“By one count, there are now over 140 goals and priorities for U.S. foreign assistance,” Senator John Kerry said during the nomination hearing for USAID Administrator-designate Rajiv Shah. If Shah is confirmed, his principal tasks will be moving development out from the shadow of defense and diplomacy and bringing definition to USAID’s mission.

“USAID needs to have a strong capacity to develop and place and deploy our civilian expertise in national security areas,” Shah said at his nomination hearing. USAID “has a responsibility to step up and offer very clear, visible, and understood strategic leadership,” as well as clarify “the goals and objectives of resources that are more oriented around stability goals than long-term development goals.”

Stabilizing and rebuilding state infrastructure in post-conflict settings has been increasingly recognized as critical to aiding the population and preventing renewed conflict. The United States has increasingly invested in rebuilding health systems, and in some cases assisting in the delivery of health services for the first time.

While global health concerns have recently received significant attention, as witnessed by President Obama’s Global Health Initiative, the importance of health system reconstruction to stabilization efforts remains unevenly recognized. On November 10, 2009, experts met at the Global Health Council’s Humanitarian Health Caucus to discuss investing in health services in the wake of war and the challenges of funding this investment.

“Deconstruction from violence extends beyond the time of war and often leads to severe damage of health infrastructure, decreased health workers, food shortages, and diseases…resulting in increased morbidity and mortality from causes that are not directly related to combat,” shared Leonard Rubenstein, a visiting scholar at Johns Hopkins School of Public Health. Rubenstein argued that while relieving suffering in post-conflict settings should be a sufficient reason to include health reconstruction in U.S. foreign policy, policymakers narrowly define rationales for engagement based on claims that investments increase peace and improve the image of the U.S. government.

Investing in Health Systems Builds State Legitimacy

The evidence for investing in health systems to deter future conflict is limited and this approach is dangerous, according to Rubenstein, because it distorts spending decisions and fails to consider comprehensive capacity development strategies. Additionally, the Department of Defense’s approach of “winning the hearts and minds” is too short-term and neither linked to “system-building activities that are effective and sustainable…nor consistent with advancing the health of the population,” he said.

Instead, Rubenstein recommended that the United States invest in health systems after conflict because it advances state legitimacy. Although additional evidence is necessary, Rubenstein maintains that the promotion of state legitimacy enhances the perception that the government is responding to their long-term needs and encourages local ownership and accountability. Developing health systems in post-conflict settings is complex and cannot be done quickly, he noted, and thus increased financial and human resource capacities will be essential.

Coordination and Transition Funding

“We need to recognize that the U.S. is not the only funder, as there are many stakeholders involved,” argued Stephen Commins, strategy manager for fragile states at the International Medical Corps. Commins argued that there is a “desperate need to coordinate donor funding … both within and across government systems, as well as an increased need for transparent donor tracking systems.”

As countries come out of conflict and start to gain government legitimacy, they need increased support to stabilize conflict and avoid collapse. Transition funding for health systems needs to support both short and long-term efforts, maintained Commins, but unfortunately the donors driving these timelines are often driven by self-interest, not the rights of the individual living in conflict.

Without a transparent donor tracking system, it is hard to demonstrate actual monetary disbursements versus commitments, so Commins called for a system that tracks allocations and spending in real time. These are not our countries, he argued, and responding to health systems in post-conflict settings should be tailored to the country’s needs, not the donor’s. He also called for increased research that describes, over time, the costs for rebuilding and transitioning from international NGO-driven systems to self-sustained governments.

Rebuilding Health Systems in Sudan

George Kijana, health coordinator in southern Sudan for the International Rescue Committee, discussed reasons for why Sudan’s health system remains poor five years after conflict. According to Kijana, the government in Southern Sudan has not been held accountable by its donors, leading to a breakdown in infrastructure and a lower quality of health workers.

Additionally, a majority of the available health data comes from non-state actors that are not easily accessible. Kijana shared that in order for Sudan to move forward, more research and data are needed to help target long-term capacity building projects, as well as short-term interventions that address infant and maternal mortality. While progress is slow, he pointed out encouraging signs of progress, as the Ministry of Health now recognizes their weaknesses and positively engages with its development partners such as the United Nations.

Photo: Romanian Patrol administers medical treatment to Afghan communities, courtesy of Flickr user lafrancevi.

MORE

The Center for Global Development’s latest report, Start With A Girl: A New Agenda For Global Health, sheds light on the risks of ignoring the health of adolescent girls. Like other reports in the Girls Count series, it links broad social outcomes with adolescent health. “Adolescence is a critical juncture for girls. What happens to a girl’s health during adolescence determines her future–and that of her family, community, and country,” state coauthors Miriam Temin and Ruth Levine.

Between childhood and pregnancy, adolescent girls are largely ignored by the public health sector. At the same time, programs and policies aimed at youth do not necessarily meet the specific needs of girls. Understanding the social forces that shape girls’ lives is imperative to improving their health.

Like recent books by Michelle Goldberg and Nicholas Kristof, the report argues for increased investment in girls’ education to break down the social and economic barriers that prevent adolescent girls from reaching their full potential. Improving adolescent girls’ health will require addressing gender inequality, discrimination, poverty, and gender-based violence.

“For many girls in developing countries, well-being is compromised by poor education, violence, and abuse,” say Temin and Levin. “Girls must overcome a panoply of barriers, from restrictions of their movement to taboos about discussion of sexuality to lack of autonomy.” The report points to innovative government and NGO programs that have successfully changed negative social norms, such as female genital cutting and child marriage. However, the authors urge researchers to examine the cost-effectiveness and scalability of these programs.

In the last five years, the international community has become increasingly aware of the importance of youth to social and economic development. Some new programs are focused on investing in adolescent girls, such as the World Bank’s Adolescent Girls Initiative and the White House Council on Women and Girls, but significant additional investment and support is needed.

“Big changes for girls’ health require big actions by national governments supported by bilateral and multilateral donor partners, international NGOs…civil society and committed leaders in the private sector,” maintain Temin and Levin. They offer eight recommendations:
1. Implement a comprehensive health agenda for adolescent girls in at least three countries by working with countries that demonstrate national leadership on adolescent girls.
2. Eliminate marriage for girls younger than 18.
3. Place adolescent girls at the center of international and national action and investment on maternal health.
4. Focus HIV prevention on adolescent girls.
5. Make health-systems strengthening and monitoring work for girls.
6. Make secondary school completion a priority for adolescent girls.
7. Create an innovation fund for girls’ health.
8. Increase donor support for adolescent girls’ health.

“We estimate that a complete set of interventions, including health services and community and school-based efforts, would cost about $1 per day,” say the authors of Start With a Girl. There is no doubt in my mind that this small investment would indeed have a high return for the entire global community.

“All trafficking is not sex trafficking,” argued Woodrow Wilson Center Fellow Pardis Mahdavi, at a recent Middle East Program event. Drawing on her ethnographic research in the United Arab Emirates, Mahdavi analyzed the policy implications of the latest Trafficking in Persons (TIP) report by the United Nations Office on Drugs and Crime. The TIP report offers information on modern day slavery–human trafficking–and includes comprehensive data on policies and enforcement in 155 countries and territories.

The TIP report paradoxically hurts the people it tries to protect, claimed Mahdavi, by placing too much emphasis on sex trafficking and failing to take into consideration other types of abuse, such as those against men and migrant labor workers. Mahdavi pushed for a “breakthrough of the labeling and politicizing of sex traffickers as women and children,” which depicts women as passive and helpless, while excluding male victims.

According to Mahdavi, in Dubai, 80 percent of the population are migrant laborers. Often, these foreign workers do not trust the government to protect them against trafficking abuses, particularly if they are working in the host country illegally. Thus, civil society organizations, and not the state government, serve as the major source of protection and recourse for abused migrant workers. In the Persian Gulf region, Mahdavi argued that the “TIP report needs to be rewritten…to include increased labor inspectors and police training,” and called for the increased “accountability and transparency” of civil society organizations.

Mahdavi cautioned countries against using the TIP report to enact policies that make migration illegal. Tightening borders forces workers into the informal economy, she maintained, where it becomes difficult to track and protect these individuals.

Although the TIP report has weaknesses, it does pressure countries to act, as Mahdavi has witnessed in the United Arab Emirates, where it has provided opportunities for dialogue on the various aspects of trafficking.

In what CNN has dubbed her “biggest trip yet,” Secretary of State Hillary Clinton has commenced an 11-day, seven-nation tour of Africa that will take her to many of the continent’s most volatile states, including Kenya, South Africa, Angola, the Democratic Republic of Congo (DRC), Nigeria, Liberia, and Cape Verde.

To promote the 20th World Population Day on July 11, the United Nations Population Fund (UNFPA) tied this year’s theme—“Fight Poverty: Educate Girls”—to combating the ongoing financial crisis. It’s a no-brainer that, as UNFPA points out, “women and children in developing countries will bear the brunt of the impact.”

Simon Dalby, a geographer at Ottawa’s Carleton University, wants to put the “human” back into “human security” with his new book Security and Environmental Change. He is trying to find a common vocabulary to bridge the disparate languages of environmental science and security studies and enable them to mesh in a way that makes “intellectual sense.”

The development reform picture became more complicated after a recent speech by Senate Foreign Relations Committee Chairman Senator John Kerry (D-MA) and congressional testimony by Deputy Secretary of State for Management and Resources Jack Lew.

Revamping State and USAID

At a Brookings Institution speech (transcript) on May 21 entitled “Diplomacy and Development in the 21st Century,” Kerry laid out the Senate Foreign Relations Committee’s plan for strengthening the civilian agencies that deal with these issues.

In the short term, Kerry favors the recruitment of more diplomatic and development professionals and a stronger emphasis on their training and education. He also expressed his desire to “untie the hands of our aid workers” by streamlining outdated regulations and rebalancing the relationship between Washington and the field.

“Over the long term, we need to take a close, hard look at exactly what we want our diplomatic and development institutions to achieve,” said Kerry. “We need to make sure that we give those people the resources they need to get where we have decided they must go.”

To meet these goals, he and Senator Richard Lugar (R-IN) will introduce two pieces of legislation: a Foreign Affairs Authorization Act and a foreign aid reform bill, which will serve as precursors to a more comprehensive overhaul of the 1961 Foreign Assistance Act next year, said Kerry.

A Power Grab by State?

On May 13, Lew testified on the FY2010 international affairs budget request (webcast; testimony), outlining five “smart power” funding objectives:

1. Build civilian capacities in State and USAID;
2. Promote long-term development and human security;
3. Enhance strategic multilateral and bilateral partnerships (e.g., with Israel, Egypt, Pakistan, and Afghanistan);
4. Strengthen global security capabilities (e.g., nuclear non-proliferation); and
5. Maintain the resources to respond to urgent humanitarian needs.

According to Lew, State’s approach to development will be both “top-down”—strengthening “the ability of governments to support just and capable institutions that meet the basic needs of their populations”—and “bottom-up”—partnering with civic groups to build human capacity to innovate, cooperate, and solve problems.

Lew indicated that State should coordinate multiple agencies’ efforts to address challenging, cross-sectoral problems. He said, “We must be able to look at a country, a function or an objective and be able to identify everything that the U.S. government is doing in that area—not just State.” For instance, he wants the State Department to lead “a whole-of-government process to design and implement a new food strategy.”

Lew’s testimony seems to indicate that State wants to oversee all of development policy, with no apparent role for the National Security Council (NSC). But it is not at all clear that State has the human and financial resources to coordinate all the other agencies involved in development. If State were granted this authority, the organizational implications would be immense.

At the NSC, development issues fall under the purview of Deputy National Security Adviser for International Economic Affairs Michael Froman, but he has many other issues on his agenda, including the G20 and the G8. I would be surprised if the NSC does not see this kind of overall coordination as part of its mandate. But there have been no public reactions to State’s grab for power.

At the same time, both Kerry and Congressman Howard Berman (D-CA), chairman of the House Foreign Affairs Committee, see development reform as a major part of their portfolios. The State Department has strongly opposed Berman’s bill mandating that the administration produce a government-wide “National Development Strategy,” on the grounds that the responsibility for drafting such a document should be given to the State Department, and not (as it is now written) to the President. The future of Berman’s legislation is not clear, but Kerry also has indicated his desire for an overall strategy paper.

USAID Still Seeking Chief

Finally, USAID still lacks a director. The latest rumors in the blogosphere revolve around Dr. Paul Farmer, the renowned physician who founded Partners in Health, a major NGO focusing on global health. Farmer would be the first USAID administrator in recent years with extensive on-the-ground development experience, but I understand he has no experience with Washington bureaucracy (outside, perhaps, of the health arena). Furthermore, he is known more as a charismatic leader than as a manager.

Farmer would be an unconventional choice for running USAID, though there are conflicting opinions on whether he even wants the job. But if he does want it, he should ensure he had a deputy secretary rank, as well as authority over the Millennium Challenge Corporation, the President’s Emergency Plan for AIDS Relief, and other independent development programs. He also would need the funds and staff to completely revamp USAID to meet the challenges of the 21st century.

John W. Sewell is a senior scholar at the Woodrow Wilson Center and the former president of the Overseas Development Council. ECSP published Sewell’s review of Trade, Aid and Security: An Agenda for Peace and Development in ECSP Report 13.