Briefing Book

How to Save Lives by Breaking All the Rules

How former U.S. Global AIDS coordinator Mark Dybul ditched the bureaucracy, stopped intergovernmental turf wars, pushed for results, and helped create an anti-poverty machine that actually works.


The world of international development has hit hard times. Critics say that overseas efforts to fight poverty aren’t working and, even if they were, there are more pressing concerns. In recent months, Washington has heard calls from both sides of the aisle to reboot the system — or dispose of it altogether. Even some Africans have argued for the latter.

The critics have a point: There are many examples of failed development. The anti-poverty fight is built on fragmented and ineffective systems; often goals are not set, measured, or met; resources sometimes enrich the corrupt; and paternalistic strategies are creating dependency rather than empowering countries to solve their own problems. Still, while catchy slogans like economist Dambisa Moyo‘s "Dead Aid" might sell a lot of books, acting on them would jeopardize the lives of many millions and leave countless more behind.

So what are we to do?

Do what the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) did: break the rules and then rewrite them. As a member of the small group that developed PEPFAR, and later as the program’s director, I was part of an initiative that helped prove that development is still worth doing — if it’s done in a completely new way. PEPFAR was the start of a fundamental change — a break from the past — in not just the intellectual foundations of development but in the nuts and bolts of how it is done.

PEPFAR’s roots trace back to new thinking from then-President George W. Bush, which turned the development debate on its head. The idea was to favor personal and national responsibility, rethinking the traditional roles of "donor" and "recipient." The United States, with such great resources, had a responsibility to less-fortunate parts of the world. But those countries and peoples to whom the United States pledged help also had to do their part. Bush called for local problems to be solved by local governments and people; for good governance and an end to corruption; for accountability that focused on results rather than how much money was committed; for people from every sector of society — government and nongovernment alike — to contribute to the effort; and for an emphasis on trade and economic best practices as the ultimate engine of sustainable growth.

In short, Bush called for a partnership between equals. So fundamental was the change that it wiped away the usefulness of words like "aid" and "assistance" — a lexicon that reflected an old system laden with paternalism, post-colonial guilt, and Cold War meddling. These new ideas became the foundation for PEPFAR and what Bush called a "new era in development." The New York Times called it a "philosophical revolution."

Today, the Barack Obama administration seems intent to build on those good ideas. Yet ideas alone cannot fix the structures that perpetuate old, bad habits. In developing PEPFAR, whole new systems were needed to turn ideas into reality. There was much work to do.

Just take a look at the situation in 2004, when our efforts began. Before PEPFAR, it was common for individuals in the various U.S. agencies working on HIV abroad not to know each other — or the programs and policies they were supporting. U.S. ambassadors were also kept out of the loop to ensure the agencies’ bureaucratic autonomy. Government agencies in Washington were similarly fragmented. In short, there was no coherent strategy for fighting HIV, nor was there a unified plan. Host governments were rightly annoyed because they had no idea how much money was being spent in their country or for what it was being used. As a result of the piecemeal operations, it was impossible to justify HIV/AIDS efforts abroad to the U.S. public. Nor were host governments able to effectively plan their own national strategies for combating the disease.

Faced with such bureaucratic barriers, the small PEPFAR planning group looked to the example of the U.S. military. After years of operating within independent and at times antagonistic branches, military operations had been unified under a Central Command in 1986. Approximating their model, we introduced a central command for HIV programs, one that retained the identity and function of individual agencies but directed them under one strategic mission. All U.S. government entities working on HIV reported to the first U.S. global AIDS coordinator, Ambassador Randall Tobias, with the backing of the president.

Simple as it may sound, this new structure was groundbreaking both in Washington and in the field: Besides the Central Command, it is difficult to find other successful examples of such high-level interagency collaboration. That central structure organized prevention, care, and treatment, as well as reporting systems, to ensure that goals were being met. Because the U.S. government’s efforts were consolidated under one umbrella, for the first time it could tell host countries what was done in their own backyards and how much money was being spent.

Overhauling the process was not easy. There was significant resistance at first and a scramble among agencies to claim their turf. Top agency officials declared the goals unachievable and one dubbed the whole effort "half-baked." To our surprise, there was strong resistance to setting goals and systematically collecting data on results. The old system favored money allocated as a benchmark rather than money spent and results achieved. This rendered development programs essentially unaccountable to Congress and hence, unpopular to fund. PEPFAR’s logic changed all that. In the program’s early days, one of the most senior development officials in the government told me to "stop giving Congress so much information; they’ll just ask for more." They did ask for more, and we provided it. And the fact we shared information was key to the strong bipartisan congressional support for the program.

Over time, people came together, and as a result, lives were literally saved — more than 1 million from treatment alone in just the first three years, according to a recently published, independent evaluation. PEPFAR met its ambitious goals early and on budget. Structural fixes alone would not have been enough; the bureaucracy would have done what it often does, i.e. slowly but surely prevent change. But there were a few key factors that kept the bureaucracy at bay. For one, PEPFAR significantly expanded resources under the control of the coordinator, making the procedures more efficient, limiting overlap, and creating a little healthy competition among the agencies. Also essential was the president’s personal commitment to, and engagement in, the program. Senior policymakers, most notably former White House Chief of Staff Josh Bolten, would intervene whenever obstacles needed to be overcome. But perhaps the most important factor was simply that rank-and-file U.S. development workers are a talented and good-hearted group. As the program moved forward, many learned that if they got on board with the process, they could do what they signed up to do: save and lift lives.

Despite PEPFAR’s remarkable success, the wheels of bureaucracy could always be heard rumbling in the background. And even today, one of the greatest risks to PEPFAR — and the millions of lives it touches — is a return to the old ways of every-agency-for-itself government. Equally damaging would be a return to old governance structures that remain blind to a new era of development. The risk is real and present — and is even reflected in some of the proposals for development "reform" sitting in Congress. Calls to fold PEPFAR into the U.S. Agency for International Development, for example, would be a significant step backward.

Ultimately, PEPFAR’s results are the achievements of the remarkably creative, committed, and talented people in the countries with whom the United States partnered. The bureaucratic structural changes in the U.S. government were focused on supporting them to solve their problems. But PEPFAR was an emergency response. Especially in the early days of the program, we struggled to really merit the description of a "country-led" program. Moving forward, the most important task is to complete the transfer of decision-making power from G-8 capitals to the capitals of low- and middle-income countries where countless people are working hard to improve their lives.

Two other new development institutions are rule-breakers and, as originally designed, have the greatest chance of ensuring the ideals of a new era in development: the Millennium Challenge Corporation (MCC), a U.S. fund that provides resources to countries meeting certain standards of good governance and democracy, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, a program that combines government, civil society, and private-sector solutions to improve health. Both programs require host countries to formulate and lead — in development-speak, to "own" — their solutions. Both emphasize metrics, results, good governance, and the importance of all sectors. The road for these programs has not been easy either. But such is the nature of the radical change they can bring.

In the long term, expanding the MCC and the Global Fund is the right strategy, so long as institutional issues can be resolved. The Global Fund, for example, should be expanded and resourced for a broader spectrum of health issues, including maternal and child health, nutrition, and clean water, so as to become a one-stop shop for a range of health services. This broader approach is something that host countries very much want but existing development institutions do not deliver, thanks largely to the structural silos that govern the current system and the turf wars they create.

While we were developing the plan that became PEPFAR, we discussed the program as the "tip of the spear" that would break open the approach to effective development. We are at a unique moment in history in which that opportunity — to finally get development right — is an open door. There is unprecedented awareness and demand to address human suffering as a moral and strategic imperative. There is a new generation of extraordinary and committed leaders across sectors in global institutions, and more importantly, in low- and middle-income countries, who will change the world if they are given the chance. It is a make-or-break time. And it would be a great tragedy to take the easy way out by killing development quickly or starving it slowly with partial and ineffective reforms. Instead, we need to harness our new ideas to change the course of human development. Not really much of a choice when you stop to think about it.

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