Africa, once known as the Dark Continent in the pre-PC era, enjoyed a vogue year
in 2005. Both the G-8 and the United Nations declared 2005 the “Year of Africa”,
and rock stars inspired politicians and fans alike to end poverty. But 2006 may
prove to be more momentous for Africa and other impoverished corners of the
globe: The United States, the largest and most influential international
development aid donor, has set out to overhaul its aid structures. This is welcome
news because the most important U.S. aid vehicle, the United States Agency for
International Development (USAID), has failed disastrously in its mission. An
array of perverse incentives has plagued USAID staff and contractors, particularly
since a series of “reforms” in the mid-1990s altered its original modus operandi.
Change is long overdue.
The Bush Administration announced its reform package on January 19 in a speech
delivered by Secretary of State Condoleezza Rice. Rice admitted that previous
attempts to integrate State and USAID programs and budgets had failed. She was
right: The U.S. government ran 19 separate major aid accounts in 2005, ranging
from child survival to strategic support for Egypt, and including those run by the
new and promising Millennium Challenge Corporation (MCC). Taken together,
these accounts totaled about $17 billion in spending. As the Administration
realized, that’s a lot of money to risk wasting on account of organizational
After what the Secretary termed a “comprehensive review”, the Administration
concluded that “the authority to allocate foreign assistance” was still “too
fragmented among multiple State Department offices and bureaus, and between
State and USAID.” Reform was necessary for three purposes: to ensure that
foreign assistance is used as effectively as possible, to more fully align the foreign
assistance activities carried out by the State Department and USAID, and to
demonstrate that the Administration is a responsible steward of taxpayer dollars.
So what changed? The Secretary announced the creation of a new position called
the Director of Foreign Assistance, to be held concurrently by the Administrator of
USAID (Randall Tobias, who had served as Coordinator of the Office of Global
AIDS, was confirmed for that position on March 31). The Director of Foreign
Assistance, who is nominated by the president and confirmed by the Senate, has
the rank of deputy secretary—co-equal in title, if not in fact, to Deputy Secretary
of State Robert Zoellick. This Director is now responsible for a newly integrated
structure for planning, budgeting and implementing policy across all agencies and
entities within the government having to do with development assistance,
including the MCC and the Office of Global AIDS.
In addition, Secretary Rice announced new efforts at professional education at the
Foreign Service Institute concerning development and governance efforts, and a
new personnel exchange program between State and USAID. At the same time,
State Department spokesmen and fact sheets all noted that these changes fell
within the authority of the Secretary of State, that no new legislation was necessary
to enable these changes, and that USAID’s status as an independent organization
with an administrator reporting directly to the secretary of state would remain
All of this was both more and less than initially met the eye. Stephen Krasner,
director of the State Department’s Policy Planning Staff, emphasized that in
addition to these announced changes, USAID would take planning and evaluation
a good deal more seriously than it had in recent years. Krasner, who played a
major role in the Administration’s comprehensive review (and earlier, as an NSC
staffer, a major role in the creation of the MCC), noted that Ambassador Tobias
would develop both specific five-year country plans and one-year implementation
targets, and that USAID would start using and publicizing specific quantitative
indicators of progress to measure its efforts. Former USAID Administrator
Andrew Natsios was a part of the review process, and toward the end of his tenure
he enacted several other changes in USAID’s operations that paralleled the new
planning, evaluation and implementation goals.
Clearly, then, a good deal of thinking lay behind the Secretary’s January 19
announcement. On the other hand, the decision to keep the reform effort within the
ambit of the Secretary’s authority, at least for the time being, and not go to
Congress with a more broad-ranging initiatives—such as the total integration of
USAID within the State Department—limits what can be done. There are real
questions as to whether USAID, as presently constructed, is reformable, whether
under the guidance of a new deputy secretary or not. And there are real questions
as to whether some elements of the reform package may end up being
USAID Then and Now
USAID wasn’t always such a mess. When the Kennedy Administration created it
in 1961, USAID represented a significant advance over the existing haphazard and
inefficient mix of several aid-dispensing agencies. As a single agency that
consolidated the development functions of its many predecessors, USAID’s
mission would be, as President Kennedy put it, “To prevent the social injustice and
economic chaos upon which subversion and revolt feed.” By blending
development aid and national security interests, USAID became a “soft power”
weapon in the Cold War long before the term itself was invented. And it worked.
The end of the Cold War, however, thrust USAID into political limbo. Since the
agency’s primary purpose had been to use foreign development assistance to help
win the Cold War, many in Congress saw no further need for it. Foreign aid
spending steadily declined during the 1990s and conservative congressmen,
foremost among them Senator Jesse Helms, called for USAID’s elimination.
Helms, who famously described foreign aid as “throwing money down foreign rat
holes”, and his colleagues eventually agreed to keep it alive on three conditions:
USAID would shrink; it would be held accountable to the State Department; and it
would embrace private sector reforms.
Subsequent Clinton-era transformations of USAID had an immediate impact on
the character of U.S. development assistance. As part of the initiative to streamline
government through privatization and make the agency acceptable to Congress,
USAID became largely a contracting organization. USAID closed 24 missions
between 1993 and 1997 and reduced its full-time professional staff from 11,150 to
7,609. With an eye to its own survival, USAID supplanted its national security
constituency with an influential interest group of commercial supporters.
Prohibited from lobbying for funds in Congress itself, USAID now actively
beseeches its “partners”, as it calls its contractors, to push for greater funding
through what, for lack of a better term, we may call the K Street consultants’
Though USAID is not unique in pursuing its objectives primarily through
contracting, it has drawn sharp criticism for its particular way of doing business.
One major criticism is the Agency’s strong preference for using large, U.S.-based
organizations with which it has long-term relationships. Ruben Berrios’ insightful
analysis, Contracting for Development (Library of Congress, 2000), found that the
market structure for development aid contracting was segmented and largely
uncompetitive. Since a significant part of the supposed advantage of contracting
lies in competition, drawing from only a small pool of organizations seriously
hampers USAID’s efficiency and increases the likelihood of rent-seeking behavior.
Berrios found that for-profit firms receive the most money from USAID, that the
geographic distribution of all contractors skews heavily toward the Washington,
D.C. area, and that some of the firms rely exclusively on USAID contracts to stay
Adding to this “insider” culture, USAID employees tend to trade jobs between the
Agency and its contractors with great frequency. The Research Triangle Institute,
Chemonics and the Academy for Education Development are but three of the
many contractors that actively court USAID employees. From the contractors’
perspective, inside knowledge of the Agency is valuable for procurement purposes.
Indeed, a quick search of any international development job board shows that
previous experience in procuring USAID funding is a high-demand skill.
Other criticisms of USAID persist as well. One of the most serious is that the work
typically performed by contractors actually undermines the local institutions and
indigenous capacities the aid process is presumably trying to build. Why does
USAID continue to pay contractors U.S. rates for work that local organizations
could do much more cheaply? Largely because the mission closings of the 1990s
made the Agency incapable of monitoring operations in remote locations.
Consequently, the Agency has little knowledge of local operators capable of doing
the job at a cheaper rate. The corollary is that local contractors have no access to
the USAID lobbying process nor, without expert help, do they have the capacity to
fulfill the regulatory requirements for aid projects.
This raises a larger issue: the incompatibility between what the rich world wants
for the developing world and what the developing world desires for itself. Aid
recipients with few resources are not in a position to complain about aid they
receive, even if it eventually proves counterproductive. The fact that USAID hires
almost no local people compounds its insular thinking. U.S. contractors often share
the same aims as the U.S. Government, or at least know how to pay lip service to
them, thus reinforcing approaches that are often unwarranted.
For years USAID justified its existence, to Congress especially, by stressing that
foreign aid money benefited American domestic economic interests through
contracts to U.S. organizations and commodity import programs for U.S. products.
Although exact figures are hard to come by, USAID spends a significant
percentage of its international development funds on U.S. goods and services
going to recipient countries. Data from USAID’s Buy American Report, the best
available assessment, indicates that over the last decade between 70 and 80 percent
of funding appropriations were directed to U.S. sources. In gross terms, the
Business Alliance for International Economic Development estimated in 1996 that
foreign aid sustained 200,000 U.S. domestic jobs.
USAID itself is not solely responsible for choosing U.S.-based organizations to
carry out the bulk of its development work. The 1961 Foreign Assistance Act that
created USAID included special guidelines that extended the 1933 Buy American
Act to ensure that agency funds financed goods and services of American origin.
While these “Buy American” provisions remain a source of contention for many
aid specialists, they have appeased USAID skeptics in Congress with domestic
interest arguments, allowing lobbyists of USAID-dependent contractors to win
increased funding. These are clear benefits to USAID and, despite the higher costs
that result from not buying local goods and services, the Agency has never
advocated changes to the policy or made much use of the generous loopholes
available to it.
Take the example of former USAID Administrator Brian Atwood. After leaving
the Agency in 1999, Atwood told the Washington Post that the Buy American
procurement laws were “the biggest headache I had to deal with.” Yet during
Atwood’s tenure, in all his appearances before Congress and statements to the
press concerning his initiative to reform USAID (including its procurement
policies), he never mentioned his Buy American migraine. Indeed, in 1995 he
boasted to a Senate subcommittee that he “introduced reforms to open up USAID’s
procurement to the best expertise in America”, but omitted any reference to non-
American sources. During that same testimony, he tacitly endorsed the Buy
American policy, stating, “Foreign assistance is far from charity. It is an
investment in American jobs, American business.”
Atwood’s actions were unsurprising, as his Agency’s endorsement of Buy
American rules earn it substantial political capital in an otherwise hostile
environment. No USAID official has ever attempted to change this longstanding
policy, though there is some hope now that Tobias has been named to head
USAID. As head of President Bush’s Emergency Plan for AIDS Relief, Tobias
challenged Buy American requirements by openly announcing to Congress his
intention to waive them in procuring anti-retroviral treatment. But will he hold fast
to this attitude at USAID?
Another criticism of USAID’s contracting process is its lack of transparency.
USAID policy forbids the disclosure of “proprietary” information related to its
contracts, which keeps the financial details of the bidding process hidden from
public view. Part of the reason for this is that some of the contracts secured by
USAID are for operations in geographically sensitive locations (Islamic states, for
example) or for work involving national security concerns. Rather than
differentiating between these types of contracts and those for, say, child
immunization in a predominantly Christian African nation, USAID lumps both
sensitive and non-sensitive financial information together, protecting it from
external scrutiny without good reason. Congressional pressure (notably from
conservative Senators Sam Brownback [R-KS] and Tom Coburn, [R-OK]) has
only recently been applied to rectify this opacity. Even general facts about Agency
policies and procedures are kept from the public. In response to my office’s
request for information regarding evaluation procedures, a USAID-Kenya
employee explained the rules: “I’m unable to respond to your queries due to strict
Agency policy of sharing USAID information with people or sources we are NOT
familiar with” (emphasis in original).
In addition to its secrecy, USAID also has a habit of punishing contractors or
employees who criticize the agency. Some employees have had their career paths
derailed after publicly criticizing USAID. One example involves former Chief of
Travel and Transportation Shirl Hendley, who raised the alarm in 2002 that
USAID travel practices violated federal rules. Despite being ignored by top
USAID officials, who benefited from the rules violations (estimated to have cost
U.S. taxpayers about $250,000 every year for two decades), Hendley refused to
stay quiet. She was subsequently reassigned because, according to her
reassignment letter, “you have chosen to do what you believe is correct, even if it
contradicts the instructions you have been given.” A subsequent investigation
spearheaded by Senator Charles Grassley (R-IA) vindicated Hendley and strongly
rebuked top AID officials, including Andrew Natsios and Inspector-General
USAID in Global Health Policy
Despite its problems, USAID is a trendsetter in global development aid practices,
particularly in the health policy arena. Though its leadership role is more subtle
today than it was when U.S. funding and expertise dominated World Health
Organization (WHO) disease eradication campaigns, Department of State figures
for 2003 show that American contributions still constitute a quarter of the
organization’s budget—by far the largest single national share.
As the world’s most powerful nation, U.S. input remains the single most important
influence on global health policy. Ilona Kickbusch, a former WHO employee and
current head of Global Health at Yale University, argues that U.S. support for
global health initiatives is so crucial that “many international documents read as if
they have been written for members of the U.S. Congress rather than for the
broader global health community.”1Kickbusch, “Influence and Opportunity: Reflections on the U.S. Role in Global
Public Health”, Health Affairs (November/December 2002). As the development arm of the U.S.
government, whose financial and political support is crucial for global health
programs, USAID thus has considerable clout over policy design and strategy. Part
of that clout flows from the fear of losing U.S. funds. Such fears are well
grounded. In July 2002 the United States redirected $34 million from the U.N.
Population Fund to USAID since the U.S. government opposed spending on
abortions and abortion rights.
USAID also acts as a role model for private lending. Private donors to
international causes, whose giving, according to the Hudson Institute, more than
triples official U.S. government assistance, look to USAID as the arbiter of which
programs and interventions to fund. Corporations, which value the good publicity
generated from charitable contributions, are wary of crossing swords with official
U.S. development policy. ExxonMobil, for instance, explicitly endorses the failing
approach of USAID’s co-sponsored Roll Back Malaria program and funnels its
$1.5 million contribution to the battle against malaria through USAID-affiliated
ITN (Insecticide-Treated Bed Net) programs. USAID thus has influence over
resources far exceeding its congressional earmark.
In the case of the Roll Back Malaria program, which USAID shaped and continues
to influence, USAID’s clout has actually harmed global health. Malaria rates have
probably risen since 1998, when Roll Back Malaria was set up with the goal of
halving rates by 2010. This poor result is not for lack of resources; since RBM’s
inception, USAID has increased its malaria eradication budget from $18 million to
$90 million (as of 2005). But the Agency’s flawed malaria control strategy has
rendered public and private investment unproductive.
It is not clear exactly how these poor results have come to pass, again because
USAID refuses to release details of the contracts, grants and cooperative
agreements used to disburse malaria funds. But from the documentation that is
available and communication with USAID staffers and contract employees willing
to speak off the record, we know that USAID spends very little money purchasing
the tools necessary to fight malaria effectively. Three methods of combating
malaria save lives: indoor residual spraying; insecticide-treated bed nets; and
effective medicines. Despite the Agency’s claims that it takes a “comprehensive
approach”, it spent less than 10 percent of its $80 million malaria budget for 2004
on purchasing these interventions (most on only one intervention—bed nets).
So what of the other 90 percent? Some sleuthing reveals that about $10.5 million is
dedicated to researching and testing a malaria vaccine, and the rest is spent on
“capacity building”, “technical assistance” and “strengthening” or “supporting”
government health ministries in malaria-affected countries. USAID does not
disclose any details as to what these categories actually mean, but as Agency
malaria staffers explained to me, many involve U.S. consultants giving advice to
government ministries. For example, the consultancy Management Sciences for
Health (MSH) received $64.3 million from USAID in 2003 (the last year for which
figures are available) for dispensing such advice. MSH is active on many malaria
projects, and its 2003 IRS Form 990 illustrates how USAID malaria funds are
typically spent: Between 52 and 70 percent of MSH’s program expenses are
dedicated to compensation and travel. That amount is separate from what MSH
designates as overhead.
Aside from their considerable expense, Western consultants are often ineffective
because they lack detailed knowledge of local conditions. During a $5 million
malaria effort in cooperation with the ministry of health in the Bungoma District of
western Kenya, the local health staff ran into major problems when USAID’s
consultants did not ever once visit the program area.
USAID claims that its comparative advantage lies in the institutional knowledge it
can dispense, and in the fact that it coordinates its technical expertise with
organizations that provide actual interventions, such as the Global Fund and
UNICEF. Unfortunately, except in a few isolated circumstances, USAID has not
provided any evidence of such complementary and careful coordination. In some
instances its failure to coordinate effectively has turned tragic. For example, the
Vurhonga child survival project in Chokwe, Mozambique, a USAID-funded child
survival effort implemented by Save the Children, was all but wasted because no
arrangement was made to buy medicines. In the final evaluation report submitted
by Save the Children to USAID, team leader of the project Armand L. Utshudi
noted that “frequent stock-outs and unreliable supply of essential drugs at
community-based health facilities” impeded the program’s operations. Although it
used the well-designed community participation technique developed at the Johns
Hopkins School of Public Health, this project met only seven of its 36 objectives.
It did raise the proportion of children with malaria symptoms treated within 24
hours from 2 percent to 50 percent, but it failed to reduce the number of children
dying because they were given outdated drugs. The project’s medical advisor,
Peter Ernst, says that efforts to convince USAID and UNICEF to persuade
Mozambique’s health ministry to stock the proper drugs failed due to cost
concerns—costs that USAID could easily have covered.
That we know anything of these projects is highly unusual, as USAID generally
does not collect enough data to evaluate its own activities. USAID can offer no
evidence that its strict capacity-building and technical assistance approach to
malaria has yielded any dividends. The only outcome measurements offered to a
Senate subcommittee are its statistics on increases in mosquito net ownership: in
Malawi (from 13 to 60 percent); Senegal (11 to 43 percent); Zambia (9 to 40
percent) and Ghana (zero to 21 percent). These figures were derived from surveys
from the $65.4 million Netmark Africa program run by USAID and its contracting
partner, the Academy for Educational Development. However, while these figures
show an increase in ownership of mosquito nets, they tell us nothing about how
much protection they provide (lower protection is the result if: nets get ripped,
which happens often; one emerges from the net, for example, to go to the
bathroom in the middle of the night; one does not go to bed at dusk). Repeated
requests to USAID from my colleagues and me, and from Senators Brownback and
Coburn, for more information, which would include USAID’s contracts, have gone
Aside from poor basic data collection, USAID’s evaluation of program
performance is also inadequate. An internal review of the substantial drop-off in
USAID evaluations (from 529 in 1994 to 167 in 2004) found that past
recommendations for improving evaluation systems have been systematically
ignored by the Agency’s senior leadership, and that current evaluation practice is
rife with impropriety. Such practice includes allowing project managers to grade
their own projects and to claim success without offering evidence. The evaluator of
the above-mentioned Save the Children effort inexplicably recommended that the
program’s approach be “replicated in other parts of Mozambique.”
Change or Perish
If the malaria effort is any indication at all, USAID is failing to make a positive
difference in an important facet of U.S. foreign policy and may well be a liability.
USAID can and must improve. Transparency improvements should come first.
Senator Coburn has suggested posting all USAID contract and budget details on a
web site. If USAID is indeed actively cooperating with other agencies, measuring
meaningful outputs and tailoring programs to the needs of recipients rather than to
the needs of its contractors, USAID should delight in sharing this evidence with
the politicians, policymakers, academics and ordinary citizens concerned with
American efforts to fight poverty and disease in the developing world. A refusal to
be held accountable ought to be understood accordingly.
Fortunately, after the malaria battles of 2005 many within USAID’s Global Health
Bureau want change—although recent improvements in rhetoric on malaria have
yet to be matched in other areas of Global Health or in any other program. But
change takes time and there is undoubtedly good intent from many appointees.
And of course, as already noted, top-down reform is even now in train.
As these reforms proceed, it would be wise to keep three key imperatives firmly in
mind: First, do no harm; second, match means to ends (i.e., link development
strategies to U.S. principles and interests); and third, neither overestimate nor
underestimate what organizational reform can accomplish.
Do no harm: As William Easterly demonstrates in The White Man’s Burden
(Penguin, 2006), much aid has not only not helped but has slowed development,
propping up odious dictators. It is ironic that USAID was set up in 1961 partly to
streamline a disorganized clot of foreign aid agencies, for in recent years it has
become anything but streamlined. One reason the Millennium Challenge
Corporation and the President’s AIDS initiative exist today is USAID’s poor
performance. It would be tragic if the relatively decent performance of these two
new efforts was undermined by shortsighted policy “reforms.”
For example, the Millennium Challenge Corporation actually refused to disburse
funds until the prospective recipient countries were able to efficiently absorb
them—a sensible stance that would be unthinkable at USAID. But the MCC has
come under pressure from recipient countries who wanted fewer aid hurdles to
jump over, as well as Republicans and Democrats, especially in Congress, to speed
up grant disbursement, even though that would probably mean in some cases
providing money to countries ill equipped to spend it. Paul Applegarth, the first
director of the MCC, may have been a casualty of that pressure. It is possible that
it took too long to establish procedures at the MCC and grants can flow more
easily now. But it is still far too early to say whether the new approach of
disbursing larger grants under the new MCC head, Ambassador John J.
Danilovich, is the correct way forward. It would be regrettable if reform were to
diminish the Corporation’s ability to achieve its mission. In her January 19
remarks Secretary Rice stated that the Millennium Challenge Corporation, “which
operates under unique, conditions-based standards for assistance”, as well as other
aid entities of the U.S. government, will fall under the overall leadership of the
newly created Office of Foreign Assistance in the State Department. Pulling MCC
under stronger control of the State Department to improve coherence in foreign
assistance operations certainly makes organizational sense. Even so, as both
Director of Foreign Assistance and USAID Administrator, Randall Tobias’
greatest challenge will be to foster an environment where MCC and USAID can
work together while improving overall effectiveness.
Match means to ends: It is essential that the Administration stick to its own
principles. Improved governance, both in recipient nations and in financing and
delivery of western programs, is the key to using aid resources wisely. It is and
always has been simply foolish to spend money just because it is available. As
distinguished development economist William Easterly put it:
Let’s not kid ourselves that spending more money on foreign aid accomplishes
anything by itself. Letting total aid money stand for accomplishment is like the
Hollywood producers of Catwoman, voted the worst movie of 2004, bragging
about their impressive accomplishment of spending $100 million on its
production.2Easterly, “The Utopian Nightmare”, Foreign
Policy (September/October 2005).
The keys to matching means and ends in development aid are setting measurable
goals, and actually measuring them to inform continuation of aid and seeking
constructive feedback. The Millennium Challenge Corporation’s approach, using
and thereby building civil society, effectively fosters constructive feedback from
local officials in recipient countries. At a meeting with African leaders in June
2005 for example, President Bush pledged to “work harder and faster” to increase
aid after receiving complaints about MCC’s bureaucratic bottlenecks that slow aid
disbursement.3Andrew Balls, “Awkward Timing for US Aid Chief’s Departure”, Financial
Times, June 21, 2005. It therefore makes sense that USAID should work with the
Corporation and remain open to local concerns as the MCC has done. Incentive
structure matters: If employees of an aid agency were penalized when an aid
recipient complained about project design and implementation, they would soon
become more responsive. Of course recipients have incentives to complain if they
don’t want to implement what donors might think to be sensible policy changes
(for example, aid tied to reductions in corruption), so feedback has to be dealt with
logically and criticism not assumed to be accurate or fair.
It also makes sense to prioritize aid according to a country’s strategic importance,
which of course is an argument for structurally reintegrating foreign development
aid with U.S. foreign policy itself—even going so far as distributing USAID’s
current mandate within the geographical bureaus of the State Department. That is
precisely what the U.S. Commission on National Security/21st Century (the Hart-
Rudman Commission) recommended in March 2001.
When the story of the reorientation of U.S. aid policy first broke on the front page
of the December 12, 2005 Financial Times, critics argued that planned reforms
would lead to the politicization of aid. This is a simplistic and naive complaint.
Implicit in the critique is the idea that development is a simple input-output
exercise: more resources and technical expertise get you more development.
Governance is usually the subject of diplomacy. But the supposedly sharp
distinction between development and diplomacy is purely artificial. USAID has
always been politically driven, with the (partial) exception of humanitarian relief.
While the critics may be right about the harm done by politicizing aid in the past—
for example, aid given to the likes of Mobutu Sese Seko in Zaire—spending
taxpayers’ money along the lines of U.S. strategic interests might not be such a bad
idea. At least we would have one metric by which to determine success or failure.
It would also be useful to bring the President’s vision into all U.S. aid policy. That
is not the case today. Current HIV prevention policies favoring abstinence over
condom distribution are not routinely followed in the field by USAID contractors.
For instance, an excellent research project with sex workers in southern Africa
violated the explicit instructions of the President’s policy. While this policy or
other policies may or may not make sense, they should be adhered to for the sake
of coherence. If a policy were fully implemented according to presidential edict,
properly evaluated, and then found to be a failure, a better course of action would
become clear. What we have now, more often than not, is an incoherent muddle.
Neither overestimate nor underestimate what organizational reform can
accomplish: Organizational reform can be a powerful impetus for better
performance. It can provide a more efficient and rational use of resources and a
chance to capture and implement intellectual innovation. The mere expectation of
organizational reform can put the fear of God and the fighting spirit in some
bureaucrats, too. But organizational reform cannot substitute for a lack of
intellectual energy. It cannot easily change cultural bias and it may not lead to
growth, even at MCC. If a new aid structure continues to rely excessively on
mostly unaccountable contractors, it will very predictably do little or no good.
And organizational reform cannot by itself substitute for vision and determination
in American leadership. President Bush appears to care deeply about all aspects of
development. He has been personally involved in policy judgments like no other
president since Kennedy. There is no substitute for good leadership; more is the
pity that Bush has not been as well served as he has deserved by the aid apparatus
of the U.S. government. A lot is riding, therefore, on the boldness, wisdom and
competent implementation of recent reforms. Lives literally depend on it.
1 Kickbusch, “Influence and Opportunity: Reflections on the U.S. Role in Global
Public Health”, Health Affairs (November/December 2002).
2 Easterly, “The Utopian Nightmare”, Foreign
Policy (September/October 2005).
3 Andrew Balls, “Awkward Timing for US Aid Chief’s Departure”, Financial
Times, June 21, 2005.