of vaccines.
But having the right tools to take on a pandemic won’t do the world much good if we fail to detect and respond to outbreaks in the critical early phase – before exponential growth of a pathogen makes containment impossible.
We know that when we combine the expertise and resources of the CDC and USAID, we can be powerful partners when emergencies strike. Last year, USAID launched an Outbreak Response Team that works with the CDC and the State Department to surge support at the first sign of crisis.
Already, this team has sprung into action to help quell outbreaks fast. After an Ebola outbreak in Uganda in September 2022, for instance, our team delivered thousands of sets of personal protective equipment, provided crucial information on recognizing and preventing the spread of illness to seven million people, and offered mental health support and assistance for survivors reintegrating back into their communities, combating the terrible stigma that keeps so many from seeking lifesaving care. Some predicted at the beginning of this outbreak, in Uganda, that it might become one of the worst Ebola outbreaks in history. Instead, it was snuffed out in less than three months.
But being able to respond to just one crisis, in this world, is not enough. When many health emergencies are happening at once – when there’s, say, an Ebola outbreak in one country and a spike in waterborne disease because of flooding in another – we need to be able to put out several simultaneous fires.
So today, I am announcing a new initiative that will help us tackle multiple crises quickly, at one time. It’s called the global health emergency response system. I know that a new “system” may not sound like the most exciting thing in the world. But USAID’s long history of marshaling rapid and effective responses to humanitarian crises has taught us that success in an emergency relies on just that. Relies on having a system in place to rapidly deploy surge funding and staff, and to coordinate a response across relevant bureaus at USAID and across our large U.S. government. The new global health emergency response system is going to help us do that.
But even more important than bolstering the U.S.’s own response capabilities, we’ll be building greater capacity in all nations, so that they can prevent, detect, and respond to outbreaks.
The World Health Organization has spelled out the core capabilities that all countries should have in order to keep safe. Local scientists need to be able to conduct disease surveillance – testing water and sewage for pathogens, for example, and looking for unusual patterns of disease in the people who are coming through health systems. Health care workers need to be able to recognize warning signs, report unusual symptoms, and use the protective equipment and the protocols that help contain a threat. And citizens need to understand when they should visit a clinic, and they need to trust that they won’t be ostracized if they do catch a contagious disease, but instead will be treated with care and dignity.
The United States and other partners are investing in helping countries build these capabilities. Under President Biden’s new National Biodefense Strategy, the U.S. government is committed to supporting 50 countries to achieve international standards in their ability to prevent, detect, and respond to emerging infectious disease threats. And last year, the G7 collectively committed to support 100 countries in these efforts.
We’ve also worked with the World Bank and the WHO to establish a Pandemic Fund to drive greater investments in health security and break the typical cycle of panic and neglect, which we know so well, in the wake of health emergencies. The U.S. has contributed $450 million so far, which in turn has helped unlock $1.6 billion in total investments. But the WHO and the World Bank estimate that the annual funding gap in pandemic preparedness is a whopping $10 billion. President Biden has requested another $500 million in the FY24 Budget Request to help meet this need. And I really hope more governments will also step up and contribute to closing this gap.
We know these investments in health security work. We saw that recently in the DRC.
In 2018, Ebola hit the Eastern part of the country, circulating for at least four months before it was detected – 2,287 people are reported as having died.
But then, starting in 2019, the DRC worked on strengthening its outbreak response capabilities – an effort that we, at USAID, were thrilled to be able to support alongside the CDC. We worked together to improve lab testing, surveillance, and reporting, and to distribute a lifesaving new Ebola vaccine. And we partnered with the brave community health workers to help them recognize disease warning signs, and respond safely when new threats emerged.
Well, Ebola hit the Eastern DRC again last year. But this time, it didn’t take four months to detect the virus. It took 48 hours. Instead of thousands of casualties, there were five.
The COVID pandemic showed that health risks anywhere are a threat to people everywhere. We can either let ourselves be scared by that fact, and retreat into ourselves – or we can come together and strengthen the health and safety of all communities.
And the last thing we need to do, third and finally, if we are to continue the past century’s story of global health progress?
Invest in the people who have been driving this progress all along.
This story of progress has both villains and heroes – and historically, the global health community has tended to focus our efforts on the villains: the diseases that cause unnecessary death and suffering all around the world.
The global health community has long organized our investments, our campaigns, and even our bureaucracy primarily by disease. And we have seen remarkable successes from taking on the most deadly killers. In our own government, the President’s Malaria Initiative has helped save nearly 12 million lives. PEPFAR’s work to turn the tide against HIV/AIDS has helped save more than 25 million. Multilateral efforts, too, have had great success by combating specific diseases: the Global Fund to Fight AIDS, Tuberculosis, and Malaria has helped save an astonishing 50 million lives. So, focusing our efforts on the villains has led to very substantial impact – and we will need to continue and bolster these efforts.
But there aren’t just villains in this story. There are heroes too – heroes who we tend not to focus on much at all.
We do sometimes celebrate – as we should – the great scientists who drove the breakthroughs that helped us take on these diseases in the first place, and the leaders who convinced the world to commit to distributing them.
But their efforts would not have changed the world without the millions of primary health care workers who bring this essential care to people around the planet. These workers cross rope bridges in isolated mountain communities in Nepal to extend the reach of childhood vaccines to the world’s most remote places. They race on motorbikes through crowded cities to provide lifesaving care to women in labor. They build relationships with communities by listening to people’s concerns, by building trust, and offering care and advice to reduce suffering and to help people meet their fullest potential at every stage of life.
And when health crises strike, they go to the front lines to keep their communities safe. I will personally never forget visiting Sierra Leone at the height of the Ebola outbreak there in 2014. Cases were growing exponentially, I’ll remember this well, forty percent of people who caught the disease were dying from it. The Director of the CDC Tom Friedman told me that he’d never seen a disease of this lethality spread so fast. The risk was so real that, when I began to organize a trip to the affected countries as U.S. Ambassador to the UN, my own family begged me not to go.
Yet on my trip, I visited a health worker training center that the United States and the United Kingdom were running in partnership with the local government where masses of people were queuing up, offering to spend their days working closely with infected patients. I asked them what was motivating them to join the fight and one of them responded: “If we leave our brothers and sisters to die, who knows – it might be us next. It is a point of duty.”
Heroes. And when I say we haven’t focused enough on them, I don’t just mean that we haven’t seen or celebrated their contributions as much as we should – although we haven’t – I mean we haven’t invested enough in them.
Today, Africa has a quarter of the world's burden of illness, but just 4 percent of its health workers.
Many of these workers are significantly underpaid, or not paid at all – a common phenomenon when a profession is dominated, as primary health care is, by women. A recent report found that in total, six million women in the global health workforce are either grossly underpaid, or not paid at all. Six million.
When you are providing lifesaving care, there should be no such thing as working for free. A lack of adequate compensation furthers gender inequality – and of course it makes it impossible to recruit and retain the workforce that communities need. Particularly when you consider the fact that these frontline workers can be exposed to harassment, to violence, to disease, and that they often lack the basic protective gear they need to stay safe.
The WHO reports that 55 countries already face dangerously low shortages of health care workers – eight more countries than were struggling with this challenge before the pandemic. 37 of these countries are in Africa.
When we strengthen primary health care, we make virtually all of our programs to fight individual diseases more successful – since primary health care workers are the ones who carry out our campaigns against everything from HIV to malaria to TB.
And primary care workers don’t just fight disease; they build community health. They offer family planning tools so that families can choose to have children when it’s healthiest for them. In Ghana, for example, when we funded primary health workers in a randomized trial, the share of families choosing to use contraception increased by a third – which in turn helped cut child mortality in half.
Primary health care workers promote mental health. Over a billion people suffer from some type of mental disorder. Yet governments spend, on average, just two percent of their health budgets on mental health care. Primary health care workers can help meet this urgent need. More than 80 percent of people with mental health conditions can be treated effectively by properly trained primary health care workers.
And on top of all that, primary health care workers are essential to our pandemic preparedness efforts. Because of the relationships that they uniquely develop with communities, they can help spot diseases as they emerge – and pivot quickly to administer treatment in the face of an outbreak.
The good news is that many countries have shown an enormous willingness to take on this problem and to invest in building up their primary health care systems. They are recruiting more primary health care workers and equipping them with the tools, the resources, and the facilities they need to do their jobs well.
Give one example: Indonesia. Indonesia has been steadily increasing its investments in primary health care – they are now spending over 25 percent of their health budget on primary health care. And I think that’s up from ten percent not long ago. In the coming years, they plan to invest 50 percent of their health budget in the primary health care system, which would put a well-equipped, fully staffed primary health care center in every one of Indonesia’s 75,000 villages. Imagine.
And we have seen strong commitments to improving health care systems like Indonesia’s from many other nations as well.
But building primary care systems requires far more substantial investment – and many are attempting to take on this challenge while resources are significantly strained in the wake of the pandemic and while many countries are gripped by debt distress.
So USAID has started a new initiative called Primary Impact, which is starting out by supporting seven countries as they work to strengthen primary care: Côte d’Ivoire, Ghana, Indonesia, Kenya, Malawi, Nigeria, and the Philippines.
Through Primary Impact, we are working with these governments to develop action plans that identify their most pressing needs in the primary care systems. And then, as they strengthen their investments, we will work, collectively, to fill the gaps created by the silos in our own funding. We will also critically coordinate with the World Bank and other funding partners around the world to help countries meet these pressing needs.
Our goal is to get survival rates for children under five and women under 50 in these countries back to better than pre-pandemic rates by 2025. That’s soon.
To meet that goal, we are going to need to offer more support to help implement these action plans once we have established them.
And to get progress back on track more broadly, we need to see action like this not just in the initial seven partner countries, but across the world.
Fortunately, President Biden has recognized this need and he’s launched the Global Health Worker Initiative. If Congress commits to making this vision a reality, we will be able to support more countries that are investing in their health workforce with the training and the tools that these workers need to be effective.
But we do need other nations in the G7 to commit to investing in primary care. As you heard, we have seen incredible commitments to invest in global health security and emergency response – commitments that we know we’ll need to build on in the years ahead.
But now we need a matching commitment for everyday primary care.
Research shows that scaling up affordable primary health care across low- and middle-income countries by 2030 could save 60 million lives – and increase average life expectancy by 3.7 years.
That is the kind of action we need to get progress back on track.
A century ago, as millions of formerly healthy young people lay dying around the planet during the Great Influenza Pandemic of 1918, it would have been almost impossible to imagine that the next century would bring about the global health miracle of doubling life expectancy.
But we learned our lessons and used that pandemic recovery to spur extraordinary progress on exactly the same fronts that we need to focus on today: turning the illness that caused that pandemic into a manageable disease, improving outbreak response, and extending basic primary care to more people. That was the playbook.
In the years after the Great Influenza Pandemic, we kept up the fight against the flu, even as the emergency receded, developing better treatments and vaccines – stunning gains that advanced modern medicine.
We began coordinating our health efforts to improve our emergency response. In the 1920s, U.S. states began a national disease reporting system, and countries came together to open an international bureau for fighting epidemics – that was of course the predecessor to the WHO.
And we extended primary care to more people. Before the Great Influenza Pandemic, most doctors were either self-employed, or worked for charities or churches. Many people didn’t have access to health care at all.
After the flu emergency, however, many nations created or revamped their health ministries, extending basic care to people who had never had access to it before.
These investments didn’t always appear transformative in the moment. But they set in motion a rush of global health progress that changed the course of human history.
Today, we too, can learn lessons from this period of crisis, and use the lessons of the pandemic to build up not just individual immunity, but our societal immunity – so that this remarkable story of progress does not end with us, but builds for future generations to come.
Thank you so much.
Question and Answer
MS. AMANDA GLASSMAN: Thank you so much Administrator Power. That was a hugely important speech, really a benchmark speech for our sector and global health. And, as you call it, the story of the century that we have to keep the pages turning on. I'm really grateful to have the opportunity to sit down and have some moments for questions. And we're also going to go to the audience. And we're joined, of course, by the Assistant Administrator for Global Health and just basic health celebrity, Dr. Atul Gawande – I recommend his documentary.
Okay, so I'm going to kick off with a couple of questions. First, you've outlined a call to action around the decline in life expectancy and stalled progress on global health goals, a three part agenda. USAID is already playing a role. But a question to you is how might USAID reimagine your approach to partnership? You know, we know that in 2022, U.S. health money only went direct to governments in about four countries, about $43 million. That's about one less than 1 percent of U.S. global health spend. You've already committed to working more with local partners and governments potentially. So how are you thinking about that? Especially because you talked about the fiscal distress that some countries are under, you talked about the need to pay community health workers potentially through public budgets. How would this be managed? How can we reimagine partnership?
ADMINISTRATOR POWER: Great, well, I will start and then we'll get our real expert to weigh in here and maybe offer some examples of what we're already doing, I think, in this vein. So first, we are as an Agency, trying to shift resources to more local partners. So that's a whole separate conversation. But it very much graphs on to this one, in setting a target of having 25 percent of U.S. assistance flow to local partners by 2025. And for 50 percent of our assistance by the end of the decade, to be the product of local partnership, codesign, coevaluation, co-implementation. We're moving in that direction. It's very slow. The barriers to entry are fairly substantial. Our compliance requirements up on the Hill are prohibitive for many local partners. There's still a lot of skepticism in certain quarters here in the United States about the reliability of G2G.
But I think – then maybe Atul can say more about this – I think PEPFAR has really paved the way and shown just how doable it is. I mean, people would have thought that those targets were unachievable. I think they were very – it's been, you know, hard on the system to get there so quickly. But one of the things that we've done in our broader agency-wide look at localization is trying to study how have our – how have our PEPFAR programs managed to move in that direction so much more quickly than we have managed in other sectors? So, let me just say that at the outset.
Second, you know, our broad approach at USAID, really born of necessity, because of the gap between public sector resources and all the needs out there – I mean we spoke today about health, but I could give a food security speech that was a lot like this; I could give give a democracy and governance speech that would sound – just in terms of those gaps and the needs for those, those gaps to be filled. So we're trying to sort of shift the mindset.
And we've learned this really from many trailblazers at USAID who are already doing this, but from a – what do we get from Congress, and what do we do with it, to what are the problems we're trying to solve? How do we graph our resources against those problems, and even if we have no resources – if it's the problem that we know needs solving, we are the United States. You know, we're a major player in every major multilateral institution, we're the largest donor in most of them. We have thought leaders, you know, like Atul, that we draw on, research from from people like you and people here in CGD and elsewhere. I mean, we have a lot to offer, even before we reach into, you know, the coffers, or to what Congress has appropriated to us. And that sounds kind of obvious, I know, maybe, if you're not in government, but because program management is so time consuming, and so elaborate, it really can actually, you know, cause one to focus on the kind of four corners of whatever that program is you're managing.
So, this is a shift, we're trying to change the incentives at USAID. So you also, even in promotion, kind of get credit for cooking something up with the World Bank or the private sector alongside, you know, what you might be doing, again, within the dedicated program space. So here, I think, on the – on the health worker side, or on the primary health side, one of the biggest players is the World Bank. I think we're already seeing, you know, they already have those pre-existing relationships but, you know, if we are working with countries to develop these action plans, then being in a position to work with those countries to be putting forward proposals – actionable proposals, very specific proposals, proposals that are well thought through – if some training has gone on – there's the training of the health workers, but then there's also training of the people who are actually figuring out how to appeal to the large MDBs or to other institutions. So there's that kind of catalytic role that we can play. And we've can appeal to Congress, to provide us with additional resources that will allow us, as well, to be doing more more direct funding. But Atul do you want to speak to some of this underway in our seven primary impact countries?
ASSISTANT ADMINISTRATOR ATUL GAWANDE: Well, first of all, the first thing I think I need to say, how lucky are we to have someone as formidable as Samantha Power, coming in to talk on health.
I took this job, in large part, because Samantha is someone who understands diplomacy, who understands humanitarian advocacy, and the power of what that can create. When you have zero budget much of your career, and knowing how you can create change there, you know, I bring health. I get to learn how we can do all of this and I see examples. I'll talk about two.
Ukraine was my first big education in all of this and USAID played a critical role, in our Office of Health Systems, in supporting the transition of post-Soviet Ukraine – from a world of hospital based and specialty based care, to have a no real health coverage system, no health financing system – to actually having a universal health coverage financing system that covers everybody in Ukraine. And that technical assistance, the working through the models of how you do that led to relationships and also helped us work on a pathway to reduce corruption and both of those aspects of the relationships and made it so that when they were – when Putin invaded Ukraine, and all the medical supplies got cut off. You know, Russia supplies medical supplies, a large chunk of it, and then Europe wasn't able to send into a war zone. These teams were the ones who now had the relationships and ability to support a transition that could get 5,000 humanitarian aid organizations plugging in to enable a pharmacy system that works to get 250,000 HIV patients needing their next month's meds to stay alive – getting getting their medicines and capabilities – all with reprogramming the existing funds we already had in the country, before we even had a product, that budget.
So now, you know, do we have a major investment yet, in primary care as a solidifying emphasis? No. We intend, that we are making the case that we can get there. And what we recognize is that, to take the example of Indonesia that you just spoke about, Indonesia has made a commitment of a radical reorientation of their health system towards primary care. As Samantha said, from less than – from about 10 percent of their budget, going to their health budget, going to healthcare to primary care, to 25 percent, on the way to 50 percent. They have, again, with some expert technical assistance, been able to make a health financing system that has moved now down the path to universal health coverage. They are picking up the costs increasingly of HIV meds, for example, that we used, was used to provide. But the bigger thing now is, they are leveraging over a billion dollars in World Bank loans – much more than we would ever put in – they are putting their own domestic financing on the line and taking on loans to shift towards primary care. And then we can come in to make sure that all of our programs, from HIV to malaria, to TB, to maternal and child health are, you know – it's the same primary care workers that are supporting and delivering the babies, diagnosing the tuberculosis, and given the COVID shots. And our technical assistance for the managers and their training for improving quality of care for and the training of the frontline workers, those are the spaces we are able to lean in and make the difference. And then yes, every additional investment we're able to put in can target how we incentivize enabling that broader health base.
MS. GLASSMAN: Okay. And do you have an example from sub-Saharan Africa that you could share with us.
ASSISTANT ADMINISTRATOR GAWANDE: Yes. Ghana is a long, USAID success story. Ghana – so we have learned, actually, because of a large scale randomized trial done in Ghana, where USAID, was partially supporting, that when you finance frontline health workers, who have traditionally not been trained to be trained at a level to be at least nursing levels – that 18 month training program – put in enough density that they're able to touch every home at least once a year and be equipped so that they're not out there on their own, but are plugged into a primary health care clinic system. So that primary care is not primitive care, that actually is making sure that, can frontline community health workers are delivering the – some critical health care priorities. But then for the ones that can't meet that they're being brought into a larger system. That started as a small-scale trial in the northern part of Ghana. And they demonstrated that within three years, they cut child mortality by 50 percent. That within seven years they cut child mortality by 70 percent. That the family planning program ended up reducing the birth rates by a full [inaudible] drop in fertility rate in the course of that time. That then, we supported the technical support to scale up that to nationwide. And Ghana exceeded the seven-year life expectancy on the, on the track that took you know, took from the early 1990s to where we are today. That kind of capability is the kind of thing that we are now helping Ghana secure at a time when they're in a time of financial crisis and keep on moving forward as one of our primary health care countries, primary impact countries. But then also want to see that it's replicated in other parts of African countries that have the chance to grow from as well.
MS. GLASSMAN: Okay, great. Well, we'll watch that. I have one more question I know the audience wants to ask, but I have to ask, which is that as you know, our U.S. global health budget is very much oriented towards the killer says, as you put it. How would you imagine, as you think about increased primary health care or a more strategic relationship with governments, how to make all of these vertical funding flows work for the objectives that we've talked about – whether it's within the USG or beyond the Global Fund, Gavi, etc.
ADMINISTRATOR POWER: I will let Atul give a more fulsome answer, since he's the silo breaker day to day. But, you know, I do, I don't want it to get lost, actually how substantial the investments we are now making, as a U.S. government in global health security are. Because, you know, again, the temptation is panic, flood the zone, retreat, don't learn lessons, same thing happens, gets worse. So I think the fact that we now have 50 countries where we're making global health security investments also creates a little bit of flexibility. That's a growth area. And, as a result, some of our objectives here in the primary health space, we're going to want to be imbuing, you know, in the work in the global health security area.
I think that additionally, again, this is the first time in a long time, at the very least, that an Administration has come forward with an appeal for dedicated health care worker resources. As of yet we don't have the response from Congress, we would like I mean. I mean, part of the challenge, and we'd welcome your support in addressing this, is that constituencies are also very disease based. You know, you have a community of people who are very dedicated to the malaria cause – God love you. And thank you. Needless to say, the HIV/AIDS community and the success of PEPFAR both was predated by tremendous advocacy, and then that constituency has grown over time. This doesn't quite have you know, that that same – and that's on the primary side. But by even having a program now called Primary Impact, you know, we're hoping to create something that people can rally behind, but in terms of the silos among diseases, I’ll let Atul speak to that.
ASSISTANT ADMINISTRATOR GAWANDE: Well, let me just say, we've learned over the last 20 years how to create change in global health as, as your work as global health works. But how does it work? First of all, you have to be able to set goals, so you have to be able to measure. So we learned in HIV, TB, polio, we need your way of measuring in those cases, diseases, then our progress against them. You need to orient all sections of the community in the country around the country plan, for how you're going to attack the problem and what everybody's role in that is. And then you hammer away year by year and actually works. That now we're applying in global health security.
We have crisp metrics for whether your labs are in the right place, whether your people are trained appropriately, and so on. And so now we have $900 million in FY23 that will go toward – which is a market increase from any where we've ever been. And it's amazing to see that continue after the pandemic, because that's crucial. And that is now making sure that we are knocking out each of those barriers, one by one. In primary care, we've not had that. But over the last decade, there have been efforts. I was involved in one with the World Bank and the Gates Foundation, called primary health care performance initiative, that established metrics that are now adopted by the WHO in the same way, we can now measure the percent of the budgets that go to primary health care. We can look at the density of your primary health workers. We can look at whether they're appropriately trained, and whether they're connected into clinics in the appropriate ways. And whether the patient experiences are that they are turning to those places because they can serve the majority of their health needs instead of going around them to hospitals miles away after it's too late. And that capability now, we are working with these seven countries to have national level plans on delivering on those goals. And we are partnered in this effort with the World Bank so that we are collectively starting to make these contributions. We can now build these out and demonstrate that we can get, rally many more to these causes. So we've made primary care visible, we've made it measurable. And we can now show the components that result in better coverage of essential services like immunizations, family planning, tuberculosis, etc. And then that and we know how that leads to improve life expectancy.
MS. GLASSMAN: Okay, so we're going to the audience. If you have a question, can you please raise your hand and someone will bring a microphone to you. Be very, very brief. We'll collect three and go back to our illustrious panelists. Please say who you are and where you work.
QUESTION: I am Gordon [inaudible] from Biodesign Innovation Labs. I'm from India, here at the fellowship at Halcyon. I would like to ask my question regarding the population growth: we can see India has exceeded the population, as opposed to China, and what do you think for a country which is having a population of 1.4 billion people, you know, the health care system should be prepared. We have seen COVID first wave and second wave in India. And as a company which manufactures ventilators, we work on the medical devices. We responded to COVID-19 and having seen firsthand, it was very overwhelming experience. How do you think, as a country like India – first population country – how do we respond for next threat? In the pandemic? How can we best be prepared?
MS. GLASSMAN: Thank you – here.
QUESTION: Hi, everyone, I'm Aruba Dodd [phonetic] from Women in Global Health. I really appreciate, Ambassador Power, that you have cited the report about six million women health workers are currently unpaid and underpaid. My question is very much related to this, to both of you, on: how does the US government plan to address this issue, which we know is only going to worsen and is already worsening as a result of the pandemic. Thank you.
MS. GLASSMAN: Thanks, and the last question. On the right side, you haven't had a chance right here in the middle. Here in the middle. If you can stand up, go ahead. We can find you.
QUESTION: Thank you, Tristan Reed [phonetic] from the World Bank. There's been some attention to USAID’s procurement policies, you mentioned limits on being able to buy services from from firms overseas. People have also pointed out that there are restraints on trade even in the United States so that in order to bid for a contract you have to have worked with AID before. I was wondering if you could just say a little bit about you know what you're doing to open up procurement with AID.
MS. GLASSMAN: Okay, so a big question about India. How do you advise? Obviously, it is a strategic partner of the United States. What kind of work are you doing in the global health pandemic preparedness space? A second on the approach of the U.S. government on the women community health workers, their payment, their adequate payments? Is there a policy agenda there? And finally, on what's happening in terms of procurement, access, competition, and things like that? So, shall we start.
ADMINISTRATOR POWER: So, I guess maybe I'm thinking of my comparative advantage when I'm next to Atul Gawande. I will just pull back a little bit on the first two questions. So which – in some ways relate to each other – because it's about in the sense of resourcing. If we're talking about care, it's about resourcing that commit – a booming population with health care workers, unpaid or underpaid. And this is where I think the work that we need to do collectively outside of the public health space is so critical to securing gains on global health. And, so if you take, for example, you know, to come to the health worker underpayment issue, we have countries now coming to us, you know, saying we would like nothing more than to increase our investments like Indonesia has done. We just have a problem, which is we're spending nearly half of government revenue servicing debt. You know, when you have debt service payments that are literally crowding out basic investments in the health sector, also we hear the same in the agricultural sector for countries that are trying to, you know, expand agricultural productivity to be able to feed themselves, especially in light of high food prices. So, we have actually gone to Congress and also asked for USAID to grow, when it comes to core economic development programming, you know, as much as we feel under-resourced in this space.
You know, if you look at PEPFAR funding globally, and compare it to anything we do on economic growth, inclusive growth, counseling countries as to how to engage in their debt restructuring negotiations, trade facilitation – the kinds of programs that could help countries generate their own revenue to be in a position to have enough domestic resources to allocate appropriately to be, you know, true, the kinds of partners they would most wish to be and making their own investments. That's about one tenth – our investments globally are about one tenth of those in PEPFAR, you know, for – and that's not to say we shouldn't anyway, you know, diminish what we're doing on PEPFAR, but it is to say everything is connected to everything else, unfortunately.
And so there's no great answer, in the long term, on paying health workers that doesn't involve the fiscal health of the countries in which we work. And we just absolutely have to be much more laser focused on that. Given again, the calamity of dead, which really is a very, very different problem today than it was even five years ago, nevermind 10 years ago, when it just really wouldn't have been the gaining issue, it might have been corruption, it might have been political will, it might have been military expenditures. But now this is actually really cabining what people can do.
And then on that score, as well, I would just say that India is a great example of where, I think, some of our best work and Atul can can speak directly to the question, but has come also by virtue of working with the government, as well to incentivize private sector involvement in this space. I mean, and that is where so much of the innovation has come. We saw the vaccination campaign, which was the likes of which I think no country has ever seen. Even, you know, if again, the health costs of the pandemic were still tragic. So that is what our mission does, is think beyond “what are we doing,” I mean, given Modi's investments directly, but what are the ways that we can be catalytic? You know, when it comes to bringing other stakeholders to the table. And then, I don't have a lot to say on procurement. It’s a specific set of questions. We have a new acquisition strategy that really is aiming to open up this process, we do have workwithusaid.com, or .gov, one of the two – try both [workwithusaid.org]. But where new partners, you know, are actually getting, you know, access earlier, getting more of a sense of how to compete. But this is something we know we need to diversify our partner base, it's something Congress pushes on. We have exceeded our target this year in working with small and disadvantaged businesses, by two percent, but that target is going to go up every year. So hopefully, again, we will see more pluralism in the range of large contracting partners particularly.
ASSISTANT ADMINISTRATOR GAWANDE: Let me jump in on – just add a little bit on the first two. On India, just say – so my family's from India. My father's from the village in Maharashtra, the Yavatmal district, where he was a village boy, and, and his mother died of malaria at a time when the life expectancy was just 30 years. The solutions existed, it simply did not get to them. The only doctors he'd ever experienced were people in white coats who came to do smallpox vaccines in the 1970s, a major effort of USAID, of which now I'm here as a beneficiary of that, right? And brought the, the Green Revolution that enabled the community in which my father grew up in to go from famine, and, you know, his own family members dying from famine, to being one where today India is an agricultural exporter. It is the president of the G20 this year. And now I get to be on the other side of the table negotiating with India. And what do we talk about? The priorities of India at the G20 are primary health care, and especially digital health care. And right now, India is leading a set of work to build health and wellness centers that actually follow through on what the evidence shows get at least nurse or higher level workers at the community-base level, integrated into more comprehensive primary health centers. And in India is now past 71 year life expectancy. The United States is currently 76 as our last numbers, we probably will rebound to 78 or 79. And India is on a path that can recover that with a strategy that includes their primary health care focus, a global health security focus as well.
I'll say second, around female health workers, that the most important thing we can do is start paying health workers. In Africa, 85 percent of the health workers are unpaid 85 percent of community health workers are unpaid and most just getting basic stipends. And they are well over 70 percent female. What we've seen in Ghana is that when you pay those health workers, you know, the view is always – it's too expensive. It's – you can't train to a nurse level. It's not feasible. It has demonstrably produced a – been a driving force for the economy. Health care spending is not spending, it is investment in the human capital of your country. And it results in your improved livelihood in economics for decades to come. And so that economic benefit immediately redounds to the female workforce because there's such a large segment of the capacity and untapped capacity in our health care space.
MS. GLASSMAN: I think that we're at time unless you can stay a little longer. No, we cannot.
ADMINISTRATOR POWER: I don't know – I’m not the boss.
MS. GLASSMAN: In which case I see the shaking of the head. So thank you so much for an inspiring speech and for all your work.