Applying PEPFAR’s Model of Aid Delivery to Food Security and its Implications on the Nature of American Foreign Aid

William Smith, Defense and Diplomacy Center, Spring 2011

Letter from the PoLicy feLLows
The role of foreign aid as a foreign policy tool has long been a contentious debate. ‘Development’ is distinct from the other two ‘big D’s’ of Defense and Diplomacy yet to what extent is it subject to the strategic objectives of these bigger policy and political imperatives? In his Presidential Policy Directive on Global Development, President Obama laid out a vision for America’s development efforts to be one of three equal pillars of America’s foreign policy portfolio with the other two. However, the extent to which this can be realized in practice is still unclear. Promising steps, most noteworthy of which is the inclusion of the USAID Administrator at National Security Council, have been taken but appropriately placing development’s voice in the context of American foreign policy remains challenging. One thing that is clear, however, is that foreign aid and development efforts are extremely important. Nonetheless, foreign aid has come under frequent attack for being ineffective, misdirected, or even for creating perverse incentives and fuelling corruption and, ironically, underdevelopment. Therefore, a frank, open, and innovative debate on aid effectiveness is much needed. Such a debate within the development establishment is already ongoing and many initiatives have been launched to achieve and manage results for improved development outcomes. What this White Paper seeks to do is not to replicate this ongoing process but rather to provide fresh perspectives on several of the many current development challenges. This research is by no way meant to be comprehensive or to provide a single formula for improved aid effectiveness. Indeed, at the core, this White Paper desires to underscore the essential need for context-driven aid policies and activities. It is the sincere hope of the writers’ that this work becomes a contribution to the wider efforts to reframe aid and improve development effectiveness through improving the mechanisms of aid planning, delivery, and management. Matthew Eldridge and Ahmad Soliman Senior Policy Fellows Defense and Diplomacy Center | Roosevelt Institute Campus Network

1

introduction

The past of liberalization have been phased out U.S. foreignmulti-billion dollar single-issue initiatives. This shift can be seen in the decade has seen a fundamental shift in aid to Africa. Condition-based loans embodying Washington Consensus values in favor of

steady increase in aid funding to Africa throughout the 2000’s. While some of this funding increase can be attributed to humanitarian aid and one-time debt forgiveness, the majority consists of the creation and funding of the President’s Emergency Plan for AIDS Relief (PEPFAR) and other long-term initiatives.1 Indeed, PEPFAR remains the largest U.S. initiative in Africa, and has been regarded as a comprehensive and successful response to a global health crisis.2 The success of this public health venture has created exciting opportunities for the use of this model in other sectors. The influence of the PEPFAR model can be seen in the Obama administration’s new global hunger initiative, Feed the Future. Additionally, the focus on these long-term initiatives displays a commitment to global development beyond the use of aid as a diplomatic tool. While aid to Africa has increased significantly since 2001, Africa is not a new focus for American foreign aid. The U.S. has poured billions of dollars into Africa over the past several decades.3 Despite this aid, however, Sub-Saharan Africa still experienced considerable economic and political backsliding. It was the only region in the world to experience negative income per capita growth rates in the 1980’s. Even by the 1990’s, averages for the region had only barely reached positive numbers.4 The region’s participation in global trade has similarly dropped from 10% of world exports in 1980 to only 2% in 2002.5 These outcomes, given the inflow of global aid into the region, point to the fact that aid projects in Sub-Saharan Africa have been largely ineffectual, and, at times, have even been hazardous.6 The U.S.’s increasing focus on long-term initiatives focusing on specific issues has begun to reverse this trend of ineffectual aid. Initiatives such as the Africa Education Initiative, Clean Energy Initiative, and President’s Malaria Initiative have all seen measurable results in the past six years.7 PEPFAR has already seen a drop in AIDS death rates of 10% in the initiative’s focus countries.8 It is in light of these successes that this paper will analyze the structure of the PEPFAR model that makes it so successful, and whether or not this model can be adapted to improve the success rate of other initiatives. A specific look will be given to the White House and State Department’s new hunger initiative, Feed the Future, and whether it represents a shift in the focus of American foreign Aid to Africa towards the model utilized by PEPFAR. Finally, this paper will discuss how long-term initiatives such as PEPFAR and Feed the Future have led to a changed relationship between American foreign aid and American diplomacy, particularly in Africa.

ii. PePfAr modeL
1. Background

As previously noted, PEPFAR was initiated under President Bush in 2003. By this point the HIV/AIDS pandemic had spread throughout Sub-Saharan Africa, making it the region worst affected by the disease. Prevalence rates had already soared above 20% of the adult population in several Southern African countries. When PEPFAR was launched, the number of Africans receiving anti-retroviral therapy (ART) was barely over 50,000, while more than 20 million people were HIV+ across the continent.9 Millions were dying from the disease each year, and in nearly all countries, prevalence rates showed no signs of slowing their climb. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 created the State Department Office of the Global AIDS Coordinator in order to oversee the $15 billion committed by President Bush to address the AIDS crisis (this financial commitment was the basis of PEPFAR). PEPFAR’s goals were to provide treatment to two million people, prevent seven million new infections, and to provide care to over ten million people affected by the disease.10 This was quickly expanded to providing additional care to over four million orphans affected by the disease and prevention of over 15 million mother-to-child transmissions of the disease. PEPFAR initially was not scheduled to meet these goals until 2010, but all of these major benchmarks were passed by 2008. As a result, in 2008 the program was expanded to provide a further $48 billion through 2013, with the hope to double the goals set for 2010.11 This expanded what was already regarded as the largest health initiative ever initiated by a single country to combat a disease. While the initiative is targeted at a single disease, the approach is anything but narrow. PEPFAR attempts to address all facets of the disease: from funding early education programs on the dangers of HIV, to the import of millions of life-prolonging ARVs for those already suffering from AIDS, to capacity building of local health systems that were woefully unable to handle the pandemic on their own.

2. successes of the model

While PEPFAR initially struggled securing the funding that had been promised, once the funds were allocated the initiative saw almost immediate impact. By the beginning of 2008, PEPFAR had already surpassed the goal to provide ARVs to two million people. 2

During this same time period over ten million people had received care, including nearly four million orphans and vulnerable children. Additionally, PEPFAR had funded over 57 million counseling and testing sessions by 2008.13 Prevention numbers are much more difficult to gauge, as they can only be measured through the fluctuations in incidence rates from year to year. Also, the program’s specific goals in its 15 individual “target” countries, particularly in Nigeria and Ethiopia, were not always realized.14 Regardless, it became clear that by 2008 PEPFAR had been extremely successful in reaching its overall goals regarding treatment and care. The quick and efficient nature of the first few years of the initiative can largely be attributed to the treatment of the issue as an emergency situation. Cheap, yet WHO approved treatment was immediately sought out and delivered in bulk. Funding ran through established NGOs that worked with local communities to distribute the necessary materials e.g. home care kits, HIV tests, educational supplies, and, after political debate, condoms.15 However, it is also important to note that these early successes came about partly because of the system of substantive accountability, the ability to reach specific goals, PEPFAR was built around. Lack of accountability has long been considered one of the major failings of foreign aid. Aid projects have been criticized for simply dumping money into a developing country without proper structure or specific goals in mind.16 PEPFAR had created, within its structure, a system of clearly identifiable and attainable goals. It used a system of statistically measurable amounts, such as the number of people receiving treatment or number of people receiving care, to determine the success of the program.17 As the initial goals of the program were reached in 2008 and a further $43 billion was committed to PEPFAR through 2013, the scope of the initiative also began to change. Rightly criticized about the sustainability of a program based on an emergency framework, PEPFAR came out with new objectives in 2008 based around a plan to foster more sustainable change in the fight against HIV/AIDS, particularly in Sub-Saharan Africa. The main changes to the PEPFAR model have been focused on increasing partnerships with recipient country governments and building local capacity within the communities receiving aid. PEPFAR now claims that programs will be country-owned and countrygiven, meaning funding will be given within the context of the respective national AIDS plans. While funding will still be held accountable to the measurable outputs of these programs, American NGOs will no longer largely implement it, instead the recipient country governments will primarly decide where the funds are allocated.18 This funding will increase the resources of the public sector in recipient countries, leading to greater internal capacity building. Local system strengthening has also become a focal point of the program. This means ensuring local clinics are properly equipped, properly staffed, and the staff is adequately trained. In addition to material needs, this system also addresses the need for human resource development in areas where there is a significant shortage of properly trained staff.19 As PEPFAR continues to operate through 2013, the combination of accountability and sustainability with a particular focus on partnerships and local capacity development we have already witnessed a stabilization of prevalence rates throughout Sub-Saharan Africa. Incidence rates have now dropped in 22 Sub-Saharan African nations, and, in nations such as South Africa, mother to child transmission has been almost eliminated altogether.20

iii. Application of the PePfAr model to Agriculture
1. Agriculture in Africa

Agriculture, specifically in Sub-Saharan Africa, is perhaps the industry in greatest need of a comprehensive overhaul. Beyond the issues of periodic famines that cause widespread hunger, 33% of the world’s hungry live in Africa.21 The lack of agricultural development in Sub-Saharan Africa has had several widespread effects. One of the largest negative effects of agricultural underdevelopment has been the pervasiveness of micronutrient deficiencies.22 These deficiencies, caused by a lack of vitamins and minerals such as iron or vitamin A in the diet, can lead to physical stunting, slowed mental development, and higher rates of infant mortality. In several African nations, upwards of 45% of children of pre-school age and women bearing children are suffering from vitamin A deficiencies. Food security is widely defined as “all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life.”23 Considering this definition, both the amount of people living with hunger and those suffering from micronutrient deficiencies display many African nations’ inability to provide adequate food security for their populations. A large part of this is due to the majority of African nations neglecting to invest in agricultural sciences. While much of Southeast Asia, and later Latin America, underwent the “Green Revolution” of the 1960’s and 70’s, Africa’s leaders did not invest the same amount into developing agriculture. So, while Southeast Asia’s marginal product of agricultural labor and yield per acre totals increased significantly, Africa’s have remained some of the lowest in the world.24 Poor infrastructural development, low levels of skills training, and high transaction costs have greatly decreased the productivity of African agriculture. And, considering that Africa’s population is projected to swell to twice its current size by 2050, the agricultural system could be facing significant added strains.25 In order to address these concerns, the member nations of the African Union signed the Maputo Declaration in 2003, requiring all 3

member nations to increase agricultural investment to 10% of the national budget by 2008. However, by 2007 50% of the member nations still had agricultural expenditure at less than 5% of the national budget, and less than a quarter of the countries ever reached the goal of 10%.26 African nations, particularly in the past two to three years, have been especially vulnerable to global food price hikes. In 2008 global food prices rose quickly due to a combination food price speculation by western firms and shifting of large sections of agricultural land to biofuel production. This resulted in an additional 75 million people suffering from malnourishment just due to the 2008 price hikes, with a significant portion of the people found in Sub-Saharan Africa.27 This increase in malnourishment occurred in such countries as Malawi and Niger despite that fact that both countries had strong agricultural yields for the year. The issue of food security, relating to diversity of diet, agricultural output, and protection from price shocks, is one that requires a comprehensive solution. Too often our agricultural aid goes to the improved production of cash crops that may increase agricultural profits, but do little to improve the food security of the population as a whole.28

2. feed the future

Much in line with Bush’s announcement of PEPFAR in 2003, the Obama administration announced in mid-2010 that it would be committing $3.5 billion over three years to address the issue of global food security.29 Unsurprisingly, 12 of the 20 focus nations for the initiative are in Sub-Saharan Africa. While funding has yet to be fully secured and most of the programs are waiting to start in earnest, one can still make a comparison between the plan of this new initiative and the successful PEPFAR model. Firstly, right from the offset it is clear that Feed the Future has learned PEPFAR’s lesson in regards to sustainability of the initiative. Unlike the HIV/AIDS crisis in 2003, food security, while certainly a tremendous issue, cannot be treated as an emergency. Therefore, Feed the Future has needed to keep in mind the sustainability of its programming from its outset, much like PEPFAR following 2008. In this manner, Feed the Future pledges to work in close partnerships with the governments of the recipient nations and, just as importantly, the regional organizations that deal with intra-regional trade (e.g. the Southern African Development Community).30 A close level of partnership will encourage both capacity building and mutual accountability, both of which will help develop the human resources in the recipient countries, rather than just providing material resources. The emphasis on mutual accountability is another lesson learned from the PEPFAR model. This forces both the initiative and the aid recipients to take into account all of the stakeholders of the different programs. This is shown in the wide variety of success indicators that Feed the Future is looking for. For example, measurable indicators that the initiative will be looking for include everything from increased agricultural production, to reduction of transit time along transport corridors, to increased private sector investment in agricultural technologies.31 All in all, Feed the Future will be monitoring up to 26 separate indicators in Southern Africa alone. While some of the indicators, such as improved management and leadership by firms and financial institutions,32 are not as easy to quantify, it is clear that many of the indicators are measurable and allow progress to be more easily charted. By basing progress on these measurable values, monitoring and evaluation of projects becomes streamlined and funding can be allocated to projects shown to be successful. Feed the Future’s comprehensive approach to food security is also very much in line with PEPFAR’s participation in all aspects of the HIV/AIDS issue. The initiative spreads its focus to address all of the factors compromising regional level food security: low agricultural production, lack of agricultural investment, poor understanding of agricultural sciences, high costs of transport, and ineffective agricultural policy. Much like PEPFAR, many of these issues are being addressed through human resources development. Feed the Future has a significant focus on local capacity building through using technical experts to train agricultural researchers, improve crop and livestock management, and educate policy makers on the importance of agricultural research and investment.33 Considering that a recent global agricultural report estimated that the application of existing agricultural knowledge and technology could alone increase average yields two to three fold in many areas of Africa,34 local capacity building could very easily have an immediate and lasting impact. Additionally, Feed the Future seeks to target infrastructural development. Much like PEPFAR has strengthened local public health infrastructure in order to increase the range of healthcare access and delivery, Feed the Future seeks to improve transport infrastructure to the transport of goods, critical for regional food security. Currently, transportation costs can reach up to 77% of the value of their exports in several African nations.35 Such a heavy deterrence to export forces each nation to attempt to become agriculturally self-sufficient, leading to much greater susceptibility to price shocks.36 It is no coincidence that Feed the Future’s structure is so similar to that of PEPFAR’s. The Obama administration has adopted the multi-billion dollar initiative approach that has worked so well in combating HIV/AIDS, and has applied it to another global concern.

3. criticisms of the model

PEPFAR’s successes certainly have not been unqualified. While Feed the Future has certainly been structured to avoid many of the 4

sustainability issues that initially faced PEPFAR’s emergency approach, both initiatives still face the need for structural improvement. PEPFAR’s major criticisms have been targeted at the initiatives moral and religious overtones. However, these criticisms have little relation to potential issues with Feed the Future, so discussion will be limited to analogous criticisms between the two initiatives. A major criticism centers on the collaboration between PEPFAR and other donor agencies such as the Global Fund. In many cases funding agencies will collaborate to provide funds to the same project in order to increase the resources of that project. PEPFAR and the Global Fund, the two largest donor agencies in regards to the procurement of ARVs, collaborate in order to purchase greater quantities of ARVs. However, this has caused both organizations to take credit for approximately 864,000 people who are on ARVs that are provided partially by each organization.37 While this does not change the fact that more than 800,000 people are on treatment now that would not have been otherwise, it does display an overwhelming concern for boosting numbers. This absolute focus on quantitative reporting of achievement could leave the door open for neglect of actual quality of treatment. And, considering the necessity of proper treatment for those suffering from AIDS, qualitative standards are essential for the future of the initiative. Feed the Future has managed to address a certain number of these issues by expanding the number and depth of statistical indicators to measure the progress of the initiative. However, like PEPFAR, it does rely heavily on quantitative results to measure success leaving the potential of statistical boosting. PEPFAR has been criticized for claiming credit for the construction of clinics, procurement of supplies, and treatment of patients in certain regions despite providing only minimal financial or technical assistance to the local programs already engaging in these activities.38 Currently, Feed the Future lacks sufficient monitoring capabilities to prevent similar statistical reporting. In order to address these statistical issues, greater depth is required in regards to statistical evaluation. Rather than taking full credit for any statistical indicators that are at all affected by program funding, greater weight must be put on the extent of funding provided and corresponding incremental improvement within the indicators. Finally, both PEPFAR and Feed the Future are heavily decentralized initiatives. While PEPFAR is loosely organized under the Office of the U.S. Global AIDS Coordinator, it has also now been placed at the core of the larger Global Health Initiative proposed by the Obama Administration.39 Feed the Future lacks even this loose central organization. It was started as a collaboration between the U.S. Department of State and USAID, and has since shifted under USAID following the release of the Quadrennial Diplomacy and Development Review (QDDR).40 The lack of centralized coordination between the varied initiatives creates potential for overlap and redundancies within the initiatives.41 More importantly, despite the different focuses of the initiatives, many are addressing different facets of the same issue. For example, both PEPFAR and Feed the Future positively affect women and children’s health, a major goal under Obama’s Global Health Initiative. Coordination between the initiatives could create a more effective and balanced approach to the issue. In the short-term this lack of collaboration may do little to effect the efficiency of either initiative. However, over the long term, greater outreach and impact can be achieved by coordinating the leadership of the initiatives under USAID, as is suggested in the QDDR report.42 This could help foster collaboration on similar issues, pooling of resources, and expansion of local networks in target countries.

iV. the changing relationship between foreign Aid and foreign Policy
The Obama administration has claimed that development and diplomacy are the “twin pillars” of U.S. foreign policy.43 Yet, as our development projects shift towards long-term, comprehensive initiatives, its relation to foreign policy has changed. This is particularly evident in Africa, where 80% of U.S. assistance came in the form of food or medical aid, up from only 40% in 1998.44 A large portion of this assistance is composed of PEPFAR’s programs. Because so much of PEPFAR’s funding, initially a floor of 55%,45 goes to treatment, the U.S. has entered into a long term commitment to continue funding HIV/AIDS aid. Due to the nature of ARVs they must be taken daily for the remainder of the patient’s life in order to be effective, the U.S. could not reduce funding for PEPFAR without decreasing the current access to ARVs, essentially a death sentence for those who would no longer have access to the medications. PEPFAR continues to try and increase overall access to ARVs, while simultaneously developing human resources and public health infrastructure within the recipient countries. All of these projects are sufficiently long term, hence the extension of funding through 2013. Similarly, Feed the Future represents a long-term commitment to development aid. There is no single part of the initiative that must be funded indefinitely, such as ARV access with PEPFAR. Yet, agricultural training, transport infrastructure development, and agricultural research development all represent long-term projects. Moreover, in order for these programs to have a sustainable, long-term effect, there needs to be some aspect of future monitoring and evaluation of the programs. India, one of the first countries to undergo the Green Revolution in the 1960’s and 70’s, is already facing significant food security problems again. Agricultural investment in India has dropped steadily since the Green Revolution, and as a result agriculture is only growing at a rate of 3% per year, compared to India’s overall growth of 9% per year.46 Food security is a long-term investment that needs to be maintained. Were Feed 5

the Future to operate for only three years and then withdrawn, it is likely that any gains would be diluted over time. This means that the U.S. has now committed itself to several multi-billion dollar long-term projects in developing countries. While perhaps an intriguing long-term diplomatic incentive for developing countries, these programs sacrifice the short-term maneuverability that diplomacy requires. Researchers Lyman and Wittels argue in a recent publication that this change in foreign aid has caused the U.S. to lose significant leverage in its foreign policy.47 The U.S. is simply unwilling to remove aid to developing nations if it means that civilians will die as a direct result of aid removal. This has been evidenced in both Uganda and Ethiopia. In 2006, President Bush attempted to convince President Museveni of Uganda not to run for another term, while in Ethiopia the U.S. has been criticizing Ethiopia’s human rights record since a disputed election in 2005. Neither country heeded the U.S.’s warnings, and in Ethiopia’s case the replies were particularly insulting. Yet, the U.S. was reticent to pull its foreign aid to either country, as so much of it was tied up in medical aid that was necessary to the survival of civilians in both nations.48 The cases of Uganda and Ethiopia are beginning to show a growing trend in our aid to Africa. The U.S. continues to commit $500 million annually to Zimbabwe, the majority of which goes to emergency PEPFAR programming in the country. This money is sent despite our increasingly negligible influence on the rule of Robert Mugabe.49 The U.S. government is simply unwilling to remove aid in instances where this aid is keeping significant civilian populations alive. While this is certainly more the case for PEPFAR, where ART procurement and distribution is quite literally keeping millions alive, initiatives such as Feed the Future are designed to impact the standards of living of civilian populations. Deployment of funds followed by withdrawal before the completion of the projects for diplomatic reasons would be most damaging for the very populations the initiatives are seeking to help. Additionally, budgetary constraints have called into question the long-term viability of these initiatives. Recent House of Representatives attempts to address the U.S. government budget have led to several budgetary cut proposals. Many show a significant decline in U.S. foreign aid funding.50 While it is doubtful that these cuts will be enacted, it does show a decline in commitment to foreign aid. Even though Obama has requested that U.S. foreign aid levels will not be frozen in the fiscal 2012 budget, House republicans are still attempting to decrease the funding to foreign aid programs.51 These two issues are leading to a major turning point in the relationship between our foreign aid and foreign policy. The long-term aid initiatives represented by PEPFAR and Feed the Future require adequate funding and diplomatic and congressional support over the course of several years in order to be effective. Yet, on the other side, the initiatives do represent significant funding requirements and long-term commitments within nations that may not always adhere to our foreign policy standards. However, given that Obama is seeking to make development and diplomacy the “twin pillars” of American foreign policy, long-term initiatives represent a strong movement in that direction. Rather than development being used as a tool of diplomacy, crafted to make countries heed our political influence, it is being established as a separate option of foreign policy. Long-term commitments help build American goodwill in foreign nations, particularly when development aid reaches out to populations that local governments are unable to sufficiently help. PEPFAR strongly helped boost African opinion of President Bush, even when international opinion of his administration was down across the rest of the globe, suggesting that these projects do not cause a significant drop in political leverage.52 While this goodwill amongst the general populace may have little effect on the country’s leadership, as in the case of Zimbabwe, it does make future development projects easier to implement, as local groups will be more willing to work with programs from countries they trust. These long-term initiatives do skate a fine line, however. There are very clear hazards in providing humanitarian and development aid in countries with unpopular regimes. On one side, the money can be seen to prop up the unpopular regimes, causing public resentment towards the aid. On the other, humanitarian aid that supports civilian populations can allow regimes to further neglect the needs of its people. Both cases would be inimical to the interests of both our diplomacy and development aid. Therefore, these projects need to have comprehensive monitoring and evaluation tools built into their structure to make sure that the money is going to where it is most needed and that the programs are effective in delivering the aid. At the same time, sustainability must be a core value, in order to prevent foreign governments from becoming too reliant upon aid to provide for the basic needs of their people.

concLusions
PEPFAR’s measurable successes since 2003 have shown that development projects can have a significant positive impact, even in areas such as Sub-Saharan Africa where broad development plans have had a history of failure. PEPFAR’s public health model of comprehensive programming combined with accountability to both donor and beneficiaries. Feed the Future, the Obama administration’s new food security initiative follows this model in an attempt to adapt it to a different sector. The focus remains on a comprehensive approach that is built around partnerships with the recipient country while developing human resources to make sure that the programs can continue to be effective in the future when direct oversight by the initiative is less. While it is too soon to measure the successes of the Feed the Future initiative, this model could present a clearly definable approach to the future of American foreign aid. No longer will our aid be limited to simple humanitarian aid and quick fixes to pervasive issues. Instead, aid could become 6

markedly more long-term, providing a framework for local institutions. These initiatives mark a sizable shift in the nature of our foreign aid program in its relation to foreign policy. Long-term projects sacrifice foreign aid’s ties to the quick-changing diplomatic world. Instead, these initiatives require a commitment to funding and operation over the course of several years in order to address specific issues facing the developing world. While it does not make aid entirely apolitical, it does require these initiatives to continue to operate even within countries that do not always follow U.S. diplomatic demands. They represent a commitment to the development of underprivileged communities rather than a political incentive, to be wielded or withdrawn, often at the cost of the goals of the development program. Given that PEPFAR has been so successful because of its focus on the future and our commitment to its goals even in changing political climates, this shift could represent a fundamental commitment to the importance of global development.

references
1.P. Lyman & S. Wittels. “No Good Deed Goes Unpunished: the Unintended Consequences of Washington’s HIV/AIDS Programs.” Foreign Affairs, July/August 2010,
Volume 89 Number 4. Pg. 74 2. Plaut, Martin. “Has Bush Been Africa’s Best Friend?” BBC.com, 16 January 2009. http://news.bbc.co.uk/2/hi/africa/7831460.stm 3. Cooper, Frederick. Africa Since 1940. Cambridge University Press: New York, 2002. Pg. 130 4. Moss, Todd. African Development. Lynne Rienner Publishers: London, 2007. Pg. 89-90 5. “Our Common Interest,” Report on the Commission on Africa, 2005. Pg. 248 6. Moss, Pgs. 126-127 7. “USAID Status of Presidential Initiatives,” USAID Press Release, 2004. http://www.usaid.gov/press/releases/2004/pr040323.html 8. “Stanford study first ever to show US AIDS Relief program saved a million lives”. EurekAlert!. April 6, 2009. http://www.eurekalert.org/pub_releases/2009-04/ sumc-ssf040209.php 9. Stolberg, Sheryl Gay. “In Global Battle on AIDS, Bush Creates Legacy” The New York Times, 05 January 2008. 10. “Executive Summary of PEPFAR’s Strategy,” December 2009. http://www.pepfar.gov/strategy/document/133244.htm 11. “About PEPFAR,” http://www.pepfar.gov/about/index.htm 12. “Celebrate Life: Latest PEPFAR” Results Office of the U.S. Global AIDS Coordinator, U.S. Department of State. 1 December, 2008. http://www.pepfar.gov/about/ c19785.htm 13. Ibid 14. Ibid 15. “Following the funding for HIV/AIDS” Center for Global Development, October 2007, http://www.cgdev.org/content/publications/detail/14569 16. Moyo, Dambisa. Dead Aid, Allen Lane: London, 2009. Pgs. 44-47 17. J. O’Neill & G. Pappas : “Health Diplomacy: lessons for global health from PEPFAR.” The Internet Journal of World Health and Societal Politics. 2009 Volume 7 Number 1 18. “Executive Summary of PEPFAR’s Strategy,” December 2009. 19. J. O’Neill & G. Pappas 20. “Report on the Global AIDS Epidemic 2010,” UNAIDS. Pgs. 8-10 21. “Food Security: concepts and measurement,” Food and Agriculture Organization. http://www.fao.org/docrep/005/y4671e/y4671e06.htm 22. Millstone, Erik. The Atlas of Food. University of California Press: Berkeley, 2008. Pg. 26 23. “Food Security: concepts and measurement.” 24. Ndulu, Benno J. Challenges of African Growth, The World Bank: Washington, DC, 2007. Pgs. 145-147 25. “The Future of Food and Farming: final project report,” The Government Office for Science, London, 2011. Pg. 14 26. Mwape, Faustin. “How are Countries Measuring up to the Maputo Declaration?” NEPAD Secretariat Agriculture Unit Policy Brief, June 2009. 27. Vidal, John. “Food Speculation- ‘People Die From Hunger While Banks Make a Killing on Food,” Guardian Global Development Network. 25 January, 2011. 28. Bunting, Madeleine. “How Can We Feed the World and Still Save the Planet?” Guardian Global Development Network, 21 January, 2011. http://www.guardian. co.uk/global-development/poverty-matters/2011/jan/21/olivier-de-schutter-food-farming 29. “USAID Administrator Dr. Rajiv Shah Announces 20 Feed the Future Initiative Focus Countries,” USAID Press Release, 24 April, 2010. http://www.usaid.gov/ press/releases/2010/pr100424.html 30. “Southern Africa FY 2010 Implementation Plan,” Feed the Future. Pgs. 9-10 31. “Southern Africa FY 2010 Implementation Plan,” Pg. 24 32. Ibid, Pg. 25 33. Ibid, Pgs. 16-18 34. “The Future of Food and Farming: final project report,” Pg. 80 35. Ibid, Pgs. 85-86 36. Ibid, Pg. 96 37. “The Power of Partnerships: Fourth Annual Report to Congress on PEPFAR” Office of the U.S.Global AIDS Coordinator, U.S. Department of State, 2008 February. http://www.pepfar.gov/press/fourth_annual_report/ 38. Office of the U.S. Global AIDS Coordinator, “Response to the Government Accountability Office Report, Global Health: Spending Requirement Presents Challenges to HIV/AIDS Relief,” 7 April, 2006. http://www.state.gov/s/gac/rl/pr/2006/64248.htm 39. “PEPFAR’s Role in the Global Health Initiative,” http://www.pepfar.gov/strategy/ghi/134850.htm 40. “Quadrennial Diplomacy and Development Review,” U.S. Department of State. 41. Bristol, Nellie. “The Long and Winding Road Toward US Aid Reform,” Devex News, 17 December, 2010. http://www.devex.com/en/articles/the-long-and-windingroad-toward-us-aid-reform?source=EM+DefaultHomepage_Headline 42. “Quadrennial Diplomacy and Development Review,” U.S. Department of State. 43. P. Lyman & S. Wittels. “No Good Deed Goes Unpunished: the Unintended Consequences of Washington’s HIV/AIDS Programs.” Foreign Affairs, July/August 2010, Volume 89 Number 4. Pg. 75 44. Ibid, Pg. 76 45. “United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003,” http://thomas.loc.gov/cgi-bin/bdquery/z?d108:h.r.01298: 46. Bajaj, Vikas. “Galloping Growth, and Hunger in India,” The New York Times, 11 February, 2011. http://www.nytimes.com/2011/02/12/business/global/12food.html?_ r=3&hp 47. P. Lyman & S. Wittels. Pgs. 75-76

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48. Ibid, Pgs. 76-78 49. Ibid, Pg. 77 50. Mungcal, Ivy. “On Capitol Hill, Rajiv Shah Busy Lobbying for Robust USAID Budget,” Devex News, 1 February, 2011. http://www.devex.com/en/blogs/development-assistance-under-obama/on-capitol-hill-shah-busy-lobbying-for-robust-usaid-budget 51. Rosenkrantz, Rolf. “Obama Unveils 2012 Budget Request; Foreign Aid Largely Spared from Cuts,” Devex News, 14 February, 2011. http://www.devex.com/en/ blogs/development-assistance-under-obama/obama-s-unveils-2012-budget-request-foreign-aid-largely-spared-from-cuts 52. Plaut, 2009.

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