New Day, New PEPFAR Coordinator = Improved Program

January 29, 2009

Ambassador Mark Dybul's sudden departure from the OGAC has unleashed the worst political vitriol from the left and right-the "radicals" are delighted to see him go but still continue to seethe about Dybul's role in interpreting policies into restrictive guidance as Coordinator of PEPFAR and the "right" is whining about "their" man's removal from THE most important foreign assistance program initiated by the Bush administration.To be clear, the case of Mark Dybul, in the absence of a clear explanation from the current administration, does come across as a set of sloppy moves-they ask him to stay, but then they ask to him to leave. But acting heads were also named for USAID and the MCC and a similar switch occurred with Kent Hill at USAID-he was asked to stay on and then replaced by Alonzo Fulgham, and there is not much noise in the press about that.Whether or not politics were at play on the Dybul issue, Dybul's service and commitment to PEPFAR is undoubted; he demonstrated concrete results and earned bipartisan support for the program from Congress. A smooth handover, and one where knowledge and lessons learned could have been shared with Dybul's successor, would have been the logical approach; there aren't many out there who can grasp, let alone implement, the many components of this massive and complex foreign assistance program that is saving millions of lives.Yet, there are examples of what is NOT working with PEPFAR at the country level. Research from CGD's HIV/AIDS Monitor has highlighted several examples of what is not working with PEPFAR with specific recommendations:--Make programs more responsive to country needs and build country ownership (see Following the Funding for HIV/AIDS)--Transition from an emergency response to a sustainable response that involves the transfer of skills, expertise and technological know-how (see Following the Funding and The Numbers Behind the Stories: PEPFAR Funding for Fiscal Years 2004 to 2006) and financial sustainability (see Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and What to Do About It) by my colleague Mead Over--Ensure that health systems are strengthened with their support of the national AIDS response (See Seizing the Opportunity on AIDS and Health Systems)--Design and execute a strong prevention strategy on a per country basis (rather than in response to global and ideologically driven directives) that can deliver measurable results for every fiscal year AND those that also add up to real changes in the fight against HIV at the end of 5 years. i.e. that new infections decrease over time. (See The Numbers Behind the Stories: PEPFAR Funding for Fiscal Years 2004 to 2006)--Ensure that gender-based vulnerabilities that drive infections and impede access to services are addressed and that measures to demonstrate these outcomes are reported for prevention, treatment and care. [forthcoming analysis from CGD's HIV/AIDS Monitor and ICRW]Given the sudden departure of Dybul and the uncertainty about who will next lead the program (or when), I hope the Obama Administration (and others) can move past politics and personalities to ensure that the incoming leadership is prepared to tackle these complex challenges. It has to be smart about PEPFAR because it is a widely acclaimed "success" of the Bush era and despite some shortcomings has demonstrated an ability to "get things done." If the administration makes changes that impede its visible effectiveness that could be a real problem. While it is a tricky task to reorient (away from emergency response, toward country ownership, toward comprehensive prevention etc.), and maintain the apparent effectiveness of the program, the new administration must appoint someone who can shape programs and measure success with metrics that show outcomes and impact-decreased mortality due to AIDS and decreases in new HIV infections-by country AND with country stakeholders. Simply enrolling patients into treatment programs and caring for them when they are sick (although these are not simple tasks) were critical components of PEPFAR's success in its emergency phase and will remain so, but these alone cannot define its success as it evolves into another U.S. President's Program for AIDS Relief.


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.