Describing avoidable deaths, the overnight loss of local expertise and workers, and zero data released since the process began as "uncomfortable" is...a choice.
Three years inside PEPFAR does not equate to a Global Health expert. 30 + years in the sector, working alongside host country civil society, health facilities, national and local governments does. Why not actually talk to the people who have this depth of experience for clear-eyed guidance and ideas to improve foreign assistance processes? We all agree that the goal of International Development is to end the need for such assistance. And we are all still here, unemployed or underemployed because of the chainsaw. Process matters. Trust matters. Reputation matters.
This seems to be an “ends justify the means” argument. It is very difficult to assess the harm done by this approach with no PEPFAR data release since this administration started. Any sense of whether the usual public PEPFAR data will be shared?
Good, thoughtful analyis. I am a semi retired dev professional and I have always been a fervent believer in country-led development because countries can’t own or sustain what they didn’t create. G2G pilots have been tried before and they often stumble due to lack of investment in strengthening PFM systems of the host govts. Sadly, the MOUs - and I read potions of the Kenya one - are rushing headlong into the same trap!
Would love to see some investment return to the G2G work and public financial management for health. If countries are going to assume greater responsibility as they should and as the MOUs are aiming for, they are going to need some support in PFM areas and the G2G historic work under PEPFAR that I understand is continuing in Malawi is a great example of this. AND Also, some of the governance work that happened around tax reform and better budgeting and transparency for health has awesome evidence from El Salvador, Kosovo, Mozambique, and others. Grateful for the dialogue. Thank you!
Thank you both for this insightful discussion. +1 to “we simply laundered them through softer language before." I can’t even count the number of times I’ve said recently, “It was *always* about US interests.” Anyone who ever read a CDCS could see that. PEPFAR started after HIV was declared a threat to national security.
“Some stakeholders feel sidelined” also reads like laundering through soft language to me. They ARE sidelined. USAID saw NGOs as important partners and sought to work with more of them (with mixed success). Reverting from “locally led development” to “country ownership” is not just semantic. I helped evaluate the PEPFAR Local Capacity Initiative in Uganda, and I keep thinking about how the US might respond today to something like the AHA.
I'm also not sure I've heard anyone suggest that legitimacy only flows from maximal inclusion. More modestly, the first localization progress report said “localization without attention to inclusion has the potential to reinforce discrimination and unequal power structures." I agree with others here that while discomfort is not proof of harm, in this case the proof is clear.
Good comment. Funny how neither side acknowledges that the system was broken insofar as it spent over $100Bn in Africa alone yet about 25% of people living with HIV are still not accessing successful treatment. Emily does not seem to see this either as she talks about stakeholders and community engagement but where is the concern about treatment gap? It is a 100% fatal virus without treatment.
I think achieving the 95-95-95 targets is everyone's central concern (with the possible exception of the people who abruptly ended most support for prevention services, which is going to make that harder). There's been tremendous (if uneven) progress, and engaging priority and "key" populations—as the term suggests—is crucial. Governments don't always do a great job of this, to put it...mildly.
Agree. No real change ever came about quietly, but then some did. It's both. Also, change is always happening. No future, just now. Thank you for the bold response. Whether in one exam room or a policy change that affects millions, it's all in the healthcare bucket. Like it or not.
Describing avoidable deaths, the overnight loss of local expertise and workers, and zero data released since the process began as "uncomfortable" is...a choice.
Three years inside PEPFAR does not equate to a Global Health expert. 30 + years in the sector, working alongside host country civil society, health facilities, national and local governments does. Why not actually talk to the people who have this depth of experience for clear-eyed guidance and ideas to improve foreign assistance processes? We all agree that the goal of International Development is to end the need for such assistance. And we are all still here, unemployed or underemployed because of the chainsaw. Process matters. Trust matters. Reputation matters.
This seems to be an “ends justify the means” argument. It is very difficult to assess the harm done by this approach with no PEPFAR data release since this administration started. Any sense of whether the usual public PEPFAR data will be shared?
Good, thoughtful analyis. I am a semi retired dev professional and I have always been a fervent believer in country-led development because countries can’t own or sustain what they didn’t create. G2G pilots have been tried before and they often stumble due to lack of investment in strengthening PFM systems of the host govts. Sadly, the MOUs - and I read potions of the Kenya one - are rushing headlong into the same trap!
Would love to see some investment return to the G2G work and public financial management for health. If countries are going to assume greater responsibility as they should and as the MOUs are aiming for, they are going to need some support in PFM areas and the G2G historic work under PEPFAR that I understand is continuing in Malawi is a great example of this. AND Also, some of the governance work that happened around tax reform and better budgeting and transparency for health has awesome evidence from El Salvador, Kosovo, Mozambique, and others. Grateful for the dialogue. Thank you!
Thank you both for this insightful discussion. +1 to “we simply laundered them through softer language before." I can’t even count the number of times I’ve said recently, “It was *always* about US interests.” Anyone who ever read a CDCS could see that. PEPFAR started after HIV was declared a threat to national security.
“Some stakeholders feel sidelined” also reads like laundering through soft language to me. They ARE sidelined. USAID saw NGOs as important partners and sought to work with more of them (with mixed success). Reverting from “locally led development” to “country ownership” is not just semantic. I helped evaluate the PEPFAR Local Capacity Initiative in Uganda, and I keep thinking about how the US might respond today to something like the AHA.
I'm also not sure I've heard anyone suggest that legitimacy only flows from maximal inclusion. More modestly, the first localization progress report said “localization without attention to inclusion has the potential to reinforce discrimination and unequal power structures." I agree with others here that while discomfort is not proof of harm, in this case the proof is clear.
This article might take a crack at some of the nuance you are looking for:
https://nayaol.substack.com/p/the-accidental-window
How did you get clearance on this?
Good comment. Funny how neither side acknowledges that the system was broken insofar as it spent over $100Bn in Africa alone yet about 25% of people living with HIV are still not accessing successful treatment. Emily does not seem to see this either as she talks about stakeholders and community engagement but where is the concern about treatment gap? It is a 100% fatal virus without treatment.
I think achieving the 95-95-95 targets is everyone's central concern (with the possible exception of the people who abruptly ended most support for prevention services, which is going to make that harder). There's been tremendous (if uneven) progress, and engaging priority and "key" populations—as the term suggests—is crucial. Governments don't always do a great job of this, to put it...mildly.
Agree. No real change ever came about quietly, but then some did. It's both. Also, change is always happening. No future, just now. Thank you for the bold response. Whether in one exam room or a policy change that affects millions, it's all in the healthcare bucket. Like it or not.