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| Presider: | Laurie A. Garrett, Senior Fellow, Global Health Program, Council on Foreign Relations |
|---|---|
| Panelists: | Seth Berkley, President & CEO, International AIDS Vaccine Initiative |
| Isobel Coleman, Senior Fellow for U.S. Foreign Policy and Director of the Women and Foreign Policy Program, Council on Foreign Relations | |
| Nils Daulaire, President & CEO, Global Health Council | |
| Helene D. Gayle, President & CEO, CARE | |
| Nita M. Lowey, U.S. Representative (D-NY), U.S. House of Representatives | |
| Princeton N. Lyman, Adjunct Senior Fellow for Africa Policy Studies, Council on Foreign Relations | |
| Stewart M. Patrick, Senior Fellow & Director, Program on International Institutions and Global Governance, Council on Foreign Relations |
January 22, 2009
Council on Foreign Relations
LAURIE GARRETT:
Good Morning. Please turn off all noise-making electronics; this meeting is ON the record.Welcome to the new CFR office in Washington.
We are here today to launch the Action Plan on Foreign Assistance. My name is Laurie Garrett, Senior Fellow for Global Health at CFR – I authored the Plan. But the plan is actually the result of a very extensive process involving a large number of key players, some of which are listed in the back of the report, and a few of which are with us today;
The Council takes no institutional position on policy issues and has no affiliation with the U.S. government. All statements of fact and expressions of opinion contained in its publications are the sole responsibility of the author.
Today’s events will flow in three segments, with NO BREAK between the first two. Segment One will feature comments from Representative Nita Lowey, who I am proud to say comes from my home state of New York. Rep. Lowey has been a tireless voice on foreign assistance issues on the Hill, and we are honored by her presence. Also joining us during this first hour will be my CFR colleague, Isobel Coleman, who has virtually pioneered work on the relationships between the health, education and political inclusion of females in societies and the relative stability and security of those countries. We will leave plenty of time in this first segment for your questions and comments;
In our second segment I will be joined here on the stage by some of the smartest people I know, each with expertise in key aspects of U.S. foreign assistance. I will ask them a round of questions and then, again, give all of you in our audience an opportunity to join in the conversation;
Finally, we encourage all of you to join us for an informal lunch, and continued opportunity to discuss the Council Action Plan.
Welcome to Day Two of the administration of President Barack Hussein Obama, 44th President of the United States. Welcome to Month One of the 111th Congress.
Fifteen months after taking office George Bush discreetly set to work with a team of advisors on creation of what would be called PEPFAR – the President’s Emergency Plan for AIDS Relief.
At 2 o’clock in the morning on May 27, 2003, after considerable amendment, the Senate passed the law, committing America to a multibillion dollar chronic care program overseas.
Last week in her remarks to the Senate Foreign Relations Committee, Hillary Clinton, President Obama’s nominee for Secretary of State, highlighted the achievements of George Bush’s PEPFAR program, adding that the Obama Administration will-- [QUOTE] -- “build on this success by partnering with NGOs to help expand the infrastructure of health clinics in Africa...”
Noting that 2 billion people today survive on less than $2/day, amid rising food prices, Clinton said that the Administration’s -- [QUOTE] -- “Calls for expanding civil and political rights in countries plagued by mass hunger and disease will fall on deaf ears unless democracy actually delivers material benefits that improve people’s lives...”
These remarks seem to signal that the Obama Administration will continue to support PEPFAR, and billions of dollars worth of other programs overseas, despite – or because of – the World’s grave financial situation.
For about two years the leading global health and development organizations in the U.S., and nearly every top think tank in this town, have issued calls for radical changes in the mission, goals, statutory guidelines, and hierarchical structure of foreign assistance within our government.
All of these efforts have been laudable; some are brilliant. But there are problems.
First, there is the perception that many of these groups and individuals are demanding Congressional allocations that, frankly, will support their programs, their salaries, their initiatives. As one former member of the National Security Council put it to me, “Why should anybody take seriously groups that just say, ‘Give us more money,’?”
Second, when budgetary push comes to shove, many of these groups and initiatives put aside their common interests and go to the Hill to fight for the tiny piece of foreign assistance or global health real estate that they call their own – often at the expense of other health and development programs.
Which leads to Problem Three: There are too many proposals, all demanding more reading time than Congressional staff can spare, and more money than Congress or the White House has the appetite to spend.
About a year ago the Council on Foreign Relations’ Global Health Program decided to weigh in. We felt that we were uniquely positioned.
Why?
Under the Council charter we are forbidden from accepting direct financial support from any agency of the United States Government. We have no dog in this fight.
When we started this process the primaries were underway, and it was not clear who would be the Presidential candidates for either party. This is important because the fundamentals in the Plan were arrived at through a bipartisan – even NON-partisan – process.
Time does not allow me to walk you through it in detail. I would like to underscore just a few key items.
The original 100 page Foreign Assistance Act was written during the Kennedy Administration. Over the 48 years since, Congress has amended and added to it. It is now an internally contradictory, unwieldy and frankly unusable document of more than 2,000 pages, containing 247 separate directives that engage 22 different federal agencies. This document cannot be repaired. Congress, the Office of the Secretary of State and the White House should write new statutory language guiding all aspects of foreign assistance.
Such legislation must begin at the beginning, asking: Why is America engaged in the needs and problems of poor, non-Americans? What is the mission? The strategy? This was decided by Congress in 1961, but today we have a 21st Century multi-polar world in which the gaps in wealth and life expectancy between the richest/longest-lived societies, and the poorest/shortest-lived peoples are widening. What is America’s modern mission?
The Obama Administration and Congress must agree that having 22 different agencies with statutory authority over foreign assistance is impossible: There is no coherence, no possibility of executing strategic missions; instead we see gross inefficiency. From the countries’ points of view this is untenable, as there are too many players on the ground, each waving the American flag. Who can keep track?
Two immediate solutions are suggested. Pending Congressional rewrite of the Foreign Assistance Act, which then would lay out a different set of possible structures, name a deputy director of the National Security Council tasked with overseeing and coordinating all foreign assistance activities. And as has been argued by the three gentlemen, who most recently served as administrators of USAID, set up an inter-agency advisory panel to provide regular input into White House foreign policy and aid decisions.
Let's talk about budget balance. When George Bush took office in January 2001 about 3 percent of the U.S. foreign assistance was funneled through the Department of Defense; by 2005 that had jumped to over 22 percent. In 2000, combined, Iraq and Afghanistan received less than 1 percent of U.S. foreign assistance monies. In FY 2007 the two countries garnered 24 percent of U. S. support. Since 1980, USAID has lost more than half its FTEs, or staff size, and over the last eight years it has lost an additional 30 percent of its budget.
Are these correct changes? What is the process for deciding? How tightly are such choices linked to the National Security Council, state, defense or general foreign policy exigencies? How tightly should they be linked?
Foreign assistance is cheap -- for a mere $36 billion in 2007 it was less than 0.5 percent of the federal budget. Millions of lives are saved, children are educated, homes are built and the safety and security of Americans is strengthened. As the action plan states in its final conclusion, quote, "America needs a new face in the world." And in return the world needs calm, stability and the hope for long healthy productive lives. Muddling along with foreign assistance business-as-usual is a recipe for failure and fiscal waste.
Moving forward with generous support and strong leadership, guiding a bold strategic vision of why and how America engages in the world is the right thing to do. Whether it is about prolonging lives with anti-HIV medicines, protecting infants with vital vaccines, building economic capacity with roads and bridges for transport of goods, or preparing the children of today to be the leaders of their communities tomorrow -- these are America's challenges.
I thank you.
And now I'd like to introduce my wonderful colleague, Isobel Coleman, a senior fellow for Foreign Policy at the Council on Foreign Relations and director of the council's Women and Foreign Policy program.
(Applause.)
ISOBEL COLEMAN: Thank you, Laurie. Is this on?
GARRETT: Yes.
COLEMAN: Laurie, I want to commend you for wading in on this incredibly challenging issue of foreign aid reform. It's complicated, it has been on the agenda of multiple administrations and I think it's much like some of the other big pressing issues facing this new administration. Everyone knows it's broken -- like domestic health care -- and yet there are multiple suggestions on how to fix it, little consensus on how to move forward, and lots of ideas and disagreements about what we should be doing. There's tremendous inertia and bureaucratic resistance to -- and vested interest against -- change. And yet now is the time to meet the challenge.
I think this is an excellent moment to be coming out with this action plan. As you mentioned, various stabs at reform have been made, particularly in the last 20 years since the end of the cold war -- focused attention on the fact that our whole foreign aid regime really lacked clarity and needed to be refocused on a new mission. But change is hard and reform has drifted; and now the urgency of Iraq and Afghanistan take up a full quarter of our foreign assistance budget -- at the expense of much of the rest of the world, which remains important.
Secretary of Defense Bob Gates has voiced concern about the militarization of our foreign policy and called for the reinvigoration of civilian capabilities -- in particular, USAID. And he has joked publicly about how it's unusual to hear a secretary of defense offering to give up resources. But I think it's telling that now is a moment with the people who are in charge and in place -- who appear willing to marshal the political will and capital necessary to make some of these hard changes. I think Gates recognizes that the military certainly has a role in providing aid in emergencies and beginning that task of post-conflict reconstruction in unstable environments. But it is not to anyone's benefit to have the military attempting to do long term development work.
Change is not going to be easy. Rolling back some of the developments that have organically occurred in the foreign space over the last decade in particular is not going to be easy. But I think now is a moment where there can be bipartisan attempts at those hard choices and it means coordinating things like trade policy with aid. We all know that the left hand is sometimes working against the right hand while we have development programs in place and yet our trade policies directly undercut those, making hard choices on things like food aid. The report notes how nearly 40 percent now of our food aid is taken up with transportation costs and just shipping and delivery. And yet the real vested interests that want to see what's in place continue -- and these are tough economic times and no one wants to give up their slice of the pie.
It's also making sure that USAID and the State Department have the resources they need to make good on their commitments to tackle global poverty, global health issues and, as Secretary of State now Hillary Clinton said in her hearings, to reflect the United States' commitment to make good on human rights around the world and make it a reality for millions of oppressed people.
So now I think is truly a moment of time for many of these hard choices to be made and it's not going to be easy. I think that there are lots of competing ideas out there and they all have various merits; and I think, Laurie, you've done a terrific job in pulling together some of the most important pieces. So thank you.
Now for -- the fun part is introducing Congresswoman Nita Lowey, who I had the pleasure of introducing, gosh, it seems like just yesterday -- it was a couple of months ago in New York now -- and I said she was at that time serving her 10th term and now she's serving her 11th term in Congress, representing Westchester and Rockland counties in New York. She is one of the most influential members of Congress. She's well known here in Washington. Her disarming grandmotherly approach I think can induce a false sense of ease around people because this is a woman who really has her finger on the pulse in so many different ways; and from our perspective here is incredibly important because as chairwoman of the State and Foreign Operations Subcommittee, she does have huge say in controlling the purse-strings for the foreign aid budget. And so it is with great pleasure that we have her here to talk about some of the challenges facing foreign aid reform today.
(Applause.)
GARRETT: Is she with us? Representative Lowey? Oh, you've just been introduced! (Applause.) I hope you heard some of the --
REPRESENTATIVE NITA LOWEY (D-NY): I'd hate to flop on my face. (Chuckles.) Okay.
GARRETT: Up here at the podium.
LOWEY: Oh I'm ready. I didn't know -- (laughter.)
COLEMAN: I've introduced you. I said all sorts of nice things about you.
LOWEY: Hello, hello. You've introduced me? Well good and I think this microphone is on and I'm delighted to be here and thank you so much Isobel for your introduction. (Laughter.) It's really great to see you again and to be here at the Council on Foreign Relations with so many good friends. It really is a pleasure for me to have an opportunity to share some thoughts with you -- so many thoughtful leaders, past members of Congress, leaders in the foreign policy community, global health community.
The United States, as we all know, has made unprecedented investments in global health over the -- I keep walking around and smiling but if I acknowledge a few people here I know I will get into difficulty, so I will begin. We all know that the United States has made unprecedented investments in global health over the last 60 years and they have been some of the most effective of our foreign aid dollars. And with other donors and governments we've really made impressive strides, eliminating polio in Latin America and the Caribbean, increasing life expectancy in many developing countries from 40 to 65 years, extending the lives of millions of people living with HIV-AIDS, and doubled child survival rates.
Yet there is so much to do, as evidenced by too many populations struggling simply to survive. One out of seven children born in every developing country will not survive to celebrate his or her fifth birthday. In Sub-Saharan Africa, because of the HIV-AIDS pandemic, life expectancies have dropped in the last decade to 48 years.
But what a day, what a day -- on November 4th our country collectively renewed our faith in the power of hope and the promise of a brighter future. And in the president's inaugural address -- and, by the way, I didn't pay extra for that seat. (Laughter.) It was really thrilling for those who were smart enough to watch it on the TV because I know I have friends who were waiting for the blue area -- it took about three hours. I guess the equipment broke down. But for me to sit there with John Lewis and watch what was going on was amazing. And I happened to just be in the way of the camera when they were really trying to get John Lewis, I know.
Now, in the inaugural address, despite the fiscal crisis and troubles both here and abroad, America will uphold our responsibility to lead the world community, to address the security threats and moral imperatives of our day. And there is a growing consensus in Washington and in the new administration that effective foreign assistance is one of the most important ways to confront the complex challenges of our increasingly dangerous world. President Obama has selected economic and national security teams that inspire confidence. As you know, our new secretary of State was official today. And, indeed, we are confident that he can deliver the new direction he has promised Americans. I'm not as confident that he'll be doubling the foreign aid budget but I'm confident that he will lead us in a new direction.
His Cabinet does reflect confidence, competence, experience first and foremost. And I am so pleased with the appointment of Senator Hillary Rodham Clinton. Hillary, as you know, was a leading proponent of women's rights, developed excellent relationships with foreign leaders, gained the respect of people around the world, and subsequently as a senator serving on the Armed Services Committee. She has developed a deep knowledge of the security challenges facing our country, has fought to bolster development because she shares my belief that open, healthy, functioning societies are essential to global security. For example, Hillary and I are the lead sponsors of the Education for All act, which would improve the U.S. government's ability to provide basic education in the developing world, because we know that education is an equalizing force that can neutralize vulnerability, to radicalism and poverty.
And as your report notes, a major health issue facing the developing world is the lack of educated health care providers. Access to both basic and higher education in the developing world will enable countries to expand their capacity to address their own health challenges in the 21st century. In many regions of the world, development assistance is our strongest weapon in our foreign policy arsenal, yet State and USAID face many challenges in maximizing their efficiency and effectiveness. At its core, the future of foreign assistance depends on revitalizing the U.S. agencies responsible for implementing development programs.
In the 110th Congress we laid the groundwork for improving these key agencies. I've worked to reverse years of cuts to the operating budget of USAID and the State Department. And the draft FY 2009 Foreign Operations Appropriations Bill, combined with the FY 2008 emergency supplemental, will provide over 1,000 new state employees and 500 new -- if we ever get this bill through, but the omnibus will come any day -- in addition it has 500 new USAID hires. I'm confident that the Obama administration and Congress can build upon this foundation to bolster these understaffed and demoralized agencies so that they are prepared to confront the growing and pressing challenges that demand U.S. leadership around the world.
As you all know, reforming foreign aid is not a new topic. Almost since the day our foreign aid program was established there have been efforts at reform. Virtually every administration has attempted to re-tool our redevelopment toolbox. However the failure to undertake a comprehensive reform looking at long term needs as well as short term priorities has resulted in layer and layer of new programs, new mandates, new bureaucratic structures and new Congressional and administrative directives being heaped on an over-stretched and outdated infrastructure.
Now, rather than rebuilding and revitalizing USAID, the last administration chose to go around USAID and create new agencies. And in the past eight years we've seen a proliferation of new initiatives -- PEPFAR, the president's malaria initiative, the Millennium Challenge Corporation, The Middle East Partnership Initiative, just to name a few. The movement away from USAID is the primary entity for devising and implementing humanitarian and development assistance has further weakened and demoralized the agency and decreased the effectiveness, in my judgment, of our development assistance overall.
Another trend since 9/11 is the growing role of the Department of Defense and other Cabinet agencies in implementing the aid programs. A Congressional Research Service study found that nearly one-fourth of our foreign aid dollars are appropriated to and implemented by the Department of Defense, and another 22 percent are implemented by other departments and agencies.
The diffusion of resources and the responsibilities across agencies and departments need to be reexamined. The involvement of 10 Cabinet departments and over 15 sub-Cabinet or independent agencies has created a management nightmare for our ambassadors in the field and has led to a lack of oversight, accountability, coordination, coherence of assistance programs.
In this political and economic environment, if we are to maintain the support of the American people in Congress for continued increases in foreign aid spending we must show a greater return on all our investments. It's time for the U.S. to reinvigorate our foreign assistance apparatus to reflect the challenges of the 21st century. A renewed, more focused mission and mandate, a better understanding of the expectations of Congress and the American people, and a streamlined coherent and empowered structure to implement this vision are urgently needed.
In addition to the report you're releasing today, a number of other reports over the past two years have examined this issue and I am encouraged by the considerable consensus in these reports on needed reforms -- including greater coordination between U.S. assistance, other donor governments, the private sector, entities like the Gates Foundation, Clinton Global Initiative, which will enable us to maximize our investments and improve the effectiveness of our aid dollars. In order to address the lack of coordination, I co-authored an amendment with chairmen Skelton and Berman to the 2009 National Defense Authorization Act to create an advisory panel for the secretary of state, secretary of defense, and administrator of USAID to better collaborate on matters of national security. This panel will bring together defense, diplomatic, development perspectives to guide our foreign policy and national security strategies and we expect an initial report from the panel by mid-2009 and are hopeful that the process will help shape the Obama administration's understanding of the problems facing the agencies and lead to thoughtful solutions to the current bureaucratic quagmire.
In addition, we know that the House Foreign Affairs Committee Chairman Howard Berman held hearings in the 110th Congress on aid reform and pledged to rewrite the State Department Reauthorization and Foreign Assistance Act -- so I continue to work closely with the authorizers throughout this process. I believe the rewrite is desperately needed. Unfortunately, authorizing legislation often gets bogged down in politically sensitive traps and the political will to move foreign aid legislation is often fleeting.
But the administration, Congress and the American public will need to have sustained buy-in on the benefits of reform, and I encourage all of you to support this effort -- and I know many of you are deeply involved. Speaking of political capital, I'd be remiss to not acknowledge the focus by many on establishing a new Cabinet-level agency for development and I do appreciate the report's nuance on this issue and recognition that immediate executive action outside of the creation of a Cabinet-level position can be beneficial to the delivery and coherence of our foreign assistance. So I fear that all of the energy and reform will be naught if the debate becomes solely about Cabinet-level agency versus non-Cabinet-level agency. And we know -- and I know many in this room believe, that a Cabinet-level agency would elevate development to a new and exciting way. It might also result in an eventual separation between our foreign assistance programs and our foreign policy agenda -- but I know we'll keep talking about this for a while.
So while the details of the bureaucratic structure of State and USAID are debated, we cannot afford to waste any time reversing the damage of the Bush years on our foreign policy. And some of the most valuable contributions can result from simple policy changes at little or no cost to the federal budget. And I believe, in fact I'm sure, that the Obama administration has thought about this as has the secretary of State and they will be opening a new door of engagement with the world. For example, the administration has pledged to work in a more multilateral fashion, reengage with the UN, rebuild alliances that have been left to atrophy under the Bush administration.
Additionally, the secretary of State will have significant latitude to improve and reorganize the existing structures, and I know that Secretary Clinton, her transition team, have been and continue to evaluate the process to improve coordination and effectiveness and work with stakeholders, like you and me, to ensure that the State Department and USAID are prepared to address the urgent security, health and development challenges we face.
Now as your report reflects, this reform process could have a major impact on global health initiatives, and I believe could provide a good example of the need for improved coordination among agencies. On a recent trip to Ghana, for example, my colleagues and I discovered that even some of the staff in the clinic could not tell us who was in charge -- whether it was PEPFAR or whether it was USAID -- and all are vital to our global health activities. In the absence of coordination between the two, we are at risk of duplicating efforts and wasting scarce resources.
In addition, the most basic level of accountability for performance could be lost, as well as our ability to accurately measure the effectiveness of each. So with better management of our own resources we can then work with organizations around the world to maximize all our efforts to build strong health care systems. And as chairwoman, I have rebuffed efforts to reduce our commitment to multilateral entities, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria because when we work together we can accomplish more with fewer resources, building upon one another's success.
In addition to addressing these structural issues, an infusion of common sense and policy grounded in science will get our health policy back on track, particularly when it comes to women's health. Today on the anniversary of Roe v. Wade, many will walk the halls of Congress, protest on the Mall, not simply in opposition of a woman's right to choose but against basic health services that save women's lives and can actually prevent unintended pregnancy. So I look forward -- in fact I am eagerly awaiting news from the Obama administration, like overturning the global gag rule, which has been counterproductive to our foreign assistance programs for far too long.
What was so sad, frankly, about our passage of bills in the last few years -- that those who were so committed to foreign aid and worked so hard in the vineyards -- wouldn't vote for the bill because I'm sending condoms to Ghana but that's for another day that we can talk about that. So there are many competing priorities for so few dollars. And a focus on bolstering health care systems and preventing disease is imperative.
And I'm extremely proud of the work we've done to address a number of health crises, especially HIV-AIDS for which 5.5 billion (dollars) of the 7 billion (dollars) appropriated for global health in fiscal year 2008 were dedicated. Yet we could better integrate our health care expenditures to ensure we don't neglect the overall capacity of developing countries' health systems to address the spectrum of preventable and treatable diseases. So we need your help in this regard in advocating for a balanced health approach that promotes sustainability and self-sufficiency.
More broadly, we pursue all these reforms to grow and improve foreign assistance and civilian capacity because they're necessary to reach the millennium development goals, address underlying health threats, and promote global stability. Yet we are keenly aware of the monumental and escalating obstacles and we are just beginning to understand the depth of the economic realities that would slow many funding priorities like foreign assistance.
We cannot underestimate the fiscal disaster Bush has imparted on President Obama. Our country is facing a broken financial system, dilapidated infrastructure, a broken domestic health care system, an overstretched military, and an under-resourced Department of Veterans' Affairs. So serious extenuating circumstances will also make it difficult to achieve many of our foreign assistance goals.
Now, as many of you know, while in the Senate, Obama sponsored the Global Poverty Act, and despite the bleak outlook for immediate investments outside the economic realm, the myriad of global challenges we face today demand robust internationalism with the U.S. playing a leading role. More members of Congress really get it. I think they understand that our assistance programs are not only a means of alleviating poverty and suffering, advancing human rights, promoting democratic governance, but are also in the United States' strategic interest.
So we really have to work together to preserve this support, thwart any partisan political efforts to stymie our foreign policy priorities. For example, I was concerned that my good friend, Ileana Ros-Lehtinen, recently circulated a letter to freeze the foreign policy account, the international assistance budget. Now only four members signed this letter so it doesn't reflect a major splintering of the support for foreign assistance, but we need to remain vigilant about not politicizing such an important issue.
Let me say in closing, I am grateful for the successful efforts of think-tanks, development groups in pushing for increases in the foreign aid budget. I wish I could tell you the job was done but it's not. So expanding your advocacy, educating the public about the national security benefits of long term development, more efficient use of development dollars are essential. So in a time of belt tightening, the traditional case for more dollars for assistance, based purely on humanitarian principles, I'm telling you will be a very tough sell -- especially when it comes to health care.
Now Americans have a great big heart for helping those less fortunate but our domestic health care system is broken and is in desperate need of reform. So to continue building support for global health funding, we need to continue to link development goals, health societies and poverty reduction, to national security and educate Americans about the mutual benefits of global poverty reduction and improved health for all.
And while this economic environment makes it difficult to advocate for increased international assistance, we have to continue to do it. There is now a window of opportunity to make some extraordinary changes. The benefits of U.S. foreign assistance, including more opportunities for the world's poor, improved global security, should push us all to concerted action. And I urge you to continue to lend your intellect, your ideas to policy makers, to advocacy efforts. Educate the public. We have a big job to do and with this group and so many of your friends around the nation, I'm confident that we can do it. But we cannot take the election of President Obama and his understanding of these issues for granted. We have to continue to work to make sure it happens.
So thank you so much, it's a pleasure for me to be here.
(Applause.)
COLEMAN: I'm going to take a note from President Obama on the need for shared sacrifice and I'm going to give up my moderator privilege to ask the first question because we have about 15 minutes left. So I'm going to go right to the audience for questions. We'll start over here. Would you please rise and state your name and affiliation? And please, given the size of the audience and the limited time, if you could ask a concise question and we'll get quick answers.
QUESTIONER: Well thank you, Congresswoman Lowey for your comments and Laurie for this report. My question has to do with leveraging and the need for a broad -- my name is Sam Worthington from Interaction, sorry I didn't introduce myself. My question has to do with leveraging and the need for a national development strategy. If we look at our community we have 105,000 staff around the world and millions of Americans giving in many ways. There's lots of private resources coming in. So how do we best leverage these resources? And without a broad framework, how do we best focus these resources so that they're aligned with U.S. national interests?
LOWEY: Well, first of all, I would expect that Secretary of State -- that sounds very good -- Hillary Clinton understands the need to coordinate. Certainly she was involved with the Clinton Global Initiative. Whenever I go to a country I invite everybody to sit around the table, Diffet, Gates, Nike, Clinton Global Initiative, Millennium Challenge Account, PEPFAR. The word for me is coordination, coordination, coordination. And what happens too often, and I heard it when I met with about 100 people in Ghana, that everyone is so busy operating in their stovepipe that they don't have time -- I see shaking head -- they don't have time to coordinate and they're so busy reporting to their funding source.
And as far as I'm concerned, when I met with Hillary and the transition team -- and I know there are many unanswered questions and she's ready for input from all of you if she doesn't already have it, I'm sure she does -- the best thing you can do is just get everyone around the table. You've just got to work together with limited resources.
QUESTIONER: Hi, I'm Donna Berry from Partners in Health. This is a similar question but it's across agencies. If we take a case like Haiti where we have poured millions and millions and millions of dollars in for aid yet our trade policy doesn't support the country, we've undermined democratically elected governments there, our agriculture department is sending down rice that's cheaper than Haitian farmers can grow, how do we try to coordinate across agencies with some Congressional assistance so that we're actually really supporting where the aid dollars are going?
LOWEY: Boy that is a great question because when you think of the amount of money that we poured into Haiti and the lack of progress and the destruction and the pain and the suffering that currently exists, it's clear we have to have a reevaluation. My advice, again, to the secretary is you've just got to get all the partners to the table and figure it out.
I can remember when Paulson came to talk with a couple of us when he was on his way to China. Now we know -- this is just a similar example -- we know China's key role in dealing with our Iran policy. And several of us said, I hope this is on the agenda. Or if you're dealing with Sudan and the suffering in Sudan and Darfur, if you don't have China and India and Japan at the table you can't get anything done.
So we just have to keep working on it. Again, it's a matter of cooperation and how the NSC and the advisors interact with state and how state pulls everyone together. I don't think we're going to be taking all of the foreign aid dollars out of all the agencies any time soon in my judgment, knowing the way the Congress works. So it's just a matter of coordination. It's just pulling them at the table and having someone at the head who really thinks.
Another point. I can remember a trip to India and talking to Ambassador Mulford and he was very -- it's not important going into the details -- he was very upset about a particular policy and he said, I was never consulted. This is the ambassador. So if you begin with the country teams and come up with policies and work it up through the process, the secretary of state has to be signing off but she has to know what's going down below -- and, again, it's a coordinated strategy in my judgment. And I'd welcome, because I'm going to be going there one of these days with the speaker, I'd welcome any thoughts about it -- it's heartbreaking.
GARRETT: I think one of the things that we underscored in our report was that unless you have that committed level of coordination at the top here in Washington among the key agency players and the key components of our foreign policy and national security establishment, then it's unrealistic to expect you'll ever have it on the ground in any country unless the secretary of state has at the table the head of USAID, the head of other key programs, such as PEPFAR and so on, alongside folks from NSC, folks from the Defense Department, commerce, the trade policy people. Then you'll never fundamentally have the kind of coordinated strategy that Donna is talking about, that seems to be essential to a problem as vast as a country like Haiti.
LOWEY: No, I agree and I think it has to go both ways. I can remember a conversation before -- I don't know if Henrietta is here, I'm a great fan of Henrietta Fore -- but before her, the former head of the F process, I remember a discussion in my office and I had recently noticed a huge article in The Wall Street Journal about what Petraeus was doing in Africa. I don't know if you remember that -- more than $1 billion in Africa. And I said, okay, you're working on this F process and you're all coordinating, what are you doing with the Department of Defense? That's not my responsibility.
So I think it has to work from the bottom up but it has to work from the top down, it has to work laterally because unless the Department of Defense is working with USAID and the other agencies -- in Liberia, for example -- we've got to really get a handle on coordinating it all -- top up, bottom down and laterally.
GARRETT: I would just note the most coordinated foreign assistance I've ever seen anywhere personally is in Vietnam and it was because Vietnam has a Communist party leadership. You cannot possibly work in Vietnam without going through appropriate channels. You're just absolutely forbidden. And as a result, all the foreign agencies, whether they were United Nations agencies, U.S. government agencies or NGOs sat at a table together repeatedly, and coordinated and thought and strategized how they could each execute their affairs.
COLEMAN: That's not a call for more Communism.
GARRETT: No. (Laughter.)
COLEMAN: There are lots of hands. I see we're running out of time here. I'll take this question here and maybe some quick answers. I'll try to fit one more in after that too.
QUESTIONER: My name is Henry Owen. I've spent about half of my life in the government in which a main interest is in foreign aid in the state department and The White House and half was in the private sector, investment banks and Brookings institutions, where I had the same interest. It seems to me there are two instruments of foreign aid that are far and away more effective than any others: one is PEPFAR, the program which is fighting the pandemic of AIDS, which is headed by Mark Dybul, who is running it effectively and internally like a czar right now. He's not looking for consensus. He spends money, he spends it effectively and he gets results.
The other is the World Bank, which the U.S. is by far the biggest contributor but we're outmatched by other contributors. But it's the largest single source of foreign aid to foreign countries and has a great advantage over most state agencies. It knows how to say no. So when countries come in with stupid projects it turns them down. When they come in with good projects, it not only gives them large sums of money but it gives them technical assistance and I'd like --
COLEMAN: If you could ask your question because we're going to run out of time.
QUESTIONER: A big problem with the World Bank is we're not putting enough aid into it now and we're attaching conditions to it. I'm surprised none of you have spoken of the need for the Congress to, A, lift the release ceilings on aid to the World Bank and, B, to stop putting conditions on it.
LOWEY: I'd be happy to discuss that further but since we have a tough boss here I just want to respond briefly. Mark is wonderful and I think he's doing a great job with PEPFAR. But we were both at a little gathering with Gordon Brown and about 15 of us sat around the table. And if USAID -- just take Ghana again -- if USAID had the amount of money that PEPFAR had to give to Ghana, I would say their program could be just as effective. So if you have the capacity to give 500 million (dollars) instead of 100 million (dollars) to a local hospital, and if you have good people running the program, it's not so much that it's PEPFAR, it's Mark is great and it depends who's running the programs. But we can talk further.
COLEMAN: Thank you. Okay, last question over here.
QUESTIONER: Hi, I'm David Bryan (sp) with the Infectious Disease Society of America and I want to ask about a specific disease but let me first also say they've been very active in actually trying to expand the overall amount of money available for all foreign assistance in my previous job at Global AIDS Alliance -- which is very involved and actually AIDS activists have been in the forefront of trying to expand the mandate, trying to make money available more holistically way beyond AIDS per se.
But I wanted to ask about tuberculosis. This is a disease that kills 2 million people a year. The U.S. effort is grossly underfunded, as you know. You've been a tremendous leader on this issue. I want to ask about the vaccine. We could have a vaccine by 2016 but it's going to take an investment. Will our next appropriations bill reflect that need?
This report talks about the need for an AIDS vaccine. That's certainly true but doesn't mention the need for TB vaccine. We urgently need that. Will the Congress invest the money now?
LOWEY: I'd like to and you know that I'd like to say we have to do it all. So I think you can be most helpful, and I mean this very seriously, Obama talked about doubling, Biden talked about doubling, Hillary would like to double. I don't know how we're going to double foreign aid. But to do all the things that you talk about we just have got to get more money in the overall account because then, as I often say, when you take it from water projects you see how invaluable water is in just so many countries. I mean, it's not valuable it's essential for life. So I could go through peace keeping accounts, water accounts, et cetera, et cetera, you get the point. We just have to expand the pie. And we take everyone's advice into consideration. And I welcome your advice but I couldn't guarantee a number anywhere.
COLEMAN: Laurie asked me to do one thing which was keep us all on track. So I'm sorry, I see lots of hands out there and I'm so sorry I can't get to all the questions.
But thank you so much, Congresswoman Lowey, for being here with us again. (Applause.)
LOWEY: Thank you.
GARRETT: And as I indicated before, please don't get out of your seats. We're going to very swiftly do a little change of the panel here.
Such tremendous thanks to Representative Lowey for joining us today. You've honored us with your presence, fellow New Yorker.
LOWEY: Thank you.
GARRETT: And if the rest of the panel for the next session could please get their microphones on and take seats. And we're going to swap some chairs. And as they're coming up I'm going to introduce to you who will be joining us on the stage now to go through some more specific details, both in the report and in their own work, that they think are crucial to the future of U.S. foreign assistance and foreign assistance efficacy. We will get some more chairs up here, please.
Joining us are Doctor Seth Berkley who is the CEO of the International AIDS Vaccine Initiative. Nils Daulaire, Doctor Daulaire is -- just a couple weeks ago announced that he will be stepping down as CEO of the Global Health Council, pending perhaps, wink, wink, a new job. Doctor Helene Gayle who is CEO of CARE International and whose name has also been, wink, wink, much discussed.
Ambassador Princeton Lyman who is here at the Council on Foreign Relations in Washington, served as an ambassador to the two most strategically crucial countries in Africa, Nigeria and South Africa.
And finally, Stewart Patrick, also from here at the Council, who jumped ship from the Council on Global Development, knows a few things about development, and he's -- we're very happy that he's here now coordinating global governance programs here at the Council on Foreign Relations.
And finally, Paul Grove who is the minority clerk for the Senate Appropriations Committee for State and Foreign Affairs, one of those individuals who sits on top of the purse strings.
Now are we managing to get everybody on stage here? We don't usually ask folks to bring their own chairs.
And actually, Paul, now that you've seated comfortably, I want to throw the first question your way because I think the paramount concern on the minds of most the people in this audience has to do with the purse strings.
The severity of the budget crisis that we're in I believe that President Obama said last week that he thought it would exceed $1.5 trillion deficit.
So, how realistic when it reaches the Appropriations Committee level of discussion is the concern for both defending current levels of funding in foreign assistance and perhaps, indeed, increasing it?
PAUL GROVE: Let me start by saying that the views expressed are my own. They don't represent the views of the subcommittee, committee, or Congress.
CBO projected a $1.2 trillion deficit this year and we have pending in the House an $825 billion stimulus package, which was not included in CBO's estimate. It is troubled times out there economically. Everybody knows that. You don't need a staffer on the Hill to tell you that. Many of you feel that yourselves.
When it comes to foreign aid, foreign assistance, I see rough sailing ahead. I see choppy waters. I see expectations that are not going to be met with an incoming administration that has made promises to increase assistance.
And I say this because foreign assistance competes with everything else. It is a slice of the pie but the demands on that slice of pie are so great that I think it's going to be very difficult to meet the expectations, whether it's the 48 billion (dollars) reauthorization of PEPFAR or if it's increasing assistance for the management for the operations side of the State Department and USAID. Tradeoffs will have to be made.
If you want to increase programs you can do that but you may not be able to increase the management and the operations side for the State Department and USAID. It's a finite pie.
The difficulty that we have on the Hill -- and I'll try and keep this short, I could speak for hours on this --- is that systems don't work. OMB doesn't work. Very often OMB will send up to us a budget request for the 150 account that is underfunded. And they're gaming the system. The Executive Branch is gaming the system because they know that Congress has interests that it will support and it will fund regardless of the low-balled funding level and that's for refugees. And I think if you look at the support Congress has given refugees over the years you'll see it's much greater than what the administration has requested.
OMB needs to ask for what is needed. And that's a difficult process on their side of the fence. But what it does on our side of the fence, the legislative side of the fence, it allows us to make decisions a little bit easier not based on who do we rob because the administration has low-balled certain accounts or certain funding priorities, but how we can -- how we can maybe apportion the pie a little bit more equitable.
There was a lot of criticism on the fiscal year '09 funding level that the Senate suggested for the MCC. In part, there was concern that they weren't spending their money but in part there was concern that we needed to plus-up development assistance, child survival, global health accounts. And that was done.
So it's going to be rough sailing. And I think, what I would suggest to folks not only that are in the field that care about development, that care about foreign policy but to all Americans is manage your expectations because it's --- they're --- it will be very difficult to meet.
GARRETT: And as a follow-up on that to Paul Grove, managing your expectations --- how would you sort of gauge the level of risk involved if the global health community and the development community at large, the foreign assistance community at large, breaks down and starts (audio break) narrow --- and my mike just died --- specific --- there we go --- specifically narrow niche pieces of budget as opposed to a large pie?
GROVE: It already happens. It already happens and what it does, it's very interesting to participate in events like these because what you don't hear are advocates for the security side of the budget. You don't hear people standing up and saying that FMF or IMET is important --- that's military training and military assistance or biosecurity, or anti-terrorism programs. And they don't have advocates. And for those in the audience that have worked for the State Department and USAID there is nobody advocating for you. There's nobody advocating for an operation side of the budget. You do have Congress, House, Senate, Republicans, and Democrats that are concerned with this and have stepped up to the plate. But single issue advocacy makes it very difficult for the appropriators, for the authorizers, because then certain expectations are created and there's pressure to meet them.
If I could make one other point, what I've described sailing through difficult waters applies to the immediate financial crisis that we have. What's important to keep in mind is the budget catastrophe that we face because of mandatory spending. And so we can sail through these rough waters now and perhaps get through with funding levels that aren't too effected, having made some difficult decisions on trade-offs.
But we still have to weather the very rough storms of mandatory spending and how we reduce that so we do not get through, in the short term, an economic crisis only to have greater economic problems with mandatory spending catastrophe.
GARRETT: Well, Nils Daulaire, you are CEO of the Global Health Council which represents a huge coalition, if you will, of NGO's, humanitarian groups, development organizations, most of whom are to some degree dependant on this budget line we're talking about.
How do you, first of all, see these discussions, both the fight for the budget and the need to have larger coordination here in Washington of what we're doing, what this mission is? How do you balance these two issues when it comes down to your individual members and those that are fighting for their specific budget streams?
NILS DAULAIRE: Well with several members here on the stage with me they can reflect on that perhaps. But let me talk sort of on a broad scale. I think the past eight years have been marked by, I guess it was called the soft prejudice of low expectations, in the international development field as well. And the expectation that USAID couldn't do the job so we had to create a new structure, or two new structures, or three new structures to do pieces of that.
I think the sum total of that has been a math in which one plus one equals one and a half. I think the change that's needed at this point is to recognize, as our members do, as I do as a development professional before being a health professional, that unless we develop programs that interlink in thoughtful ways, using not the constituencies of contractors or companies or advocacy groups but rather the customers as people living in poverty in the developing world as the focal point and recognizing that the family and the community is where that focal point rests, we're going to wind up tearing ourselves apart in difficult budgetary times.
I don't think that's by any means inevitable and I recognize the harsh realities that Paul is talking about. But I think we can do a lot more with perhaps more modest resources than we'd like in linking together HIV/AIDS, other family health issues that relate to mothers and children and intact communities, the elements of sustainable development, water, sanitation, agriculture, food security, basic microenterprise and economic development. Those things are naturally interlinked and we've been dealing with them in, I guess you could call it a credit crisis mode. Credit in that everybody wants their own credit for having done AIDS treatment or for having done ---
GARRETT: Ego credit.
DAULAIRE: Ego credit, that's right.
I am hopeful that we've got a new mindset evolving at this point. And I think our community is ready to work very collaboratively across the board with the rest of the development community and with some of the other forces that you're talking about, Paul, recognizing that we need a safe and secure world as well.
GARRETT: Let me be blunt in a follow-up to you. A lot of the change that has occurred in the last, roughly, decade in how we do foreign assistance as the United States government has moved the money to a kind of a trough, if you will, on which contractors can feed. And some of the people in this room may, in fact, represent agencies that have fed at said trough.
Coming up with systems, I mean, Representative Lowey hinted at this. She said there are plenty of entrenched oppositions when it comes really down to creating better efficiency strategic mission in foreign assistance that may run right up against some of these folks feeding at the trough.
How do you balance that?
DAULAIRE: I think ultimately you have to make some hard policy and political decisions. And I'm comfortable that the new administration is going to make the decision that the mission is what's most important, that there will be losers in that process. I think we recognize that there will be and we're going to deal with that constructively.
GARRETT: There's a promise for you. Did everybody hear that one? We're going to deal with that constructively.
Well, Dr. Helene Gayle represents one of these individuals who's gone from very much a global health focus in her career and in her service in government to a much broader development focus with health as a piece of, or integrated within, now running CARE. And I wonder if you can tell us how you imagine changes could better allow that integration to be mirrored in the agencies you deal with in the U.S. government?
HELENE GAYLE: Yeah, thanks Laurie. And by the way thanks for both this as well as the report. I think it really does add a real boost to this effort. And I think looking at some of these issues that we've been talking about as far as foreign assistance and development but using the lens of health as a way of thinking of it is very important. And I think, you know, what we have done as a nation in global health in many ways has been a leading edge for our work in development. So I think this idea of how we look at this in a more integrated fashion is right on target.
And I guess I would just, you know, first state the obvious. I think we all recognize that the issue of health and development is so interlinked. I think your report brings that our very nicely, both, you know, the realities of what poverty does to health status, what it does to individual health status, community and national health status, and vice versa. And so, you know, we know there's this tight, interwoven link.
The way we're structured now and, you know, we're talking over and over again about these very, very tough issues of structure and coordination but the way we're structured now almost mitigates against any coordination.
And so, you know, I don't think any of us in this room think we have the right answer. And we've all been on different committees where everyone says this is the way to organize the foreign assistance and development entities.
But I think what is very clear, and Congresswoman Lowey said it well, is that this issue of coordination and being able to work across boundaries. And so, you know, when I talk to Mark Dybul about PEPFAR one of his biggest frustrations is that he can't figure out how to work across USAID lines so that PEPFAR, maternal health programs, family planning programs, and child health programs can all work together on the same goals.
So we have set in motion these parallel structures that don't even allow, you know, allow for some communication but the administrative lines just don't allow for that kind of working across lines.
So leave the structures the way they are for now if that's, you know, the most practical way. But let's figure out a way to break down some of these barriers, put in place simple ways that budgets can be knitted together so that the programs on the ground are more coordinated. And, you know, I'd take from points that Nils made, we've got to back up and stop thinking about our own self-interest, our own organizational interest and think about the people on the ground whose lives we're trying to have an impact on. And I think if we use that as the lens we'll back away from some of these very narrow-minded ways of thinking about it.
And, you know, and I think the spirit that I hope this administration is bringing and that, you know, President Obama speaks about, you know, the need to look --- lift our sights higher, elevate our sights, think about ourselves in a more unified way and I think if we all really take that notion seriously then we will be able to break down some of these barriers.
Let me just add one other thing, I'll shut up. But, you know, going back to this issue of advocating for individual issues versus, you know, kind of broader agendas, it's one that we all struggle with because when you go to Congress and you talk about improving infrastructure people's eyes glaze over, or if you talk about foreign development in general. But when you talk about HIV or if you talk about tuberculosis you grab people's attention and I think that's the struggle we have, you know. On the domestic side, you know, the same way, you know, arguing for my budget when I was at CDC. You could talk about health infrastructure, you put people to sleep. But you talk about, you know, prostate cancer and somebody had a relative who died of prostate cancer, you get money in your bill.
So it's just, it's a struggle we go through and I think it is the way appropriations are made that also help to fractionate our community and I'd be happy to hear your thoughts on that.
GROVE: If I could just make one point to that. I would say the good ones listen to the dry stuff as well because the dry stuff is actually very important. We can plus all the programs up as much as we want but when you have five engineers at USAID that will oversee all of that it really doesn't make that much sense, perhaps, to plus it up so much.
Part of what's needed, and I think it would strengthen the support for foreign assistance is a return to regular order, whether it be OMB asking for what is needed and not playing games or whether it's Congress holding up mark-ups, holding up the hearings and the debates on the floor and the amendment process. If there are people, and we know there are people out there that don't like foreign assistance because we do get amendments when --- as I think back and, perhaps Michelle, Paul can correct me if I'm wrong, the last time we had a conference on an appropriations bill, open conference, was fiscal year 2006. And here we are on the verge of passing fiscal year 2009.
We can get at the issues of the dry stuff because there are people that understand it. There are people that understand the operation side and are very supportive of trying to do as much as possibly can on that issue. But if you have regular order amendments can be offered, amendments can be knocked down and you can actually strengthen the hand of not just maybe HIV/AIDS spending or the operation side of things but the entire bill.
GARRETT: But one of the pieces of the dry side, if you will, that I hope members of Congress can listen to, is the voices of diplomats who have worked on the ground trying to implement both the hard and soft power pieces, if you will, of U.S. foreign policy with this gigantic, complicated miasma of alleged health and development institutions all waving an American flag.
Ambassador Lyman, I know that when you served in South Africa and Nigeria it was before there was PEPFAR and before we had the President's malaria initiative and before we had MCC and on and on and on. But, nevertheless, you had a lot of kittens to coral as an ambassador dealing with all of this. What would make a difference to make the diplomatic side of the job easier?
PRINCETON LYMAN: Thank you, Laurie. Thanks for the report which has some much in it that's valuable.
Let me just say at the outset that there is something exciting about having so much of America involved in the development process. I know we have problems of coordination and we have problems in the field of, as you've pointed out, some 600 entities operating just in South Africa. But I have to tell you it's rather marvelous when you go around the country and find this group and that group on their own or in some way engaged with the developing countries. Because --- and then I also believe that it's good to have a lot of our departments engaged with developing countries.
So it isn't just our only relationship with developing countries is foreign aid rather than we have shared views in global health, we have shared interest in the environment, etcetera. So that degree of involvement is, it seems to me, exciting and valuable.
Now, then the question is how do you manage it? And I think you have to get at it two ways. One that you've illustrated a lot in the report is what are our strategies for doing this and who is in a position in Washington to create those strategies?
What's happened with USAID over the years is it's lost that stature and capacity for doing that. To have the respect and the professional levels of expertise to say to HHS or Interior or others, we can bring you together and develop strategies because we've got the stature and the ability to do it. And hiring 500 new people at the ground level isn't going to do it. You've got to bring in top level people.
AID should not be the sole vehicle, however, because it can't and shouldn't be. It should be mobilizing around strategies. Then in the field you've got to empower the ambassadors in the aid missions, et cetera, to be able to take that strategy and relate it into the countries, whether it's clean water or the longer-term investments which you've talked about so much of building health capacity and health training or other things and how do you fit the PEPFAR into that.
That can be done at the country level and reflected back. And it's good to have NGOs out there doing service things and doing a number of other things as long as you've got an overall strategy you're working with. And then that you're not overwhelming the capacity of that country. Because thousands of people are coming in and everyone wants to see the minister, got to see the minister, that minister spends all his time doing that. And that field's got to take a tough line on that.
But that leads me to the third point; people in the field have to know that development is a major foreign policy objective. So their job isn't to just keep visitors out because, gosh, they're a nuisance and I want to get on with something else. Ambassadors, political counselors, economic counselors, as well as aid missions, have to know that development's important, that their job is to make that development process work.
I was fortunate because I spent first half of my career in AID before I moved to the State Department. And it wasn't part of the State Department culture to emphasize development and I think that has to be done.
And the final point that I would make is we have to relate these strategies to those of those countries and we have to hold them accountable as well.
African countries pledged to spend 15 percent of their budget on health. Almost none of them do. They pledged to spend 10 percent of their budget on agriculture. Almost none of them do. They will never move past dependency if we compliment that or compensate that by taking care of their services for them.
So our strategies have to be integrated with commitments on their part to make those investments, whether it's in capacity, whether it's in training, whether it's in services, so that you're really building for the long-term. And that's where you're field missions can really engage both their counterparts and Washington.
GARRETT: You know, that gets me to the moral hazard argument that comes up all the time. World Bank has raised it repeatedly. If you have a program in a country that is more than 75 percent dependent on external funds and if, in fact, the United States with maybe one or two other donor partners is the source of that 75 (percent) or 80 percent of funding who ensures the moral hazard piece of that? And is that the job of the ambassador?
LYMAN: Well, I think it's the job of the ambassador, World Bank, and other donors and the country involved to say where are you going on all of this.
Now, we have to be honest. There are some countries that are so poor that if you want to reach the millennium development goals --- and here's where Jeffrey Sachs tries to keep us honest --- you're going to have to pay for them because Mali and Niger is --- those countries are not going to have global full health standards and universal primary education and pay for it in our lifetime. Let's be honest about it. And those countries you're going to have to pay for it or not be serious about the MDGs.
But there are a lot of other countries who have capacity, who have growth capacity, who should be committing much more of their resources. That has to be part of the dialog at the country level. It has to be at the dialog when those ministers come into Washington to say, look --- and that's one of the good things, perhaps, about the millennium challenge account that is says to the country, where are you putting your resources? And how are your resources complimenting these?
And that's what you charge your missions in the field to do.
GARRETT: Stewart Patrick, you're working very hard on the global governance piece and a lot of this discussion is mirrored at the international level, trying to figure out how the multinational institutions can better execute the goal of achieving the millennium development goals but also just, at large, have more effective development and global health programs.
But they're clashing and they have a conflicting interest just the same as we've been describing for various U.S. government agencies and contractors and NGOs.
What do you see as the lesson to take to the multilateral level and about our engagement at the multilateral level?
STEWART PATRICK: What you raise is an excellent point. You know, there's a tendency, I think, with Barack Obama taking office to have a sense that the United States is open for business with the rest of the world again and that we are going to be embracing multilateral cooperation. But multilateral institutions are a mixed bag and many of them need quite a bit of work and quite a bit of reform to be updated to current power structures and to the current global agenda.
My take is that multilateral cooperation and multilateral institutions are a flawed but indispensible aspect of U.S. global engagement. And this is particularly true for the development agenda. In a world that's multi-polar and that's beset by all sorts of transnational and global challenges there's very little that the United States can accomplish on its own.
And particularly over the last eight years one of the things that we saw, partly because of a general skepticism and not always unwarranted skepticism about multilateral institutions, what we've seen is a proliferation in the development front on the part of the United States as Congresswoman Lowey pointed out, of some bilateral, stand alone mechanisms that, on the grounds that there would be better oversight, there wasn't a lot of trust for USAID as well, but that there would be better oversight and accountability for U.S. taxpayer dollars. And, you know, as usual, when the U.S. has gone in either a bilateral or unilateral direction, it's been motivated in part by a desire to retain that freedom of action and to do things as we see fit.
There are a couple of problems with that, though. One of them is just a general problem that -- you know, in 1960 the United States was responsible for about 60 percent of global official development assistance, and today that figure is perhaps 20 percent. And there is so much going on in each of these countries that we can't afford to take multilateral cooperation and multilateral channels of aid delivery as an afterthought. It really needs to be our point of departure.
And I think many of us, in the way that we approach things -- whether we're policymakers, or academics, or commentators or service providers, tend to think of it simply in terms of a U.S. lens. And I think that one of the things that's important is to try to embed U.S. leadership in the development field within multilateral institutions like most of our OECD countries have done.
Another reason of why it's important not to simply rely on bilateral channels is that it introduces tremendous transaction costs in inefficiencies in the way that we go about things. It undermines aid effectiveness, for the most part, because most studies have shown that multilateral channels of aid -- whether the World Bank or others, are actually more effective.
It also tends to hinder harmonization of donor policies, contributing to this welter of different programs that are often competing and redundant. And it provides -- it produces, as Laurie and others have pointed out, incredible administrative burdens on beleaguered development partners, who should be driving the train in most cases. So, it makes alignment with their priorities, it makes local ownership much more difficult.
And this is going to require, you know, to go -- to make a change here, and to engage multilateral institutions really is going to require a little bit of a cultural change on the part of the United States, and a recognition that "Made in the USA" development initiatives aren't really effective anymore.
What you have to do -- and this is true for the United Nations, for other types of multilateral engagement, is not to throw up your hands and walk away from things, even though some are hopeless. I'm not sure, for instance, that the development community would get a lot out of -- if the United States, working through ECOSOC, for instance, in the U.N. General Assembly.
But, the truth of the matter is that -- especially when it comes to specialized agencies, there is a tremendous amount of well, the U.N. system -- there is a tremendous amount to work with. It's just -- the importance of actually doing the hard-in, day-in/day-out engagement at the multilateral level, as opposed to throwing up our hands and walking away from it.
GARRETT: I'm going to come back to you on another issue, but first I want to jump to Seth Berkley, from IAVI, because one of the historic -- if you kind of step back about eight, nine years and look at the arc of how we've gotten to where we are right now on the multilateral, multi-national, and then again just U.S. foreign policy level on these issues is that, with the introduction of the notion that the global community should have a community-wide response to the AIDS pandemic, and that one key element of that was the access to treatment and the availability of antiretroviral drugs, we have seen a fantastic level of movement of dollars, and Euros, and yens, and so on, from the wealthy world to the poor world to facilitate this.
And I think it took awhile for the politicians in the wealthy world to understand that what they were committing to was a chronic care program that had no particular end-point, because if it worked, they would be keeping these people alive on these drugs for 20, 30, 40 years into the future.
And now we have a debate brewing. On the one hand, some advocates saying we should escalate this to the level of $58 billion a year for treatment -- and that that could lead to eliminating the epidemic, globally. And, at the same time, Italy will be the host of the G-8 this year, and Italy's parliament just voted to cut all foreign assistance by 50 percent. So, you're talking about a $58 billion annual chunk for HIV treatment alone, versus actually declining commitment to foreign assistance, writ large, in much of that wealthy world that you're dependent on.
And, meanwhile we had a question here from the side about a tuberculosis vaccine. What about an AIDS vaccine?
SETH BERKLEY: Well, I'm glad you left the easy question for me at the end. (Laughter.)
If you look at, kind of, where we are, you got to start by talking about the wonderment of science and technology. Ten years ago HIV, you know, was a death sentence -- period. Full stop. End of story. And, you know, 25 years ago, 30 years ago we didn't even know this virus existed, even though obviously it had been smoldering in some areas.
So, what happened? Science and technology got focused on that and we now have more treatments for HIV than for all other viruses put together. It's extraordinary what science can do when it's focused. And it's one of the things that the U.S. really leads in and does fabulously.
So, is it right that the activist community jumped in and forced this treatment to be put out there? Absolutely. People were dying. People are dying today. And so one of the challenges is -- if you believe that all lives are equal around the world, you try to do what you can to try to deal with that.
The challenge has been -- you know, and in a way, PEPFAR was appropriately named as an "emergency" program. What we also need is a longer-term strategy, and that longer-term strategy has to figure out how we're going to stop the epidemic. And stopping the epidemic really requires better prevention. And, given the fact that our prevention tools now are inadequate, we need new tools.
And so, core to all of this has to be that focus on the long-term, creating new and better tools, and making sure that that remains a focus on the development agenda -- because it's expedient and easy to, you know, pull back and say, well, we've got these long-term issues. We can't pull away from treatment, because once somebody's on treatment you can't back off from it. And yet we know that for every -- you know, two people put on treatment, there's five infections.
So, you've got this continuing -- this problem going on, and that's really the way we have to approach it. And, you know, for me, if I think about it, science and technology is such a critical part of many of the problems. So, if we think about, you know, how we're going to deal with water in the developing world; or agricultural and food production problems; or, you know, TB, and malaria, a host of other diseases, a lot of it is going to be taking existing technologies and getting them out better, but a lot of it is going to be in new technologies.
And so I hope that as we think about, you know, reenergizing our science and technology in this country, which has been ignored over the -- not ignored, but hasn't gotten the attention it should, the NIH budget has been flat; there hasn't been a coordinated look at science at the Cabinet level; there hasn't been a belief, necessarily, in science-based evidence and in all factors. I think a return to focus on science, and what it can do, will be an important part to solving that problem.
GARRETT: Yeah, but just to play devil's advocate here, Seth, I mean, we have any number of pretty extraordinary things that have come pretty -- you know, through the pipeline as innovations, that can make a difference in poor countries, and then they never go anywhere.
And a classic example is RTPCR Rapid Screening for multiple-potential viral assaults. So that you could do rapid diagnosis in the field, in real-world conditions for unknown viruses, as well as known, on a massive scale. Anybody here who's worked in the field in almost any place in the world could immediately imagine how much utility an innovation like that would have. But the complaint we hear all the time is, innovation is not part of the development and health process; that the development and health process operates on its own, kind of, stagnant path and isn't amenable to adopting and moving with innovation.
BERKLEY: I want to -- well, I agree with that to a degree, and reflect back what we've heard from Nita and the entire panel, which is this issue of professionalism in development. So, we've got, you know, some of the best development professionals in the world. We've had a tradition of having them. Years ago USAID was seen as the leader of the development field, not necessarily an agency that is demoralized.
And to have, the reason you have to have those development professionals -- even if, and I agree completely with Princeton that you have to have development work going on across all the agencies -- is that, in that home, you have people who understand the value of new technologies, and old technologies, by the way, new isn't always better, often new is not better, and those professionals then can help to learn from what's on the ground, from the customers; make sure that we're using best policies; make sure we're learning from other countries, other donor agencies as well.
And those development professionals are still here. They have just now operating in NGOs. They're operating in the institutions that are the contractors. And that doesn't necessarily feed up. And it doesn't necessarily feed into the multilateral institutions.
So, for me, the critical part of that innovation is to continue the research, operational research, and everything that goes on in the field. But, there's a lot of that. It's reflecting that back up and making sure that the policymakers understand that, and then can make rational decisions based upon, you know, what's available and what's out there.
And there's a million examples of where technologies aren't being used because there isn't a system to do it.
GAYLE: The other thing, I mean, the other thing your comments bring up, and others have mentioned, the fact -- I think we also have great opportunities to bring in other sectors. And we've been focused a lot on the government, but I think, particularly, when we talk about technology and innovations, and how we bring that in, you know, we know what industry, private philanthropy, et cetera.
And I think if we do a better job of not always, kind of, thinking government -- public sector only, and look at all the other actors that are in this, then I think we'll do a better job of bringing the kind of balance that I think everybody is talking about, because it isn't either/or. But, we are going to have to make some choices on what we spend our public dollars for. But then I think we can be better about, how do we work with other partners who can also add to that and bring them into the tent in a much more deliberate discussion than is the case now.
LYMAN: Let me just add as well, picking up on what Seth just said. I think the fundamental issue that we're all dealing with is that for the past 25 years -- it's not just this administration, it goes way back -- "development cooperation," and I use that word rather than "assistance," has been back on its heels. And having been back on its heels for that long, it's gotten into a defensive crouch, and has basically focused on maintenance and support.
Development assistance and cooperation needs to be about transformation. And I think a change of administration, regardless of the particular politics, is an opportunity to make that very visible change that 'U.S. engagement with the world is about helping to transform the lives of the world's poorest.'
GARRETT: The last quick question, and then I'm going to open to all of the audience to have an opportunity to -- Stewart is -- one of the big innovations, if you will, or changes, at any rate, has been this shift from about 3 percent of all foreign assistance from the U.S. government -- going through military operations, to currently about 20 percent, if you combine the drug war monies and direct DOD monies. That's a huge shift.
Gates has himself expressed some skepticism about the role of the military. It's an issue we struggled mightily with in our efforts on this report, and that you previously worked with Steve Morrison at CSIS in a real struggle on. Where is Steve? He's here somewhere, I'm sure.
And I wonder where you think it falls down now? If Obama asks you, "What do I do with all this development money that I've got over in DOD? Take it out altogether? Leave some of it there? What's the appropriate --"
PATRICK: Yeah, I'm sure happy to answer that that. I just want to identify Kathleen Hicks who, with Steve Morrison, was one of the two project co-directors of that project, who kept "herding cats," I guess, is -- (laughter) -- to use that previous metaphor.
You know, this has been one of the striking -- most striking changes of the past eight years really has been this migration of U.S. foreign aid roles, authorities and responsibilities to the U.S. military, and to the Department of Defense and to its regional combatant commands. By and large -- and I think we have to stress this, that a huge proportion of that 20 percent has been in Afghanistan and Iraq, which doesn't mean that well-resourced civilian actors couldn't pick up some of that slack.
But, increasingly, as you point out, the Department of Defense has gotten involved in, quote, unquote, "non-permissive environments" as well. And, you know, I think Hillary Clinton, in her confirmation hearing, signaled that the time has really come to reverse what Secretary Gates himself suggested could be reasonably called "the militarization of U.S. foreign -- creeping militarization of U.S. foreign policy."
And this isn't just the ODA numbers which, as we said, have gone up, it's also the way that foreign aid delivery is being accomplished in many of these situations -- the invention of Provincial Reconstruction Teams as a model in Iraq and Afghanistan; the creation of Commander's Emergency Response Program funds.
And outside of the ODA realm, but still having a lot of emphasis or implications for development of the sort of transformational kind that I think people here are talking about, the great expansion of DOD authorities, in terms of training and equipping of foreign security forces, and counterterrorism and stability operations in other environments, which really is quite a revolutionary step.
And then finally one thing I want to mention is just the increased impulse to use the Department of Defense's regional combatant commands as, sort of, platforms for integrating certain aspects of U.S. policy in the interest of what the Pentagon calls "Phase Zero," which, as I've said several times, we used to quaintly refer to as foreign policy or development policy, which is basically our bilateral relationships with particular areas and regions. And that's been described also by Admiral Stavridis of SOUTHCOM as using the combatant commands as a big "velcro cube" -- convenient thing that other U.S. agencies can, sort of, stick onto.
Now, I think there's been some "walking back" of some of that. But, you know, it's still leaves the question of the, sort of, the underlying dynamics and drivers of why things are migrating to the Department of Defense. And part of it is -- well, think about whether or not these are going to change.
The first of these dynamics is the perceived requirements of the global war on terrorism -- with an agile adversary, ungoverned spaces, et cetera, that we need to, sort of, deal with. So, it's sort of, this metaphor of control, that we can just provide stability. And the question is whether or not long-term stability is something that the Department of Defense is particularly good at providing.
The second thing is the, sort of, absence of any sort of civilian capability, deployable or otherwise, and after years of gutting USAID for much of its professional and technical expertise, et cetera.
And then the third, which is related to that, is the chronic under-funding over the years.
So, I think in all three of those there is some rethinking about how one does the global war on terrorism; there is a recognition that we really need to create the capabilities for these civilian agencies to deliver; and then on the third point is, I think -- as Congresswoman Lowey suggested, there really is a sense that Congress engaged.
What I would say, personally, if I were in a fortunate position to be able to advise the president and his advisers, is that DOD assistance in this realm should, by and large, be restricted to a couple of key cases. And one of them, of course, is the immediate aftermath of gross humanitarian emergencies, where DOD really has an unparalleled lift in logistical capabilities to be able to get something as after Indian Ocean tsunami.
The other is, no question, in hot contingency, immediate -- also even immediate post-conflict, there's still going to be a role, just because of security environment, for the Department of Defense to involve -- get involved in what they call "stability, security, stabilization -- transition and reconstruction operations. But, by and large, many of those functions could be carried out by well-resourced civilian actors with appropriate training; flexible authorities, in terms of delivering the sort of assistance that they have, et cetera. So, I'll leave it at that, but that's what I would say.
GARRETT: Thank you.
All right, we have an extraordinary group of experts to deliver questions to. I will please beg that you not only identify yourself, but you really ask a question. And keep in mind that the longer your questioning process takes, the fewer other individuals will have an opportunity.
I see a hand in the back here.
QUESTIONER: Hi, my name is Hattie Babbitt. I'm like Princeton Lyman, someone who's spent time at State and AID. But, my question really revolves around who decides in this -- who should decide, in this resource-constrained environment, how we get the most bang for our buck, be it bilaterally or multilaterally?
And here's my example on a domestic level: We know in the United States that medical schools in the United States are designed and run by "organs." That is, you leave medical school, where you were put through medical school focusing on knees, or ears or lungs -- (laughter) -- or kidneys or whatever, and it's no surprise that people leave medical school as specialists in some narrow area.
We also know absolutely that if our medical schools produced more general practitioners and internists, we would get more bang for our health buck. So discussing these -- (background noise) -- somebody, I would submit, and the question is who, on the -- if we're looking at global health, as opposed to the United States health, who in our government says, "Look, I'm sympathetic about HIV and AIDS, and I'm concerned about maternal and child health care, but the greatest bang for the taxpayer buck is -- ?"
GARRETT: Who wants that one?
DAULAIRE: I'll start.
GARRETT: Nils is going to take it.
DAULAIRE: There have been a series of recommendations that really fit together -- from this report, from the IOM report, from the MFAN report. And I think the common thread in those is that the best place for those kinds of judgment decisions to be made is at the White House, in the National Security Council, or special assistant to the president whether it's a special assistant for global health and a global health director or whether it's a deputy national security adviser for international development.
It's clear that one of the lessons of PEPFAR is that when you bring things to the level of serious presidential attention, they move. And I think we heard from his inaugural speech that President Obama values the importance of international development, and dealing with global poverty in all of its forms. And I think those kinds of decisions have to -- are going to have to be made there, and then spread out throughout the bureaucracy.
GAYLE: Yeah, now just to add to that, I think having some sort of a blueprint is going to be important. And, you know, another part of all of these papers that have been written about foreign assistance reform is the need to not only have somebody in a NSC, you know, enhance the role of development organization, but also to have some kind of an overarching national plan, because we just don't have one.
And I think we had a blueprint that really looks at what are the best -- you know, the bigger picture, and then looks at what are the best investments, but looking at that as a whole picture, you know, then I think all the different organizations -- agencies that have an impact on this, know what their appropriate role is.
And I think without that kind of a plan and blueprint, overall, along with somebody who has coordination responsibility in the White House, and then strengthening the organizations that are the implementers of these, you know we're not going to get there.
BERKLEY: Can I just add one more little point, which is, you know, that the normative technical agency in health, globally, is supposed to be WHO. It itself has many weaknesses associated it. Most of its budget is extra-budgetary. It's not well Core-funded. And it would help to have that institution regain some of its technical expertise, because what we want is not only the U.S. to make those decisions intelligently, but other governments as well as developing countries. And they're going to need some technical help that is, you know, more than just bilateral. And too often we've kind of kept them outside.
GAYLE: And a plug for another report that was just put out -- Institute of Medicine's report that was put out on Global Health Recommendations to the new administration, makes that point very clearly, about the need to strengthen WHO as well, and the role that the U.S. government has in that.
GARRETT: Princeton and Paul both also want to quickly --
LYMAN: Let me take a somewhat different approach in the short-term. You know, rewriting the Foreign Assistance Act is wonderful, and I hope, over the next five years, it can be done. (Laughter.) And if we have national development strategies, I'm all for them.
But, here's what I would suggest that Obama do: Whoever is in charge of coordinating foreign assistance -- take Mark Dybul, who's very interested in this, as Helene said, and the AID people together, and say, "Take three countries and let's see how we can take those programs and put them together so we have a broad approach to reproductive health, HIV/AIDS and other health infrastructure." "You guys got the money between you -- because it's there, let's see you do it in three countries." And then take two or three other areas.
I believe in what used to be called "metrics management," you bring people together around a common problem; you work across lines. And you demonstrate very quickly, in the new administration, you know, "This can be done." This can be done, and if resources are short, it can be done.
And then you keep the long, the big plans, and the coordination and rewriting the Foreign Assistance Act, but there are some things, it seems to me, that can be done fairly quickly.
GARRETT: Well, that, of course, is what --
GAYLE: Allow budgets to be used across lines --
(Cross talk.)
GARRETT: -- that, of course, is precisely what has been advocated by Prime Minister Gordon Brown, and Jens Stoltenberg in Norway in the International Health Partnership, with model country trials to coordinate all multi-national assistance.
Paul, a quick intervention.
QUESTIONER: Well, the only point I would make is a return to regular order would have the NSC coordinating the agencies, and OMB as part of the process to looking at the funding. And I think that's what we need, is a return to regular order. I don't think we need to be creating czars or czarinas for X or Y.
I think when it comes to the budget, and when it comes to these issues, if we can keep the mantra that "programs support policy," and we can define what that policy is, we can be a lot more efficient and effective on how we spend taxpayer dollars.
And U.S. taxpayer dollars we appropriate, and we are very sensitive on how they're spent, and I think it's important for the U.S. to have a policy itself on what -- how should that be spent to further our security interests, as defined by NSC, and OMB and others?
GARRETT: Okay, back?
QUESTIONER: Len Rubenstein, from Physicians for Human Rights, in the U.S. Institute of Peace.
There seems to be a growing consensus on a lot of important points -- about a comprehensive approach, end to vertical programs, increasing capacity, multilateralism, but there's one thing left out, which is the people who are supposed to get this aid at the bottom.
Because there very little connection, in most of these policy recommendations, to accountability to the people in these countries. There's very little connection and discussion of how you develop civil society support so they can have a voice in matters of equity, and protection of women --
GARRETT: Can you frame that as a question?
QUESTIONER: Yes. What do we need to do to make sure that we don't see global health and development reform as a technical issue about foreign assistance, and not relate it to civil society and accountability?
GARRETT: I'm going to throw that to Helene. (Scattered laughter.)
GAYLE: Short answer: Get civil society involved. You know, I think, again, I think having different actors at the table -- and it is very easy for the processes to only, again, only think about the public sector and not make sure that there is outreach to civil society organizations that have more direct reach into communities. And also, in whatever ways we can, bring voices of the community in in some of these discussions.
So, I just think we have to be mindful of that.
QUESTIONER: And I would add, measure impact on people.
GAYLE: Right.
QUESTIONER: If you're looking at that, it's going to influence what you do.
GAYLE: Right. It can't be about just spending dollars.
GARRETT: Over here.
QUESTIONER: Paul O'Brien, with Oxfam
Hopefully a useful follow-on. That's half the equation -- civil society. But, I think when we ask the "who" question in the global aid effect in this discussion, the answer one most often hears is "We need functioning, effective, responsible states working with their citizenries, providing basic health care."
We run into real problems in the U.S. Aid Reform discussion trying to get investments to focus on building that long-term state capacity. And part of that is because of Congress' concern -- basically, lack of trust that funding, given to governments, in predictable, long-term ways -- as many of the international donors are increasingly doing, will be wasted, because it will be politicized, or it won't be used effectively --
GARRETT: We got the question, Paul.
QUESTIONER: I'm Paul. (Laughs.)
QUESTIONER: As somebody who came from the democracy and governance field, the first part of what you were saying certainly rang true. And one thing that the outgoing administration focused on -- and we can talk about how it ran into major problems, was the freedom agenda; and strengthening governance; and making sure, with the MCC and other programs, that we're rewarding good behavior.
Our budget cycles are different than the budget cycles of other countries. We don't look -- five-year plan, we appropriate one-, two-year monies. So, we cannot -- with the exception of the MCC, which is a commitment for the life of the program, five years -- say that we are going to give a country, you know, five years at this level. That's not how it works. Within the State Department you might find that they have a five-year strategy, and within the Pentagon certainly they're looking at multi-year strategy.
In terms of giving budget support -- cash to governments, you betcha there's concern on the Hill. And there's absolute -- every reason to be concerned with giving money directly to governments that may not be governing justly, or whatever the verbiage is that people like to use. Corruption is a major, major issue.
And, again, when it comes to being the steward of tax -- U.S. taxpayer dollars, I think people want to make sure that regimes are in place, and there's a commitment on the recipient government's side that whatever is given will be spent for the purposes that it was given. And a difficult part of that is actually accounting for those funds once it's in the hand of the recipient government.
GARRETT: Yeah, I'd love to ask Princeton Lyman, since you served as ambassador in one of the countries most often held up as an example on this corruption issue --
LYMAN: (Laughs.)
GARRETT: -- how would sustainable development efforts, meant to build infrastructures, go to a country like that in a way that the ambassador for the United States can feel that there's some oversight?
LYMAN: And I think the dilemma here is that because we don't trust governments in this regard, and health is such a service-oriented process, that we tend to go through the NGO community and we do it for the governments -- in place of them.
It's not an easy problem to address, Laurie, but I do think you have to find partners in government that are prepared to do this. And that is not just overall partners, you have to have ministries who are serious.
And you have to build in oversight into the program. You have to have good auditing. You have to have good measurements of what's being done. And you encourage -- to go to the earlier question, you encourage civil society to hold their governments accountable. And you be prepared to pull the plug on programs that aren't being managed well.
I mean, I think you could do it, and I think you can make those investments, but you really do have to strengthen the oversight, and the monitoring, and the public pressure on them to make sure they're working. And you will find people in all these countries who want to do it right. You've just got to give them the right encouragement and backing.
GARRETT: Over here.
QUESTIONER: Fitzhugh Mullen, George Washington University.
A specific question in a specific area that we've not heard a lot about, although it's a predicate to many of the health-related programs, and that is the health workforce, or the lack thereof, in many parts of the world.
Specifically, what role does the panel -- and I'll let Laurie pick the respondent, see in terms of U.S. investment and capacity development; and, most specifically -- an idea that's come on and off the scene over many years, and more intensely recently, a Global Health Corps, where we would do more to mobilize U.S. health workers, or a Health Development Corps to work abroad in highly specific ways?
GARRETT: Nils?
DAULAIRE: Fitz, I knew you'd be talking about the Global Health Corps.
The challenge is going to be: How do we build long-term capacity in the countries that we're cooperating with? And I think we're all in agreement that the way to do it is certainly not just to parachute in American doctors. On the other hand, the need for long-term training and assistance, of both skilled and moderate-skilled health workers in these countries, would certainly benefit from a greater infusion of the kinds of people who understand both the health issues, or medical issues, and development.
And I think the challenge is going to be building this into a broader context of a Development Corps, with a medical specialty, perhaps, but with the recognition that people really have to be -- first of all, they have to understand development and development dynamics, because we've all seen enough examples of very well-meaning American doctors going into do things and not leaving much behind.
And then ultimately the last question, which goes back to Paul, will be: How do we pay for this? If it costs $60,000 for an American to be sent out there, and $12,000 for a local person to be trained, what's the -- what's the ratio?
GARRETT: Well, you know, that falls onto the multi-national stage, because all of a sudden now -- whether it's WHO, or the Global Fund to Fight AIDS, Tuberculosis and Malaria, or World Bank, the mantra is "health systems."
But when you get down to the concrete reality, no two countries agree on what a health system is, and what a financing mechanism is. If we bring the Europeans from Northern Europe in the room, and they, when they say "health system," they mean universal health care, with the government as the single payer, and that that's the model.
You get other players in the room and they start tell you how 80 percent of health care delivery in developing countries is done by private sector, and that that should get bolstered.
And so we end up getting hooked up on our own "wealthy world" debate about what a health system is, and who a health care worker is, and how we want to define their relative power structure and roles, before we ever even get agreement, on the multi-national level, about how we're going to fund all of this. How do we punch through that -- Stewart and Helene?
PATRICK: Yeah, I mean, part of it is -- okay, there are three different goals. There is policy coherence. How coherent is the U.S. policy on this, or any other national donor government? And there's policy harmonization, which is you're talking about -- can you get us to agree with the French, to agree with the Japanese, as to what a health system should look like? And then there's alignment, which is agreement with the actual country themselves.
And it strikes me that the point of departure should be alignment, and some level of ownership and agreement. I mean, unless it's a totally devastated, post-conflict society, to some degree, they are going to be able to set some priorities and have some sense -- and they will pick and choose who, you know, to some degree, amongst the different advisers that are being offered to them in terms of how they want to design a program.
And then there may be different elements of this development cooperation framework, which then different donors can elect, or not elect, to actually participate in. There's probably going to have to be some greater degree -- instead of everything like "Made in the USA" or, you know, "Made by Denita," there needs to be some sort of agreement to follow some of the lead of the host country, and to be able to, in a sense, rely on comparative advantages.
And, you know, there will be -- we won't be everywhere at once, at the same time. I'm not sure if that answers the question.
GARRETT: Hold on. I'm afraid that what I have to do here -- since we always end on time here at the Council on Foreign Relations, is I want -- you all now see what extraordinary expertise we have here on our second panel. My colleague, Isobel Coleman is with us still, from the first panel. And what I would like to invite all of you to do is both to thank everyone who participated -- and gave of their time and intelligence for us today, and to continue the discussion, and your questions, outside over a nice tasty meal.
Thank you very much. (Applause.)
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