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Secretary Hillary Clinton’s ’s vision of the future role of foreign assistance in US foreign policy, as outlined in her address hosted here at the CGD on January 6, is ambitious, nuanced and inspiring. Bill Easterly takes issue with Clinton’s list of priority interventions, saying that it is too long to be consistent with her stated intention to “target” and to be “selective,” but I disagree. From which of these areas would Easterly want to rule out US assistance in all countries of the world? And by focusing on a few of these areas in any given country, the US assistance program can attain focus and accountability at the country level.

Furthermore, sometimes wise allocation of resources requires less selectivity, not more.

With regard to health spending priorities, Clinton said:

“One of our countries' most notable successes in development is PEPFAR, which has helped more than 2.4 million people with HIV receive life-saving anti-retroviral medications. Now PEPFAR will be the cornerstone of our new Global Health Initiative. We will invest $63 billion over the next six years to help our partners improve their health systems and provide the care their people need, rather than rely on donors to keep a fraction of their population healthy while the rest go with hardly any care. [Emphasis added.]”

Here Secretary Clinton is quite rightly pointing to the need to re-balance health sector assistance away from too narrow a focus on increasing the numbers of AIDS patients who benefit from antiretroviral treatment (ART) support and in favor of health interventions which strengthen recipient countries’ ability to provide their own care for their entire populations.

But I do have one bone to pick. I wish that Clinton had replaced the words “rather than rely” in the above passage with the words “and reduce their reliance”.

The expression “rather than” suggests that the US is considering reneging on the implicit lifetime entitlement it has already granted to the 2.4 million people now on US-funded AIDS treatment. As I have argued here and here, I think the US would suffer too great a loss of reputation if it were to renege on its implicit obligation to these people by cutting them off from their life-prolonging daily drug requirements. I doubt that Clinton meant to wave that red flag, since such a decision would contradict the objectives just announced by PEPFAR on December 1 (and blogged by CGD here and here) not only to respect that entitlement, but to add another 1.6 million people to the US-supported treatment rolls by the year 2014. My suggested rewording would more accurately characterize what I believe should and may be the US policy: To slow the growth of patients who “rely” on US funded antiretroviral treatment, while expanding and improving the effectiveness of US-supported interventions that over time can save more lives at less cost, thereby gradually reducing or eliminating the need for US-supported ART. These other interventions include not only direct HIV prevention, but also e.g. education and family planning, which reduce susceptibility to HIV infection and prevent unwanted births among HIV positive women.

So “bravo” Secretary Clinton for recognizing the need to rebalance the health sector. But as with domestic US entitlement programs like Social Security, public pronouncements should strongly signal US government respect for commitments to existing beneficiaries. Careful attention to such niceties in rhetoric as well as in actions will smooth the way towards a more rational allocation of the US health assistance budget.