Littlefield spoke of OPIC’s role within the broader U.S. development apparatus:

I have seen how skillfully-deployed foreign investments provide not only jobs, but also hope and stability in poor countries. And I have seen the crucial role that well-administered government assistance from developed countries can play in making both of these things happen. Today OPIC’s work is the nexus of just this kind of U.S. development assistance.

If confirmed, I hope to be able to enhance the agency’s role as an instrument of foreign policy, creating synergies and boosting effectiveness in energetic partnerships with the State Department, USAID and other development agencies. OPIC complements the work of others in being able to respond rapidly, catalyze private investment, and do so while supporting U.S. jobs.

She told the committee that private sector investment “is crucial if poorer nations are to build the kind of infrastructure and markets that will allow their people to prosper and contribute to the prosperity and security of other nations.”

Carolyn Radelet, wife of former CGD senior fellow Steve Radelet and member of a four-generation Peace Corps family, testified alongside Littlefield as part of her own confirmation process to become deputy director of the Peace Corps. If confirmed, Littlefield and Radelet can help ensure that private sector investment and innovation and the spirit of volunteerism are reflected as key parts of our development apparatus.

GlaxoSmithKline (GSK) CEO Andrew Witty is leading the front on modernizing pharmaceutical multinational companies (MNCs) with his recent announcement for a customized drug pricing scheme for emerging market economies like India. He outlined the new approach clearly in several interviews such as this one:

“Our strategy is to grow our business in middle-income countries by increasing the volume of products we sell,” Chief Executive Andrew Witty said in an e-mailed interview. Extending Glaxo’s flexible pricing program for such nations would “improve the affordability of our medicines, increase access for patients with lower income levels and be profitable for GSK,” he said. In December 2008, shortly after he took over as CEO, Witty signaled his intention to make GSK a lead player in the global development business of increasing access to medicines: “I believe the pharmaceutical industry has a huge role to play. But we need to take much more of a leadership role. Historically we have always reacted to problems. In the future I want us to be proactive, genuinely finding new ways to increase research, increase access and eradicate disease.”

And proactive he has been. See here for a chronological list of different policy announcements about GSK’s commitment to the developing world from the reduction of its prices for patented medicines in LDCs in 2009 to a recent announcement in January 2010, at the Council of Foreign Relations of an “open innovation” strategy to help deliver new and better medicines to the developing world especially for neglected tropical diseases. In this excellent talk (and if you have time it is worth watching the video), Witty walks us through the three ways in which he is changing GSK business model around open innovation, in addition to offering customized pricing to countries. These include 1) greater flexibility around intellectual property and knowledge sharing; 2) creating partnerships for researchers to have access to GSK’s industrial scale expertise, processes, facilities and infrastructure in addition to their knowledge and know-how; and 3) releasing access to new compounds for others to join GSK researchers and accelerate discovery.

So, what’s different about this model?

It strikes me as a win-win approach-one where both GSK AND its country partners are likely to benefit. For GSK, it will create a space to compete in future markets with local firms. For example, as the pharmaceutical sector grows in India, Witty is anticipating competition and jumping in now to ensure access to these markets and to information. For LDCs and emerging market partners, the GSK approach has the potential to increase access to medicines, to direct financial investment to pharmaceutical infrastructure development, and to increase access to knowledge and know-how for their scientists, encouraging them to actively participate in the discovery and development of products.

How is GSK making this happen?

1. Tapping talent from other countries to accelerate the discovery process of new and better drugs. GSK is smartly engaging the growing scientific and technical talent in countries like India. This will enhance their discovery and development processes for drugs by offering Indian scientists actual knowledge about different compounds that can be used in drug development, access to high tech labs, infrastructure and the ability to pursue research projects that they have identified. 
2. Forging early partnerships with pharmaceutical companies in the developing world by increasing GSK’s flexibility around intellectual property. As patents expire and emerging market pharmaceuticals ramp up their R & D efforts, GSK will perhaps be in a better position, relative to other pharmaceuticals MNC, to access this information. It recognizes the value of partnerships in a very real and productive way–generate knowledge, share it with others for their use, and others who generate knowledge will likely share it with you for your use.

Andrew Witty, the economist (yes, and apparently one of the only to head a pharmaceutical MNC!) CEO seems to be thinking well ahead of his peers; other pharmaceutical MNCs are silent on these issues; supposedly staying clear of these countries (LDCs and emerging) right now, still unsure of the potential return on their investments in high volume markets. Witty, on the other hand, seems to be anticipating serious market shifts and designing GSK’s current operations to maximize its profits while doing some greater good. In his words he is building a company that is “constantly earning the trust of society, not just by meeting society’s expectation, but by striving to exceed them, because if you don’t have that trust of society — the society in which we all operate and the societies we strive to serve, then you really, in my view, don’t have a long-term, sustainable business model.” He is modernizing his company from within and in the way it deals with external partners so that the discovery and development of drugs is a more global and dynamic process that never stops. It’s still too early to tell if GSK’s approach will lead to a “successful” model, but certainly worth watching closely to see how it strikes the balance between making markets for itself and making drugs more accessible to the poor.

Shah’s testimony before the House Foreign Affairs Committee and the House Appropriations Subcommittee on Foreign Operations was clearly on message. It followed the same outline as Secretary Clinton’s testimony highlighting three priorities: frontline states (Iraq, Afghanistan and Pakistan); meeting urgent global challenges (global health, food security, climate change, humanitarian assistance); and the right people, tools, and focus on results. Perhaps more interesting is how closely the principles Shah outlined in his testimony mirrored five of the six principles Secretary Clinton set out in her development speech at CGD.

While Clinton and Shah may have had the same messages, members of the two House committees asked Shah far more targeted and specific development questions. They praised his handling of the Haiti earthquake – save for Rep. Mark Kirk who took issue with a sole-source contract – and asked him about basic education programs, maternal and child health, country ownership, trade capacity building, contracting, staffing, and the timing and results of the Presidential Study Directive on U.S. Global Development Policy and the Quadrennial Diplomacy and Development Review. They see Shah as the go-to guy on U.S. development programs and from the tone of Kirk and others, it is also clear that he is the one on the hook for development decisions and results. The question is really whether Shah, after only two months on the job, has the capacities and authorities yet to go along with these responsibilities.

When Shah was confirmed, CGD President Nancy Birdsall said “The question should be: what does Raj need to succeed? And what he needs is the administration to bolster his capacity and authorities to successfully elevate and empower a distinct development perspective and voice.” Former CGDer Sheila Herrling and I suggested the USAID administrator needed the following:

1. The right people.
2. A strong policy capacity to participate in the Presidential Study Directive on U.S. Global Development Policy (PSD), the Quadrennial Diplomacy and Development Review (QDDR), and efforts to rewrite the Foreign Assistance Act.
3. Congressional support to allow him to use notwithstanding and waiver authorities attached to the too-many earmarks put on his budget.
4. Authority over the agency’s budget—from its request, based on input from the field; to its justification, including argumentation directly to the Secretary of State and OMB as it relates to the rest of the overall State Department request; to its final allocation across sectors, programs and countries; to accounting publicly for its results.

So how’s it going so far?

• Full webcast
• Shah’s testimony
• Berman’s opening remarks and press release
• Ros-Lehtinen’s opening remarks

House Appropriations Subcommittee on State, Foreign Operations, and Related Programs:

• Shah’s testimony
• Rep. Lowey’s opening remarks

1. People: Shah has filled a number of key positions in the front office but the twelve remaining Senate-confirmed positions on his leadership team should be at the top of the to-do list. I suspect Senate Foreign Relations Committee staff would welcome nominations and, I hope, help see to quick scheduling of confirmation hearings.
2. Policy capacity: It seems Shah has the green light to build a robust policy capacity at USAID. He reported to Rep. Berman that he is building policy planning and gave a shout-out to former CGD Vice President Ruth Levine as a “world-class innovative evaluation” expert that has joined his team. But again, filling the twelve remaining Senate-confirmed leadership positions is essential for actively and effectively engaging in the PSD and QDDR.
3. Congressional support: The marks are generally high for Shah so far, but could be even higher if he regains the confidence, spark and enthusiasm he exuded in his confirmation hearing. I suspect the slightly dampened demeanor in the budget hearings may have something to do with post-Haiti fatigue and for having to defend a budget into which he likely had little input based on the timing of his confirmation. Nevertheless, he clearly has congressional supporters for development and for reform; whether this will extend to use of waiver authorities is harder to foresee and will require continued contact and engagement with key congressional offices.
4. Budget authority: Again, it’s unlikely that Shah had much input into the FY2011 budget process given that he only began his job in January. When pressed about USAID budget authority in the hearings, he told members we “will get to the place where we have the opportunity to develop a budget.”

As Birdsall said, Shah brings “tremendous talents – smarts, passion for development and strategic thinking — to the helm of USAID.” Things are moving in the right direction, but hard tasks lie ahead. Those of us in the development community should be thinking about how we can help the administration and Shah fill his leadership team, build the agency’s policy capacity, cultivate congressional support, and gain budget authority so that next time he is before these committees, he can speak with the full authority he should have, given the enormous responsibilities in front of him.

Ahead of the March 11^th hearing, the MCC’s recently published FY2011 Congressional Budget Justification offers a blueprint for how the MCC intends to use its scarce resources. (Kudos to the MCC public affairs team for hosting a small roundtable session – as we suggested – to walk us through the CBJ!) Because concept papers have not yet been received from most of these partner countries, the following is an estimate of the level of FY2011 funds and compact projects:

• Zambia has $350 million budgeted for possible projects in sanitation and water supply infrastructure, education and capacity-building, and eco-tourism expansion.
• Indonesia has $521 million budgeted for investments in four potential areas: education, infrastructure, environmental sustainability, and governance (with a particular emphasis on continuing anti-corruption activities begun in Indonesia’s Threshold program).
• Cape Verde has $100 million budgeted for its second Compact, though detailed discussions with the national government have not yet begun.
• Malawi is being jointly funded with FY2010 carryover and roughly $100 million from FY2011 resources. In Malawi, the MCC will focus on the energy sector as it looks to increase access to reliable supplies of electricity and address policy reforms required to attract future investments in the power sector.

Linked with the FY2011 budget request and CBJ are two proposals that require legislative language to:

1. Give the MCC concurrent, subsequent, and longer compact authority.
2. Allow a candidate country graduating out of an income category to retain its candidacy at the lower income category for the year of its transition and for one subsequent fiscal year.

Senators Kerry and Lugar’s Foreign Relations Authorization Act for Fiscal Years 2010 and 2011 addresses both of these issues. It allows a compact to possibly extend to seven – as opposed to five – years with congressional approval. The act further spells out guidelines for how concurrent compacts might work, specifically that no more than three may be in effect at a given time.

This legislation is critical as the FY2011 CBJ explicitly assumes concurrent compact authority for Indonesia in its budgeting. Concurrent compact authority means that projects which are investment-ready can begin in FY2011 while those projects that may need further analysis can be funded at a later date without delaying the entire compact process. Concurrent compact authority ensures the highest levels of oversight while offering greater predictability and added incentives for ongoing policy reforms within partner countries. 

The FY2011 MCC CBJ highlights other important developments that could come up in Mr. Yohannes’ hearing:

• For the second year in a row, the MCC has requested no funds for any new threshold programs. This is no doubt an indication of the on-going internal debate at the MCC of what the threshold program is and how it should be used.
• The MCC has increased requests in the areas of due diligence and M&E initiatives by a total of $7 million. As the MCC seeks to demonstrate results to Congress and the American public, these are important places to keep funding robust.
• Colombia may still be considered later this year due to the new legislative authority described above, even though Colombia is currently an upper middle income country.

To fulfill its mission, the MCC will need to ensure that it receives the full $1.28 billion in the FY2011 president’s request and gets its requested legislative fixes. Next week’s budget hearing will be a chance for Mr. Yohannes to demonstrate the inherent linkages in these two requests and advocate for their full implementation.

With so many important issues at stake, what would you like to ask Mr. Yohannes at his upcoming hearing?

While key questions remain—i.e., How is the evaluation being conducted? Will new data be collected in the communities or will it be just a review of project reports and secondary data? What and how many countries will be studied?—the evaluation comes as welcomed news. Communities and community health workers have long played a critical role in primary health care systems, and in World Bank programs. The World Bank’s MAP program in particular has a strong community focus, with a sizable amount of their funds and resources going to Community-Based Organizations (CBOs). However, while so much is going IN to the community response, there is little coming OUT of the World Bank in regards to reporting, monitoring, and impact evaluation. Donors and others in the development community are left wondering how exactly this money is spent, what programs the money focuses on, and how effective these programs are in curbing the epidemic.

Two of the main focuses of the evaluation are 1) to track the flow of funds from national to community levels; and 2) to assess the effects of the community response on the course of the epidemic. These are both important steps in identifying the roles that communities have and can play in the HIV/AIDS response, and issues that the Monitor has already examined, particularly in the report Following the Funding—which analyzes the transparency and effectiveness of funding data and flows of top AIDS donors.

There is no doubt that the World Bank MAP is a leader in channeling significant sums of money to CBOs at the community level—so much so that that MAP funds tend to be designed and reported around types of implementing agencies, rather than programmatic activities. In order for a country to qualify for funding, the government must first identify CBOs to serve as implementing recipients of funds. Given this emphasis on communities, it is particularly surprising that we don’t yet know the returns of these investments.

Findings from the HIV/AIDS Monitor (here and in two forthcoming reports on Performance Based Funding and the Health Workforce) about the MAP program, raise several issues about the allocation of resources to community based organizations that could reduce the effectiveness of community interventions:

Funding Bottlenecks: While the MAP is quick to disburse funds to national governments, the flow faces several challenges and delays once in the hands of the National AIDS Councils (NAC). Because these funds must first travel through the government system and because they are accompanied by complex reporting requirements, bottlenecks in the system often create slow and unpredictable money flows to the community, constraining program implementation. It is critical that the evaluation examine these funding flows and provide solutions to reduce these bottleneck challenges. In our Following the Funding report, we suggest that aligning reporting with national systems and increasing individual disbursement amounts based on the achievement of programmatic results could help reduce administrative burdens and ease the flow of funding to communities. Hopefully the evaluation will be able to provide more insight into how the administration of World Bank grants effects project performance at the community level.

Lack of Program Data—collection and reporting: At the national level, the World Bank collects and releases financial commitments by country and by broad program area. At the country level, while the World Bank collects disbursements to recipient organizations, this data is not shared publicly. At the community level, while individual countries may collect comprehensive data on the amounts of money committed or disbursed to different types of recipient and sub-recipient organizations, it is not required by the World Bank, and it is therefore not released publicly. Yet, since the bulk of MAP funding goes to communities, it would be beneficial to see and understand how this money is actually spent at the local level. This data should be both collected AND released because the information is vital for not only tracking recipient spending in the community, but also for identifying and evaluating the cost-effectiveness of these programs.

In addition, programmatically, the current data collected and released by the World Bank does not allow us to truly understand the extent to which communities have assisted in the response or which types of community-level programs are most effective. For instance, in our report Moving Beyond Gender as Usual, we found that the MAP has introduced gender-capacity building activities for community initiatives, but it does not systematically report on programming that results from this capacity building. Also, because of the lack of financial data collected at the community level, there is no way to know how much funding actually went to gender programming at the community level. In order to understand the effectiveness of community interventions—like gender programming—programs must be consistently monitored and evaluated.

In their current forms, MAP supported community based programs may be hindering or enabling governments’ and other stakeholders’ efforts to use aid effectively. Learning from an evaluation will help countries make informed decisions to allocate precious resources to community based interventions that are working—those that are helping to prevent new HIV infections and reducing deaths due to AIDS.

Full Hearing Webcast Coverage:

• Senate Appropriations Subcommittee on Foreign Operations (webcast)
• Senate Foreign Relations Committee Hearing (CSPAN)
• House Appropriations Subcommittee on Foreign Operations (webcast)
• House Foreign Affairs Committee (webcast)

Secretary Clinton’s opening remarks and video:

• Senate Appropriations Subcommittee on Foreign Operations
• Senate Foreign Relations Committee
• House Foreign Affairs Committee
• House Appropriations Subcommittee on Foreign Operation 

Written opening remarks: 

• Senate Appropriations Subcommittee on Foreign Operations (not yet available, see webcast)
• Senate Foreign Relations Committee (Kerry, Lugar)
• House Foreign Affairs Committee (Berman, Ros-Lehtinen not yet available)
• House Appropriations Subcommittee on Foreign Operations (Lowey, Granger not yet available)

Secretary of State Hillary Clinton testified last week before four separate congressional committees on the FY11 president’s budget request for the State Department and U.S. Agency for International Development. While the hearings covered a vast array of issues, Secretary Clinton and Democrats and Republicans on the committees signaled the importance of U.S. development and diplomacy as they tried to strike a delicate balance between support for U.S. international affairs programs — still a small portion of the federal budget — and the growing need to justify any spending increases during a time of domestic economic stress.

Secretary Clinton’s testimony before the Senate Appropriations Subcommittee on Foreign Operations, the Senate Foreign Relations Committee, House Appropriations Subcommittee on Foreign Operations and the House Foreign Affairs Committee emphasized the administration’s continued efforts to elevate diplomacy and development as core pillars of U.S. foreign policy. Clinton told the committees:

I know that this is a time of great economic strain for our fellow Americans. And as a former member of Congress, I know what this means for the people you each represent. For every dollar we spend, we have to show results. That’s why this budget must support programs vital to our national security, our national interests and out leadership in the world, while guarding against waste, duplication, and irrelevancy. And I believe it achieves those objectives.

Clinton highlighted three areas where the budget request makes significant new investments:

1. Frontline states. Afghanistan, Iraq and Pakistan receive the bulk of the FY11 budget increases.
2. Investing in development. The budget makes targeted investments in fragile societies, which Clinton argued “bear heavily on our own security and prosperity.” The administration also requests increases for the Global health Initiative, food security, climate change, investments in women and girls, and humanitarian assistance.
3. Recruit, train and empower the right people for the job. The budget allows for expanding the Foreign Service, staffing the standby element of the Civilian Reserve Corps, ending reliance on contractors, and expanding oversight.

All of these investments, Clinton said, are “designed to enhance American security, help people in need and give the American people a strong return on their investments.” She said, “one thing should be very clear from this budget: The State Department and USAID are taking a lead in carrying out the United States’ foreign policy and national security agenda.” She added that the Quadrennial Diplomacy and Development Review, set to come out this summer, will help match resources to priorities and ensure the programs are effective and accountable.

Members of Congress asked Secretary Clinton about a panoply of issues from geopolitics to gefilte fish (literally) and everything in between: Iran, Pakistan, Afghanistan, Iraq, Cuba, Israel, Somalia, Sudan, Liberia, Armenia, Tonga, Samoa, Guantanamo, terrorism, abortion, drug policies, export controls, and free trade agreements, just to name a few. (It was about midway through this list that my colleague suggested we send Secretary Clinton a sweatband and some Gatorade to help her get through the two days of testimony.) Despite the broad array of topics and countries that are increasingly important to U.S. national interests, security and prosperity, there were a handful of common themes:

1. Development and diplomacy are in our national security interest. Senator Kerry said the resources in the international affairs budget are “vitally needed for our national security” and citing Defense Secretary Robert Gates, argued that failing to invest in places like Afghanistan means the U.S. will likely “pay a higher price in the end.” Rep. Berman argued that “over the long run, these civilian efforts are much more cost-effective than putting our brave soldiers in harm’s way.” Senator Lugar made the case that our international affairs budget must deal with immediate problems and address negative trends that could ultimately “undermine domestic recovery and solvency.” He argued that global economic stress is closely linked to international political, economic and security instability and can undercut our own economy’s ability to recover, putting further pressure on the national budget.

Because the international affairs budget is considered part of the national security budget, it is not subject to the domestic discretionary spending freeze. Most members of Congress embraced the international affairs portfolio as part of U.S. national security spending; Congresswoman Ros-Lehtinen was one of the few who suggested that “in light of our fiscal situation, the international affairs budget should also be subject to selective freezes of slower rates of spending.”

2. Foreign affairs spending comprises a tiny portion of the budget. Though many members of Congress hit the same message that the international affairs budget is just a “fraction of a fraction” and “just 1.4 percent of the overall budget,” Senator Leahy summed it up best: “For the remainder of the world, the increase is about the rate of inflation. And as the president has pointed out, the total request for foreign operations is about 1 percent of the entire federal budget. If we cut all these programs, it wouldn’t make a dent in our deficit, but it would cause many other problems around the world, especially as it affects America’s leadership position. These funds are all we have besides U.S. military to protect the security and other interests of the American people in an increasingly dangerous and divisive world.”

3. Tough economic times call for transparency and accountability to the American people. Again, several members echoed the need for increased transparency and accountability and to show the American people what they are getting for their U.S. development investments. Rep. Granger said we must “ensure that our tax dollars are used efficiently and in a transparent method,” and Rep. Lowey said “if we are to increase our assistance in this time of economic insecurity at home, we must ensure that every dollar is well spent.” Senator Lugar said strong implementation, monitoring and review mechanisms must be in place and that the Foreign Assistance Revitalization and Accountability Act (S.1524) “has garnered wide support because it strengthens USAID and emphasizes greater evaluation and transparency of our foreign assistance programs to ensure we maximize the dollars that are available.”

4. There is bipartisan support for U.S. foreign affairs engagement and programs.  Senator Leahy said “As we listen to the complaints about broken government or paralysis in Washington, this is a bill that over the past number of years has had overwhelming bipartisan support.” Senator Lugar also spoke of the bipartisan support for the Foreign Assistance Revitalization and Accountability Act (S.1524), now supported by 24 Democrats and Republicans, 11 of whom are members of the Senate Foreign Relations Committee. Senator Lugar said “this level of backing for a bill related to foreign assistance is extremely rare…I’m hopeful the executive branch will recognize that a bill cosponsored by a majority of the Senate Foreign Relations Committee and nearly a quarter of the full Senate should be given substantial weight.”

5. There is interest and concern for the broader reviews of U.S. development and diplomacy policies, including around the MCC, trade and technology. Senator Menendez asked Secretary Clinton about the process, timeline and expected outcomes of the Quadrennial Diplomacy and Development Review (QDDR) to which he was told the QDDR would be completed this summer and that they will coordinate with Congress on the reforms they believe should be undertaken. Senator Lugar also said he was eager to review the QDDR and the Presidential Study Directive on U.S. Global Development Policy.

Senator Bennett asked whether the administration, as part of the review processes, might take steps to curb the independence of the Millennium Challenge Corporation (MCC). Bennett said he was impressed with his meeting with new MCC CEO Daniel Yohannes and that one of the MCC’s values has been that it is an independent agency with strong guidance from a board of directors. He also noted, with concern, that the MCC budget request was the lowest since it began. Secretary Clinton reassured Senator Bennett that “there have been no conversations that I have been part of or that I’m aware of about curbing the independence of the MCC.” She mentioned some of the small, legislative fixes the MCC is seeking and made clear that she does “want it to be seen as part of our overall efforts.” Secretary Clinton also stated that they are increasing the MCC budget over 2010. In this case, Senator Bennett and Secretary Clinton are both right: the FY11 request for the MCC is $1.28 billion which is 16 percent more than the FY10 enacted levels of $1.105 billion (point for Clinton), but is in fact lower than the FY10 request level which as my colleague Casey Dunning points out was $1.425 in FY10 and is also the lowest request level to date as the first MCC request in 2004 was $1.3 billion (two points for Senator Bennett).

Reps. Ros-Lehtinen and Mack both raised questions around U.S. free trade agreements, specifically with Colombia and Panama. Rep. Mack said he was “excited to hear in the State of the Union that this is something we can work on in a bipartisan fashion” and that he will be introducing legislation to push Congress to move on free trade issues. And Senator Gregg raised the question about whether we have “the best technology and best capability so that the support is there for the people…in the field.” It’s great that both of these issues were raised and they deserve more attention as the Congress and executive branch work together on U.S. development policy.

All in all, the hearings were the first steps in the long budgetary process and development policy reform efforts underway. They serve as a first opportunity for Congress and others to get more detail on the numbers and the policies and priorities behind them. I’m glad that in the mish-mash of topics, we still heard resounding support for investments in international affairs and many of the steps we all know we need to take—from more impact evaluation to better coordination across the U.S. government—to make sure we are getting the biggest bang for our buck. Let’s hope the hearings last week are the start of longer conversations and a joint process between the executive branch and Congress to reach the “grand bargain” many are hoping for on the mission, mandate and management of U.S. development, and foreign assistance, policy.

Next up: Raj Shah, USAID administrator, will testify before the House Foreign Affairs Committee on Wednesday morning, March 3 and before the House Appropriations Subcommittee on Foreign Operations on Thursday, March 4. What would you ask him if you were a member of Congress? And stay tuned, because MCC CEO Daniel Yohannes and U.S. Global AIDS Coordinator Eric Goosby will head to the Hill later this month to defend their agency budget requests.

The January 12th earthquake in Haiti is the most lethal natural disaster of the past 20 years. On February 12th, the Associated Press reported that official Haitian government estimates of the dead had been revised upwards, now reaching 230,000 dead. Furthermore, the number could be much higher, since the government admits they have not yet been able to count all the bodies and they have excluded those buried by families or in private cemeteries. As the figure below shows, this new total surpasses the 225,000 dead in the 2004 Indian Ocean tsunami, and dwarfs the death tolls from recent earthquakes in Pakistan-controlled Kashmir and Sichuan, China.

A catastrophe’s death toll can also be measured in relation to the total population. The bars in the next chart show the deaths as percentages of the total populations of each relevant area. For the 2004 Tsunami in the Indian Ocean, the largest death toll was in the Indonesian province of Aceh on the island of Sumatra, where three percent of the population died. The 80,000 deaths in the Pakistan earthquake represented .4 percent of the population Pakistan’s Northwest Frontier Province. The Chinese and Burmese catastrophes killed fewer than one percent of the populations of the surrounding areas. In contrast, the Haitian earthquake killed 11.5 percent of the approximately two million people living in the immediate area of Port-au-Prince, which comes to 2.5% of the entire national population.

So in relative terms also, Haiti’s earthquake surpasses any of these natural disasters which have occurred in other countries.

Finally one can compare the mortality from the earthquake to the mortality from other causes of death which afflict Haiti or have swept the world. The largest cause of mortality in Haiti for the last decade has been the HIV/AIDS epidemic. In 2007, the last year for which UNAIDS has published data, an estimated 7,500 people died of AIDS in Haiti. The earthquake killed 30 times that many Haitians in a few days.

Other notable worldwide epidemics have been the bubonic plague in 1350 and the 1918 influenza epidemic. The first killed somewhere between 30% and 60 % of the population of affected European countries and the second between 3% and 6% of the entire world population. Thus for Haiti as a whole, the earthquake has had a mortality impact comparable to the 1918 flu epidemic and for the most affected region around Port-au-Prince the impact is comparable in magnitude to that of the bubonic plague in a less affected country of Europe.

Students of the bubonic plague of 1350 believe that its longer term repercussions on society were profound, including a general loss of faith in religion, a loss of respect for hereditary authority in general and the state in particular, the empowerment of the middle class and increases in the ratios of capital and land to labor resulting in increased wages for the poorest. While parallels between that continent-spanning catastrophe and the much more focused event in Haiti are risky, it is not hard to believe that Haiti will be a very different place in ten years than it would have been without the earthquake. Let’s hope that it is a better place, not a worse one.

This post first appeared as a news item in CGD’s Evaluation Gap newsletter. Sign up for the Evaluation Gap and other CGD newsletters here.

Last week, I participated in an event at the Center for Strategic and International Studies (CSIS) in which U.S. Food and Drug Administration (FDA) Commissioner Margaret Hamburg announced a remarkable shift in the FDA’s thinking on food and drug import safety. If adequately supported by Congress and translated into concrete action, this change in strategy on food and drug safety could have significant benefits for U.S. and global health and development.

As I have discussed in depth elsewhere, food and drug safety are now global health programs. Unsafe food and drugs exact a staggering human and economic toll in developed and developing countries alike. Contaminated and adulterated food and drug products sicken and kill millions of consumers in the U.S. and elsewhere each year, fuel protectionism, raise business costs, and undermine development.

In this context, the health of U.S. citizens is interdependent with the health of other states’ citizens. The unsafe products we consume domestically are often the same products we export to other nations; the same is true for our trading partners. Given the increasing complexity and volume of the global trade in these products, no one country or national regulator alone can ensure the safety of food and drugs used by its citizens.

Ensuring the safety of foods and drugs requires strategies and tools similar to those used to successfully address other global health threats, like infectious diseases, that cross borders with trade and travel. Sustainable progress with those tools and strategies depends on the cooperation of trading partners, industry, and the multitude of entities involved in the international commerce and regulation of food and drugs.

Commissioner Hamburg’s speech last week reflected a new, high-level recognition at the FDA of the global nature of the food and drug safety problem. In addition to announcing an important new risk-based assessment tool, the Commissioner argued that it is no longer appropriate to think of unsafe food and drugs as “international or domestic [issues], but as common problems in a dramatically fluid and interconnected world, and the same kinds of strategies that we need to apply internationally, we need to apply at home – the shift from a reactive mode to a preventive mode, the focus on really assuring the safety and security of the supply chain, the notion of working in critical partnership with both industry and, domestically, with state and local health authorities.” Maintaining that the FDA could no longer “inspect its way to safety” in an era of increasing global trade, complex products, and transnational food and drug supply chains, the Commissioner stated

Now is the time for FDA to fully engage bilaterally, multilaterally and through international and regional organizations to work with countries throughout the world to share scientific and technical expertise, to harmonize international standards for safe food, drugs and medical products, to work with industry to enhance compliance with standards and, very importantly, to help countries with less mature economies and regulatory systems build capacity so that they can produce food and commodities that are safe, wholesome and meet international safety standards – both for their own consumption and for export.

Achieving that vision will not be easy. To start, Congress must pass pending food and drug safety legislation and give FDA the tools and resources it needs to work with our trading partners, particularly developing countries, to improve inspection and quality control of food closer to its place of origin and coordinate food and drug safety efforts with trading partners and regional and multilateral health and economic institutions. More targeted, effective measures are needed to encourage U.S.-based retailers and manufacturers to adopt stronger prevention, surveillance, and control of their supply chains and supplier and producer partners. U.S. efforts on food and drug safety must leverage and support international and intergovernmental resources and tools, particularly on issues of regulator interoperability, information exchange, and cooperation.

The potential implications of this new thinking for global health and development would be profound. The U.S. market has significant influence on food production and drug manufacturing practices globally. Today, 20 percent of all foods consumed in the United States originate outside our borders. As much as 40 percent of the medicines that Americans take and roughly 80 percent of the active pharmaceutical ingredients in all drugs sold in the U.S. originate from foreign sources. The FDA regulates all U.S. drugs and 80 percent of the U.S. food supply. In all, the FDA regulates nearly 20 million shipments of food, devices, drugs and cosmetics imports from more than more than 150 countries, 130,000 registered importers, and 300,000 foreign facilities. Even beyond its market influence, FDA is widely admired internationally and its practices emulated by regulators worldwide.

One important caveat is that the U.S. must be careful to consider the legitimate expectations and needs of developing countries in formulating its approach. Agriculture is an important, and sometimes singular, area of comparative advantage for many developing countries. Congress and the FDA should consider funding appropriate mitigation strategies and initiatives to help reduce costs for small and medium-sized developing country producers to comply with stricter food standards.

In the end, Commissioner Hamburg’s vision on food and drug safety is the right one. There is a pressing need for the U.S. and its trading partners to engage on global food and drug safety; the mandate for doing so has become nothing short of enlightened self-interest.

Success does depend on “crowding in” other funders’ investments, but under some scenarios the $10 billion could actually “crowd out.” Bilateral donor agencies, who themselves are fighting a tough budget climate, might breathe a sigh of relief thinking that they can hold at historical spending levels or even pull back from GAVI, and Daddy Healthbucks will save the day. Governments in GAVI-eligible countries, which under current rules now provide a co-pay for every dose of vaccine, might drag their heels a bit on moving toward greater levels of financial self-sufficiency. “Why are we chipping in 10 cents for every jab,” a Minister might ask, “when Bill Gates can afford $10 billion?” Even industry might think that they can cut a more favorable deal on both prices and support for R&D through product development partnerships.

But I expect that the Gates Foundation will use the resources in ways specifically designed to leverage others’ investments, and to lower the costs of getting vaccines to market and then to kids and teens. Accomplishing this will require a combination of incentives and institutional improvements to make all the dollars for vaccines and immunization work as hard as possible. What follows is pure speculation, but maybe they will:

• Put up all new contributions to GAVI in the form of a match: For every dollar GAVI raises from other sources, Gates could match it 1:1. (Interesting research shows that matching strategies are effective, but there’s no benefit from higher matching levels.) If particular types of contributions – say, support from private individuals – merit greater emphasis by GAVI’s resource mobilization team, the match could be higher as a special motivator to the organization.
• Invest in strengthening and streamlining the regulatory infrastructure, both globally and – very importantly – within the countries that are home to emerging manufacturers (Indonesia, India, Brazil). Ditto for clinical trials capacity and platforms that can be used for the development of multiple vaccines as time goes by. Bringing down the costs of developing these products, which is not as significant an issue in the price-insensitive markets, is high priority.
• Create the Maurice Hilleman Global Vaccine Prize, named after the remarkable microbiologist who developed more than three dozen vaccines. The prize could recognize achievements of scientists who have made major contributions to the development of vaccines that specifically benefit low-income countries.
• Explore whether and how strategic investments or incentives can hasten the development of joint ventures and other collaborations between multinational research-based firms and capable emerging manufacturers. Over the long term, moving to a high-scale/low-cost model of production is the route to vaccine affordability, regardless of whether the payers are national governments or donors.
• Recognizing that the health of the vaccine market globally is essential to the continued and diversified supply of vaccines for the poorest, make a one-time contribution to the Pan American Health Organization’s Revolving Fund to manage the introduction of higher-priced vaccines to the middle-income countries of the region.
• Create a 10-year Global Health Policy Fellows program, modeled on the Robert Wood Johnson Foundation Health Policy Fellows, to place mid-career global health professionals within Congressional and Executive branch offices. No amount of advocacy from the outside for health aid can replace dedicated, value-adding expertise on the inside. And the eventual network of Policy Fellows would be the next generation of policy movers and shakers.
• Endow immunization advocacy organizations in key countries, like Nigeria, where voices outside of the government are essential to keep the pressure on for immunization performance, and to counter the proliferation of negative messages about vaccines. An endowment rather than a grant is particularly important, so that the organizations can credibly say they are independent of a particular outside agenda.
• Work with the leadership at the World Health Organization and UNICEF to reinforce capacity for processes like developing evidence-based recommendations about vaccination schedules, prequalifying vaccines, issuing tenders, forecasting demand and more. Look at all the bottlenecks and focus resources on eliminating them.
• Create an innovation prize not for a vaccine but for a technology that will make many vaccines more usable in developing country contexts, such as for needle-free administration.

Oops, I think I just spent $10 billion!

These are just a few of the possible ways that the generosity of a lead donor can be extended and amplified. I suspect that cleverer ideas are being cooked up out there on the shores of Lake Union – and by some of our blog readers. Please use our comments feature to offer up your own thoughts.

More on the FY11 Budget

• Development and Obama’s Budget; Interview with CGD’s Sarah Jane Staats
• Obama’s First Budget Request: Modest Increases but Strong Signaling for Development
• MCC Slated for $1.28 Billion in FY2011 Budget Request
• Todd Moss’ Expert Commentary on President Obama’s 2011 Budget Request

Yesterday’s release from the White House of the FY2011 budget and a simultaneous release of a consultation draft of the Global Health Initiative (GHI) by the State Department signal a strong commitment and evolving action plan from the Obama administration for global health engagement in 2011 and beyond.

Funding commitment: Putting $9.6 billion in to perspective
With the $9.6 B requested for global health for 2011 the Obama administration is increasing its financial commitment for global health, despite the many competing domestic and global priorities in the 2011 budget. That says something about this administration’s willingness to continue the very good trend that President Bush put in to place with PEPFAR in 2003. A quick look at the graph (with a shout out to Jen Kates and her team at the Kaiser Family Foundation for providing this as it comes hot of their press!) below shows a greater than 5 fold increase in U.S. funding for global health from 2001 to 2011.

The bulk (almost $7B of which is PEPFAR, including $1B for the Global Fund) of the funding is for HIV (details of the budget for global health can be found here) but the GHI is setting for itself a broader set of global health goals, making it more ambitious than PEPFAR, and potentially more responsive to a range of global health priorities in countries of greatest need. 

Ambitious Targets
The draft strategy is ambitious, to use the administration’s own adjective for its targets:
“We have set out ambitious targets to inspire an intensive effort. While specific targets will be established at the country level, the GHI is expected to achieve the following aggregate goals by the time performance can be measured in 2015.” Full details of these targets and their specific timelines may be found in Annex A of the draft strategy (Page 12 and 13) but a few highlights of the targets and goals from this strategy are listed below as a snapshot of the challenge ahead:

HIV/AIDS: PEPFAR will: (1) support the prevention of more than 12 million new HIV infections; (2) provide direct support for more than 4 million people on treatment; and (3) support care for more than 12 million people, including 5 million orphans and vulnerable children.
Malaria: Reduce the burden of malaria by 50 percent for 450 million people, representing 70 percent of the at-risk population in Africa. This effort will include the expansion of malaria efforts into Nigeria and the Democratic Republic of Congo.
Tuberculosis (TB): Save approximately 1.3 million lives by reducing TB prevalence by 50 percent. This will involve treating 2.6 million new TB cases and 57,200 multi-drug resistant (MDR) cases of TB.
Maternal Health: Save approximately 360,000 women’s lives by reducing maternal mortality by 30 percent across assisted countries.
Child Health: Save approximately 3 million children’s lives, including 1.5 million newborns, by reducing under-5 mortality rates by 35 percent across assisted countries.
Nutrition: Reduce child undernutrition by 30 percent across assisted food insecure countries in conjunction with the President’s Feed the Future Initiative.
Family Planning and Reproductive Health: Prevent 54 million unintended pregnancies. This will be accomplished by reaching a modern contraceptive prevalence rate of 35 percent across assisted countries, reflecting an average 2 percentage point increase annually, and reducing to 20 percent the number of first births by women under 18.
Neglected Tropical Diseases (NTDs): Reduce the prevalence of 7 NTDs by 50 percent among 70 percent of the affected population, contributing to: (1) the elimination of onchocerciasis in Latin America by 2016; (2) the elimination of lymphatic filariasis globally by 2017; and (3) the elimination of leprosy.

Your chance to influence a major U.S. foreign assistance initiative
This is a tall order and the administration needs your help to think through issues of implementation and measurement of results for success. For example, are these targets the right metrics of success? Many of us criticized PEPFAR for focusing on counting numbers treated and numbers cared for rather than on a decrease in deaths due to HIV and a decrease in new infections in a given population. So, what’s different about these targets? In a refreshingly participatory process, this administration has called for your comments on the Global Health Initiative’s draft strategy. My colleagues at CGD and I will comment on specifics about the GHI strategy as we digest its different components. Send your useful and practical comments (read as–best to stay away from pushing for more money in this economic climate!) to ghi_comments@state.gov by February 22^nd. Let’s see what and how well we can do with the billions we have for global health. It’s an opportunity to contribute to the making of a major US foreign assistance program, so let’s try to get it right—that is achieving the targets laid out (relative to need by country and available budget) and being able to measure these to demonstrate success. And if you are inspired and want our readers from around the world to know what you have shared with the U.S. government, feel free to post your comments here as well.

Two award-winning journalists spent the better part of 2009 taking a global tour of drug resistance. The sights they found were astonishing – and terrifying. I spoke to one of them, Margie Mason, shortly after their five-part series entitled “When Drugs Stop Working: An Emerging Threat to Global Public Health” ran in newspapers around the world—unfortunately, in my view—during the week between Christmas and New Year. CGD has been tracking Margie’s journey and providing background information to her since she set out. Margie explained,

I was surprised by some of the things we found: I had no idea antibiotics were sprayed on fruit trees, and injected into palm trees. We also found there are 700 antibacterial or antimicrobial products on the market. Do you really need antimicrobial slippers and chopsticks?

You’ve got to admire Margie, a recent recipient of a Nieman Journalism Fellowship at Harvard University, and her Pulitzer-prize winning co-author, Martha Mendoza. This topic doesn’t exactly lend itself to the 3 paragraphs, 1 column format of USA Today. It’s complex, it’s hard to find the victims since many of them don’t know they have a drug-resistant disease, and there’s no smoking gun. “Drug resistance is not immediate”, explains Margie. “It’s a slow, silent moving problem with many different aspects…it’s a truly global problem, and one that everyone is contributing to.” She continued,

Drug resistance was a real challenge to report on. It’s such a big issue and we tried to simplify and make it interesting to read about. There have been piecemeal stories but no-one has pulled it together in a comprehensive package. Our task was how to find things that haven’t been reported.

Our star gumshoes succeeded at that. In their first article—a breaking story that had never been made public—Mason and Mendoza reveal the first case of highly drug-resistant tuberculosis (coined XXDR-TB) in the U.S. They describe 19-year old Oswaldo Juarez’s struggle with the highly contagious and aggressive disease during his visit to Florida from Peru. Although XXDR-TB had never before been seen in the U.S., Dr. David Ashkin, one of the nation’s leading experts on tuberculosis and the medical director at AG Holley, the quarantine hospital where Juarez lived for a year and a half, explains that the case of Mr. Juarez “Really is the future. XXDR tuberculosis is so rare that only a handful of other people in the world are thought to have had it. This is the new class people are not talking about.”

The capacity for TB to evolve into more aggressive and resilient strains is, in the words of Dr. Masae Kawamura, who heads the Francis J. Curry National Tuberculosis Center in San Francisco, “a time bomb…a man-made problem that is costly, deadly, debilitating, and the biggest threat to our current TB control strategies.”

Margie’s take on it?

The story of the kid in Florida was an incredible tale from a journalistic standpoint. We were trying to find XDR-TB in the U.S. There are a handful of TB centers across the country. AG Holley [a former TB sanitarium in West Palm Beach, Florida] is like a museum with all the old equipment. There are dark corridors, now without patients lining the walls, but where you can close your eyes and imagine yourself in another century. There are incredible patients there from all over the world. We met an Indian woman who came to the AG Holley with resistant TB and was separated from her newborn for eight months.

The two reporters’ drug resistance world tour tells of similarly heart-stopping sights elsewhere with the freshness that comes from seeing the problem for the first time. Frankly, it’s a welcome change from the scientific journals that produce almost all of the available knowledge about resistance. The journalists’ labor poured out over five days in late December, starting with Oswaldo’s story.

• Day Two: The first evidence of resistance to artemisinin combination drugs for malaria in Thailand – the same corner of the world where resistance to earlier malaria drugs began, and then spread worldwide.
• Day Three: The use of antibiotics in agricultural practices – amounting to 245 million tons of antibiotics consumed by animals in the U.S. alone.
• Day Four: The emergence of drug-resistance strains of HIV in South Africa – new and more resilient strains of HIV are being detected in roughly 5 percent of new patients in Africa, with higher resistance rates found in the U.S. and Europe.
• Day Five: The link between reduced antibiotic use in hospitals and better health results in Norway – while more than 65,000 people die of hospital-acquired infections annually in the U.S. alone.

Throughout the series, Margie Mason and Martha Mendoza compile personal stories, statistics and expert opinion to describe the dangerous capacity for medicine use to go wrong and create highly-resistant strains of infectious diseases. They conclude, “Forty years ago, the world thought that it had conquered TB and any number of other diseases through the new wonder drugs: antibiotics. Today, all the leading killer infectious diseases on the planet are mutating at an alarming rate, hitchhiking their way in and out of countries.”

Did they arrive at this conclusion because their reporter instincts lead them to invent a crisis? No, these conclusions come straight from sober scientists. Dr. Tom Frieden, director of the U.S. Centers for Disease Control and Prevention, and a veteran of the fight against resistant TB in the U.S. asserted, “If we’re not careful with antibiotics and programs to administer them, we’re going to be in a post antibiotic era”. Margie and Martha also quote Norway’s MRSA Control Director, Dr. Petter Elstrom, who is apprehensive about the multi-drug resistant strain of Staphylococcus aureus—commonly dubbed MRSA. “So far we’ve managed to contain it, but if we lose this, it will be a huge problem. To be very depressing about it, we might in some years be in a situation where MRSA is so endemic that we have to stop doing advanced surgeries, things like organ transplants, if we can’t prevent infections. In the worst case scenario we are back to 1913, before we had antibiotics.”

Margie’s first-hand assessment is down-to-earth.

These strains are even scarier in the developing world. They can’t get treated. You can talk about these things and make plans about prevention and treatment. But when you see the setting you realize how challenging it is to make things work. These people are moving around all the time, they are poor.

Margie explained also that she was overwhelmed by the sheer scale of the problem.

I’ve been having dreams about drug resistance, waking up thinking about it. We’ve read books, interviewed hundreds of people. There’s just so much. We tried to hit on as many of the big issues as we could, but there are many others. We didn’t get into advertising or talk much about all the incentives paid to doctors to prescribe drugs. I’ve heard all kinds of anecdotes about what people get for prescribing drugs. We’re very quick to blame poor countries but in this case it’s a truly global problem, and one that everyone is contributing to.

There are, however, some glimmers of hope. In her interview with me, Margie noted the example of a Japanese doctor, who, after realizing that the nation’s seemingly ultra-modern, sterile facilities revealed MRSA levels that were among the highest in the world, changed his practices to reduce the frequent use and dissemination of antibiotics—and got positive results. Margie and Martha finish the series with a story about hospitals using amplified precautions (including universal screening programs) to reduce hospital-acquired infections in Pittsburgh. “There are ways to control this; it’s not a doomsday scenario,” Margie reports, adding that “there is more awareness now than a long time ago.”

Awareness, such as that generated by the AP series and similar articles, will be crucial in stemming the spread of once curable drug-resistant diseases across the world. To learn more, sign up for our monthly newsletter on drug resistance. It will direct you to the consultation draft report of the CGD Working Group on Drug Resistance. This is a manageable problem if only we all are willing to take the world tour with Margie and Martha.

With a full compact pipeline at the ready, the MCC’s FY2011 resources are lined up for compacts in Indonesia, Malawi, Zambia, and the first-ever second compact in Cape Verde. Malawi was named compact-eligible in December 2007 while both Indonesia and Zambia were selected as compact-eligible in December 2008. Cape Verde was re-selected as eligible for a second compact in December 2009. These compacts will follow FY2010 compacts in the Philippines and Jordan.

Given that the FY2011 MCC request is $145 million lower than the FY2010 request, it will be important to secure strong congressional support from Democrats and Republicans to maintain something close to the president’s request level, which is reasonable for the MCC’s expected operations in FY2011. Senators Kerry and Lugar have taken a strong first step in that direction with their recent letter of support and guidance for the MCC. Hopefully they and other members of Congress will ensure that the MCC is able to keep innovating and delivering results on its unique model of development assistance.

On a side note, my colleague tells me that the Treasury Department hosted a conference call today with members of the development community to walk through and answer questions on their portion of the budget request. This is a fantastic idea and it would be great if the MCC were to do the same in the coming days.

On Friday, MCC CEO Daniel Yohannes announced my appointment as the Corporation’s Vice President of Policy and International Relations. I am both honored and excited to assume that position on Monday and work with the CEO and the immensely capable staff of the MCC on an exciting set of issues aimed at enhancing the organization’s effectiveness. It is, of course, a bittersweet moment for me. I have also been hugely honored to be a part of CGD and given the space and support to think, write and build a program that I hope has helped people better navigate U.S. foreign aid issues and helped foreign aid agencies stay true to their missions.

I want to especially thank you all for your thoughtful comments, both online and off-line. They have both informed my analysis and inspired me personally. It is much of what has made this job so much fun. The Rethinking U.S. Foreign Assistance Program and blog will continue, with posts and analysis from CGD senior staff. And before you know it, there will be a new Director you will know and love and soon be saying, “Sheila who?” 

Thanks again to all of you for your attention and support through the years. I trust our paths will cross again and that I will benefit, on “the other side,” from your continued monitoring of the MCC!

–Sheila

You can read the letter in full but the key messages to CEO Yohannes from the senators are:

1. Stick to the original mandate. In short (and more diplomatically put in the letter): don’t lose your focus — the MCC mandate is promoting growth and fighting poverty in a select group of well-performing countries. A substantial part of the letter is dedicated to advising against MCC funds to middle income countries like Colombia and Albania (who arguably have greater access to private finance and other U.S. government foreign aid accounts, as well as fewer poor people). 

2. Be distinct from but coordinate with others. Kerry and Lugar argue the success, innovation and results of the MCC are partially due to MCC’s relative independence from the rest of the aid apparatus and its ability to create its own systems, concepts and policies. (Not mentioned, but hugely important to its effectiveness is that its funds are not subject to congressional earmarks.) That said, U.S. foreign assistance would benefit from better coordination between agencies and the MCC should complement U.S. foreign policy, but Kerry and Lugar “are not in favor of merger or consolidation” and believe strongly that the MCC should maintain its focus as an indicator-based development agency. 

3. Rethink the threshold program. Muddled mandates, diffuse results and an unclear threshold country selection processes cause Kerry and Lugar to call for an overhaul of the program. Among the big questions are whether it should focus on countries at the “tipping point” of eligibility, or should be a longer-term program to improve policy performance over time. They give the MCC wide berth to consider major changes to this program.

4. We will support a request for concurrent and longer-term compacts. Kerry and Lugar express their support for the MCC’s requests to undertake concurrent compacts and to extend, where warranted, the length of existing compacts beyond the strict 5-year limit. (Indeed, I understand that their draft State Department Authorization Bill contains such language.) They are not as positive on requests for regional compacts, something asked for by the prior administration, but do allow some running room to for the MCC to explore regional approaches within individual compacts.

5. Keep on innovating, but build on comparative advantage. Kerry and Lugar want to see more emphasis on using civil society and the private sector to generate project ideas and undertake implementation. And they encourage the MCC to consider “bold and creative project ideas.” (Unfortunatley, more precision on what that means is not included in the letter.) At the same time the senators give the MCC some running room to keep on innovating, they caution against abandoning the MCC’s “comparative advantage in U.S. foreign assistance” in implementing economic growth programs and large-scale infrastructure related projects.

Most of this will be seen as welcome support and insight into the challenges that Mr. Yohannes and his management team will be navigating in the coming months. MCC staff have been grappling with many of these issues internally for some time now, and it’s good to see leadership in Congress maintaining strong support for the MCC model, while acknowledging and pushing the MCC to take on key reform issues to deliver on the model’s promise. Above all, the senators are reaching out a hand of support to the new team. The new MCC management team should grab that hand of support and, in partnership with Congress, tackle reforms specific to the MCC and related to other U.S. foreign aid programs. Such an approach will also help the MCC team more fully understand the boundaries of each of the five points above and perhaps discover, together, additional ways to help the MCC overcome the constraints of the current model.

I suspect one of the big challenges not mentioned in the letter will be ensuring congressional support for the MCA during a tough appropriations cycle. We hear that national security budget items, including the 150 account and MCC funding, will be exempt from the federal spending freeze. While this is a strong signal from the administration of the critical importance of U.S.development investments on both domestic and global security and prosperity even in difficult financial times—it also runs the risk of putting a bulls-eye on accounts like the MCC when the extremely difficult work of meeting appropriations needs across the entire budget begins.

The MCC will need to redouble its efforts to not only stick to its mandate and maintain the model, but also focus on increased selectivity, continue to demonstrate results and execute a strong communications strategy with the Hill—with both supporters and skeptics—and the major development reviews underway.

What challenges do you think the MCC will face in the coming months?

The good: Exempting national security spending, including the foreign affairs budget request–the 150 account–from the freeze signals strong support from the administration for the critical importance of our diplomatic and development efforts for security and prosperity at home and abroad.

The outpouring of support in response to the Haiti earthquake shows yet again the empathy and compassion of Americans for their fellow man, whether or not they live within our borders. This kind of surge in support for an emergency response is often hard to sustain and takes leadership from the White House and beyond. So it is great to see that the Obama administration is taking clear steps in the budget and in policy reviews to maintain and strengthen long-term development programs in its own best interests.

The bad: Exempting these accounts from the rest of the freeze means they remain a pot of discretionary spending that can be redirected as Congress struggles to fund a variety of other priorities. In many ways the exemption–while still causing sighs of relief right now in the development community–puts a big bull’s eye on this particular pot as ripe for pilfering.

Avoiding the ugly: The unenviable task ahead for Congress to make ends meet with a heavily constrained budget means the domestic politics around the international affairs budget could be hell. For several years we’ve seen growing bipartisan support for U.S. international affairs programs as increasingly vital to U.S. national security and American well-being, as well as reflecting American generosity and a belief in opportunity. The fear is that the current political climate, an election year, and a really tight budget could see a return of ugly partisan politics over these issues.

Either way, there is a real risk that the good intentions of protecting the international affairs account could backfire. It’s worth remembering—as budget guru Larry Nowels  pointed out to me—that the last time the U.S. took a meat-ax to the 150 budget in the 1990s, it fell 25 percent in real terms over five years and it took a decade and 9/11 to recover.

The trick is going to be navigating the political waters carefully and with continued leadership on the development issues. I hope tonight we’ll hear more than talk of what’s in and out of the spending freeze and that President Obama will make the case (as Secretary Clinton did in her CGD speech earlier this month) that engagement with the rest of the world matters for Americans, even in these difficult times. And that the relatively small 150 account, compared to the rest of the U.S. national security budget, is one of the more cost-effective national security tools in our arsenal.

President Obama and his team will need to keep singing this tune in the coming months, and be backed up by a congressional chorus with leaders from both sides of the political aisle to help avoid the ugly, so our policies—and purse—reflect American smart power in an increasingly interconnected world.

Wow! A vaccine this efficacious would be cause for celebration.

But medical researchers distinguish between the efficacy and effectiveness of an intervention. An intervention, they point out, can be wonderfully “efficacious” under the controlled conditions of a randomized controlled trial (RCT), but might fail miserably in the typical setting for which it is designed.

Last week I had the pleasure of participating in a workshop that gathered many of those involved in planning or potentially evaluating the rollout of medical male circumcision in the countries of Botswana, Kenya, South Africa, Swaziland, Zambia and Zimbabwe. Sponsored by the Bill and Melinda Gates Foundation, the workshop in Johannesburg was partly to expose all of these policymakers and researchers to the latest efficacy information – and to a new device for male circumcision called the ShangRing – and partly to consider how the planned rollout of male circumcision in each country should be evaluated.

One view, held by some of the researchers at the meeting, is that medical efficacy has already been evaluated by rigorous randomized design so there would be little benefit in further rigorous evaluation during scale up. In particular there is no need, they felt, to use HIV incidence as the endpoint of any future evaluation activity. All that is necessary is routine monitoring and operations research to determine how to deliver circumcision as efficiently as possible. They came to this conclusion because (1) they think that the efficacy is now virtually a biological certainty and (2) they think that any problems with effectiveness could be picked up by simply counting the number of circumcisions performed and the frequency of adverse events, without checking HIV incidence.

The contrary view is that the range of possible reductions in vulnerability suggested by the three existing trials of 38 % – 66 % leaves room for substantial concern. In actual practice, perhaps the benefits would be even smaller than a 38 % reduction in risk. For example, maybe during the rollout only those whose sexual practices are already safe would choose the intervention. If this is the case, then counting successful circumcisions without noting HIV infections would overestimate the national effectiveness of the program – and leave policy makers puzzled by the continuing momentum of the epidemic.

In a presentation on the application of the concept of statistical power to evaluating the effectiveness of interventions, Sergio Bautista and I proposed that the design of an evaluation of a program rollout can and should differ from the evaluation of the medical efficacy of the same intervention in several dimensions, each of which would inform an important policy question:

External validity

While a medical efficacy RCT, such as those done for male circumcision, is intended only to achieve internal validity, the evaluation of a large-scale rollout needs to establish internal validity and external validity. Internal validity is necessary to be sure that the outcomes can be attributed to the intervention. Getting information on the context and conditions under which the program is rolled out is necessary for judging the external validity of the findings, so that results can be applied to estimate the program’s effectiveness on the whole country.

Cost-effectiveness threshold

Since a medical efficacy RCT should and usually does ignore costs, it need only have the statistical power to reject the hypothesis that the intervention is no better than competing interventions. However, given the costs of achieving and sustaining high coverage of adult male circumcision in African countries, policy makers need to know that its efficacy is large enough to render it cost-effective in relation to other interventions. Application of the male circumcision planning model created by Lori Bollinger and colleagues of the Futures Institute calculates that through the year 2015 at 60 % effectiveness MC will cost $1,560 dollars per HIV infection averted, while at 20 % effectiveness MC will cost $4,917 per HIV infection averted. The former figure is attractive, the latter not so much. So instead of just rejecting a null hypothesis of no effect, policy makers might be interested in rejecting the hypothesis that MC is 20% effective or less. This is a more difficult hurdle for MC to clear, but could potentially be answered with the large samples that are available in a full-scale rollout.

Standard of care is a more defensible counterfactual in a rollout

Because standard IRB ethical standards required that the MC efficacy trials provide other HIV prevention interventions to those who did not receive the MC, the RCTs may have underestimated the effectiveness that male circumcision would have in a real setting, where these other HIV prevention interventions are less accessible. But an effectiveness evaluation of a rollout would typically compare the effect in those communities that first receive the intervention first to that in the communities that receive it later. Until they later receive the rolled out MC, those in the comparison group will be getting no more than is typically available in the country. So the measured impact of MC is likely to be larger in this setting than in the RCTs.

Determinants of effectiveness

Policymakers will want to know how they can maximize the effectiveness of MC. In the course of a full-scale rollout, there will be natural variation in various factors that influence both the supply and demand side of MC. A selected few of these factors can be singled out for experimental variation and the rest can be studied with non-experimental methods. Lessons on the determinants of effectiveness will help those managing the MC program, but would rarely result from efficacy evaluation studies alone.

Secondary outcomes and their determinants

Among the most important potential “spillover” effects of MC are (1) compensating risk behavior that might offset the benefits of MC; (2) infection rates among the female partners of the circumcised; (3) the effect of massive numbers of male circumcisions on the availability of and access to other types of health care; (4) the variation in unit cost of MC as health facilities first become more efficient (due to increasing scale and learning by doing) and then less so (due to decreasing returns); (5) the reproductive rate of HIV in the whole community as MC coverage increases. The efficacy trials found cause for alarm on the first of these indicators in one of the three studies, but were unable to consider the other four issues. Effectiveness trials can hope to examine all five - and with much greater external validity than could be achieved in a small RCT.

With all the benefits of rigorous evaluation of full-scale rollout, it would be unconscionable not to undertake such studies. Years ago, the feasibility of such studies might have been questioned on many grounds: financial, methodological, political, and ethical. But despite difficulties, these excuses can no longer be sustained. Bill Savedoff reminds me that public agencies and foundations are beginning to provide substantial sums of money to rigorous impact evaluations, including through the recently created International Initiative for Impact Evaluation (3ie). Researchers have demonstrated the feasibility of evaluating large-scale programs, most dramatically with rollouts of national conditional cash transfer programs. Even the political and ethical dimensions of these evaluations have been confronted and worked out by researchers and policymakers, especially those who are native to the countries in question, who recognize that their need to know the answers to the above questions is sufficiently important to society as to justify the effort of explaining the studies to the public and protecting a rigorous evaluation design.

Indeed, Moldova’s Compact is a testament to careful planning and an impressive level of project integration. Investments in Moldova will focus on irrigation infrastructure, high-value agricultural production, and road rehabilitation. These projects will all work together to increase local rural incomes and promote economic growth. Rural producers will now be able to successfully produce profitable fruits and vegetables, appropriately market them, and reliably transport them to market.

Added to this is an additional layer of improved access to credit and technical assistance. While prior compacts in Madagascar, Benin, and Morocco included financial access projects, Moldova’s innovative financing facility appears to be a step-up in terms of integrated value-added to the program. It will support related investments by farmers and entrepreneurs in the shift to higher value agriculture production, post-harvest processing, storage, and marketing. This package is co-financed by USAID. We look forward to keeping an eye on this as a model for future compacts.

Moldova’s previous $24.7 million Threshold program focused on anti-corruption by strengthening the capacity of the judiciary, increasing the monitoring capacity of civil society and the media, and curbing corruption in the tax, customs and police services. It succeeded in reducing the number of bribes connected with getting favorable judicial decisions and improved public reporting of corruption cases by the Moldovan media.

Since its release in December 2009, specific pieces of PEPFAR’s new strategy have triggered much discussion both in Washington, D.C. and abroad. In the spirit of sharing-while-doing, Ambassador Goosby spoke at a Center for Strategic and International Studies (CSIS) event on Tuesday on “Confronting the Tough Challenges in HIV Prevention,” focusing his remarks on HIV prevention in the strategy.

As outlined in the strategy and stressed in Goosby’s comments, PEPFAR’s main goal towards prevention is to match as aggressive of a response as was launched for treatment in its first phase. This includes working with governments to map the prevention needs of a country, using high-impact, evidence-based approaches—including biomedical, behavioral and structural interventions—that are also linked to care and treatment programs. The strategy lays out the steps for countries to develop a basic package of prevention, but Goosby’s remarks did not hide the fact that there is still much more to learn. Questions raised by Goosby and the audience centered on PEPFAR’s efforts to ensure that prevention interventions are effective and geared towards the right populations, actually work to reduce incidence rates, and are cost-effective in their scale-up.

This administration’s plan for a more sustainable and effective resource allocation for treatment, care and prevention is promising. To be successful PEPFAR must work with countries to tackle the challenges to prevention as they launch an aggressive prevention response. Three big challenges for the U.S. administration to think about as it enters the implementation phase of the new strategy:

1) Scale-up: How do you scale-up prevention efforts? What does a scale-up plan look like for a given country?

While the strategy is good in defining the approach to prevention, it does little in the way of defining the operational features needed to actually expand prevention efforts (i.e., roll-out, monitoring and evaluation, etc.). For example, many prevention interventions are initiated at the community level, especially to tackle risks related to individual behavior, so what is the process for expanding these interventions and approaches across a region or country in a way that will result in the reduction of new infections? Perhaps the evolving guidance and country operational plans (COPS) will be more specific about prevention scale-up by country?

2) Metrics: How to measure prevention success?

There has been a general lack of information on prevention metrics, both in PEPFAR’s past, as well as in this new strategy. However, if prevention is truly going to be a defining feature of the Obama administration’s approach towards global HIV, there need to be measures in place to identify and show—both to Congress and to its beneficiaries,—PEPFAR’s progress in averting infection.

I asked this question at Tuesday’s event, and Dr. Goosby realistically noted that measuring effects on incidence takes time. Given that it’s hard to measure something that does not happen, it was encouraging to learn that PEPFAR is developing “surrogate markers of incidence” with experts both at home and abroad on this topic. Dr. Goosby did not elaborate what these surrogate markers might be except for a quick reference to indicators from ante-natal care, but committed to vetting these more publicly once developed. Clearly, this is something to look out for in the near future.

3) Incentives to scale up prevention for success: What incentives, if any, will PEPFAR provide to countries to prioritize prevention?

Creating incentives for national governments to focus on prevention efforts is a must for them to succeed. In a forthcoming CGD working paper, CGD colleague Mead Over translates CGD’s concept of “Cash on Delivery”, to HIV prevention. In COD aid, donors commit to pay a specific amount of money for a specific measure of progress, in this case, infections averted. Incentivizing prevention in creative ways is an important step in scaling up efforts and should be a critical component of PEPFAR’s new approach with governments and other country stakeholders.

Courtesy U.S. State Department

When it comes to Secretary of State Hillary Clinton, no sliver of the international development community is more enamored than the sexual and reproductive health and rights (SRHR) crowd (yes, that’s their self-designation). Last Friday, Hillary returned the love. In a speech (see the full text here) in the regal Benjamin Franklin reception room at the State Department, Secretary of State Clinton and many of her top staff brought the international dimension of reproductive health and family planning in from the cold. It’s been a long winter.

The occasion of the speech was the 15th anniversary of the “Cairo Conference” – officially the International Conference on Population and Development (ICPD) – in 1994, at which then-first lady Clinton was a very prominent and passionate leader of the U.S. delegation. Last Friday she said,

There is no doubt in my mind that the work that was done and the commitments that were made in Cairo are still really the bulwark of what we intend to be doing and are expected to do on behalf of women and girls.

The ICPD was particularly ill-timed. Several months later, Republicans took control in the U.S. Congress and anything having to do with sex, rights, or Hillary became a political cudgel. The conditions for advancing the Cairo Plan of Action on SRHR became worse in 2000 when George W. Bush took office, the Mexico City policy (known by some as the global gag rule) first imposed by Ronald Reagan was reinstated, U.S. funding was pulled from the UN Population Fund (UNFPA)and replaced by Nordic and other European countries and the U.S. became a pariah in international circles concerned about women and their rights.

The SRHR crowd in the U.S. went into exile. They’ve been there for almost half the time that has elapsed since Cairo. As Margaret Pollack (newly appointed Senior Advisor on Population Issues at the U.S. State Department) said at a UN Foundation luncheon to celebrate Friday’s speech, a lot of time has been lost that could have been spent achieving the Cairo Plan of Action – and not incidentally, getting much closer to achieving MDG 5, the maternal health goal.

Secretary Clinton seems to be in a hurry to make up for lost time. She used the full arsenal of her top staff and emboldened them with strong words. Eric Schwartz, assistant secretary of state responsible for population issues, opened the event saying, “We recommit to the principles of ICPD and its Plan of Action.” Ambassador-at-Large for Global Women’s Issues, Melanne Verveer, in introducing the Secretary, called her a woman who has not wavered on the issues of SRHR and applauded the focus on girls and women in the Secretary’s “groundbreaking speech on development” two days earlier at CGD. (For those who missed it, you can read the text of the prepared remarks here – note the very nice reference to Start with a Girl in her sixth point.)

Maria Otero, the undersecretary of state for democracy and global affairs, drove home the point that the Secretary is dead serious about putting the needs and condition of girls and women at the center of U.S. foreign policy. And completing the all-star line-up, USAID Administrator Raj Shah, sworn in just the day before, assured the crowd that a newly energized and excited USAID is ready to live up to the core principles of SRHR and the full vision that the Secretary articulated in last Wednesday’s speech – a speech he called “the most important statement on development by a secretary of state in decades.”

So what did Secretary Clinton deliver in her tidings of comfort and joy? (this speech was originally scheduled to happen right before Christmas but a Washington DC blizzard delayed it.) Four points that pretty much capture the essence of what’s needed:

1. Girls and Women: The Secretary not only “Started with a Girl,” but she put girls in the center and at the end of her speech as well. After reciting some of the brutal statistics that describe the sorry state of women’s and girls’ health – including a woman dying every minute of every day from pregnancy and childbirth and 70 million women and girls worldwide with their genitals carved up – she declared the situation intolerable. (For a discussion of the available statistics on girls, see Ruth Levine’s blog here.) In addition to reinforcing on-going U.S. programs to prevent maternal mortality and female genital cutting, the Secretary is asking every program in the State Department and USAID to determine what its contribution is for the well-being of girls and women. That will require some careful searching, but it is the soul-searching that will accompany it that could most change the State Department.
2. U.S. as a global leader: I felt an undercurrent of last year’s inaugural mood in the Benjamin Franklin room as the Secretary and her cadre spoke of the future. They were wiping away 8 years of U.S. blockage and manipulation of international family planning programs and policy negotiations. There was a sense of pride and almost disbelief in the audience that the reversal could be so complete. The members of the diplomatic corps that I spoke with afterwards were perhaps the most gratified. One ambassador said to me, “Now, when the U.S. speaks, people will listen again.”
3. More money: Getting down to the important details, Secretary Clinton said, “We’ve pledged new funding, new programs, and new commitments to MDG5.” The Obama Administration has already renewed funding to UNFPA and “more is on the way,” according to the Secretary. She said there will be in increase in population funding within the U.S. budget (as we’ve seen already, by almost one-third), and reproductive health and family planning , in addition to maternal and child health, will be central to the Global Health Initiative being constructed by a constellation of USG agencies in time for the President’s budget speech in February.
4. Centrality of SRHR to development: Perhaps most challenging but key to it all is the connection between SRHR and so many other development goals. Secretary Clinton gets it in spades, and so she said, “We understand there is a direct line between a woman’s reproductive health and her ability to lead a productive, fulfilling life. And therefore, we believe investing in the potential of women and girls is the best investment we can make.” And some concrete actions: “We are integrating women, adolescents and girls into our Global Health Initiative and our Food Security Initiative. We will make sure the integration of family planning happens…all health programs will be designed to take into account women and girls.”

I daresay that not just the SRHR crowd – stalwarts all—were pleased when she said off-script,

“I know it can sometimes be hard to take, we might grow weary of the ups and downs in these things that seem so self-evident to the rest of us that this must be done. But work with us, and let’s create structural and institutional change that does not get wiped away with the political winds.”

For those of us in the development community who are immersed in questions of how to achieve better health in the developing world and/or issues of the empowerment of women, the renewed attention to the health of girls and women is very welcome. At the same time, it’s hard to quiet the inner questions about how to reconcile enthusiasm for SRHR within the “international community” with the much less positive view in many of the governments of developing countries. While it is certainly the case that in some countries receiving U.S. development assistance (for example, Ethiopia and Egypt) there appears to be genuine high-level support for family planning and good reproductive health care, this is far from a universal position. At best, countries that are not actively supportive will permit family planning services to be provided when donors pay – which is why there is a dramatic ebb and flow of access to services depending on the party affiliation of the President of the United States. At worst, the policies and practices of governments with which we do development business are retrograde with respect to the health-related rights of girls and women.

This puts us in a little bit of a bind when it comes to simultaneously insisting on the value of a women-centered approach in health and the principle of “country ownership” and engagement in true partnerships – a priority for development policy that Secretary Clinton articulated in her address earlier in the week. One way to manage that conundrum is to invoke the fact that the vast majority of the world’s nations are signatories to the Convention on the Elimination of All Forms of Discrimination Against Women and the Convention on the Rights of the Child, which include provisions that cover almost all of actions that SRHR advocates promote. Therefore, as signatories they have already endorsed access to quality health services, protection from gender-based violence, and many other important objectives. But, sadly, the bind becomes tighter if we attempt to use this rationale because the U.S. is among the very few countries that has ratified neither of those conventions – along with Iran and Sudan in the case of CEDAW, and Somalia in the case of the CRC. In this domain, we fall far short of being able to serve as a model or inspiration – and are significantly challenged even to highlight the disconnect between other countries’ rhetoric and practices.

In spite of these significant reasons for caution, we can all bask for a moment in the reflected warmth from the end of the SRHR community’s long winter in exile.

Building on the recommendations of the Zedillo report, I suggest four priorities below for reformat the World Bank. I then add one worry about an issue the report failed to grapple with.

1. IBRD should go 50/50 (voting shares), with developing countries rising not from 44 to 47 percent (as recently endorsed by the G-20) but to 50 percent. The 50/50 allocation should be tied to the planned capital increase. It’s the borrowers that want a bigger bank. Many have surplus reserves and could put in more paid-in capital; perhaps non-borrowers with big fiscal problems like the U.S. could increase their contributions in the form of callable capital (which would not require budget appropriations). Need the paid-in ratio be the same for everyone? By the way, the Inter American Development Bank (IDB) has been a 50/50 bank since 1994. The effect there has been more than symbolic (greater legitimacy and ownership have affected the agenda and the budget) but by no means has constituted a revolution — for good or ill.
2. IDA governance. IDA should have a separate governance structure from IBRD. The Commission recommends a voting arrangement for IDA more tied to recent contributions, but is not explicit about separating IDA from IBRD governance. Here lies a possible bargain with the UK and other Europeans: they keep more votes and chairs at IDA but give up some chairs at IBRD (where they have 8 of 24 now). IDA should also be 50/50, including only donors and IDA recipients. Middle-income countries like China and Brazil could join the donors by contributing to IDA directly.
3. Presidential selection. The G-20 and the Zedillo Commission have spoken: it is time to end the grip that the U.S. and Europe have on selecting the heads of the World Bank and the IMF respectively. On this issue, I advocate double majority voting – a majority of weighted votes, and a majority of countries. This method would enhance institutional legitimacy since small, poor countries could, if they formed a coalition, be able to block a candidate they didn’t like – just as the U.S. can (and could) do all by itself. That way an elected president would have serious and broad support, thus enhancing his or her legitimacy – and therefore the effectiveness – of the institutions. Meanwhile the U.S. Congress still needs to be reassured that the U.S. would retain a de facto veto on any candidate.
4. Global public goods. As I argue in a recent speech, a new wing at the World Bank should be a huge priority. Its governance should be shaped by three principles. First, periodic member contributions should be related positively to per capita income and to emissions per capita. Second, developing countries as a group should have influence equal to that of developed countries, whether through 50 percent of weighted votes or other voting rules. Finally, in legal and operational terms, the new entity should be as distinct or even more distinct from the main lending arm of the bank as the Multilateral Investment Guarantee Agency (MIGA) and the International Finance Corporation (IFC). And why not put the new wing in Beijing or New Delhi? Developing countries have $3 trillion in reserves. Surely they would welcome an opportunity to lend to or capitalize a substantial GPG Trust Fund. Better for them and for the global economy that some of those reserves be intermediated through a legitimate global institution. The Climate Investment Funds are already governed under a 50/50 arrangement and a GPG or Climate Fund should be similarly set up. To start, it should be at least $3 billion with at least $1.5 billion from advanced developing countries.

Finally, I have one deep worry: The Commission calls for greater flexibility and speed and for reduction of the “hassle factor” in Bank operations. But at the same time it wants increased attention to environmental, social, anti-corruption safeguards, both internal and in all lending operations that have piled up like barnacles on World Bank operations. How to reconcile these two fundamentally conflicting demands? The Commission should have pushed for more emphasis on independent, periodic ex post audits of ongoing programs and projects, and for the Bank to exit (projects and countries) that fail audits.

In general, the Commission failed to deal with the Bank’s obsession to lend (ignoring the problem of procyclicality), its focus on disbursements, the lack of ability to exit once the Bank is engaged in a country, the limited incentives to innovate, and the willful pretense that all risks – fiduciary, waste and corruption, environmental and so on – can be managed ex ante.