748 



our contributions to these international organizations. We 

 just don't get anywhere doing that, do we ? ^'* 



Mr. De Pai.ma. We have not succeeded in slowing the rate 

 of increase ; no sir * * * there have been two principal reasons 

 for the increase [$14.8 million for total increased U.S. con- 

 tributions to all international organizations=10%], Mr. 

 Chairman. A substantial portion has to do with just main- 

 taining the current level of activity in the face of rising prices 

 and wages.^^^ 



Mr. De Palma. * * * We have managed in every case to work 

 out certain savings in the budgets as proposed. We have not 

 managed to prevent increases. We have not done that, sir, 

 because in the first place we did not have the votes * * *. We 

 have also been unable to do it, because in some cases even some 

 of the major contributors have felt that the ceilings we were 

 trying to impose were unjustified. ^^° 



RECAPITULATION OF U.S. LEGISLATIVE PROBLEM 



There is no question but that the costs and benefits of external 

 activities of the United States, after an impressive outpouring of 

 wealth in World War II and large foreign assistance and military 

 activities thereafter, are coming under increasing public scrutiny. 

 Congressional control of policies and programs is historically exerted 

 by means of the purse strings. Accordingly, funding levels of U.S. 

 foreign programs are a proper subject for congressional examination. 

 However, it seems also to be an important question as to precisely what 

 the consequences are of such U.S. expenditures, in terms of benefits to 

 the United States. It is suggested that these aspects are not sufficiently 

 examined ; and the reason seems to be the enormous range and complex- 

 ity of the subje^'t matter. Accordingly, the possibility might be enter- 

 tained of enlisting the services of a qualified research institution to 

 make a thorough investigation, in depth, of the relationship between 

 actual costs and direct and indirect benefits of foreign assistance, with 

 particular reference to international agencies concerned with health. 

 Few fields of international activity present more difficult problems of 

 fiscal accountability than do health and medicine. 



Cost /Benefit Analysis as a Possible Solution 



Few programs of major significance become or remain a fruitful 

 effort which do not rest on a mutual understanding of objectives and 

 costs on the part of the practitioners and the politicians. WHO and 

 PAHO are major international health programs, and to present their 

 costs in the absence of information concerning their qualitative and 

 quantitative benefits makes the entire appropriation process an exercise 

 in arithmetic. If the American taxpayers' investment in global health 

 is not achieving the results ex]>ected from that investment, what 

 institutional and policy reforms can be implemented to change the 

 situation? And how does one determine that benefits are consistent 

 with cost ? A rational basis for the determination of priorities and in 



1'* HniiRp. "Dvpartments of State, .Tustice, Commerce, the Judiciary, and Related 

 Ajrencies Appropriations for 1971," Hearings, op. cit. page 401. 

 "9 Idem. 

 '80 Ibid., page 404. 



