Waiting for Goosby: PEPFAR’s Chance to Shine

It’s official, finally! President Obama announced Eric Goosby as his nominee for Ambassador at Large and Global AIDS Coordinator at the Department of State. With this long-awaited decision, President Obama and the White House have broken the 98-day silence on the top three development positions beyond Secretary of State Hillary Clinton: heads of USAID, PEPFAR and the MCC.Many in the AIDS community have been nervous that the PEPFAR budget might be flat-lined in 2010 (i.e. at the FY 2009 level of $6.3 billion) and are relieved to have someone in charge to represent the program’s interests on the Hill, at the White House and at the State Department. It could also be that that administration prioritized PEPFAR over USAID because it is considered to be a strong program and doesn’t require an overhaul on the same scale as USAID. There will be more debate about factors that led to this appointment and why the head of PEPFAR was named before the head of USAID – but the politics of foreign aid reform aside, it might be useful to highlight some of the many skills and experiences that Goosby has picked up on his way to this important position that will serve him well:

• Strong AIDS treatment and care skills, specifically expertise on the scale-up of sustainable HIV/AIDS treatment capacity, including delivery of ARVs within existing healthcare systems.
• Leadership in the U.S. (HHS) and at the global level (Pangaea Global AIDS Foundation) in managing AIDS treatment, prevention and care programs with a focus on country-specific responses.
• Experience with Congress and the executive branch (he reported to President Bill Clinton on all AIDS related issues).
• Leadership of scientific reviews of public health interventions like needle exchange to develop an evidence based program.

Based on research conducted by CGD’s HIV/AIDS Monitor, here are five issues for Dr. Goosby to address as soon as he is confirmed and assumes the position of Global AIDS Coordinator:

1. Make programs work for countriesDemonstrate commitment to country specific responses, and continue to make programs more responsive to country needs and build country ownership. Design and execute a strong prevention, treatment and care strategy to implement a country specific response rather than in response to globally set objectives and targets. (see Following the Funding for HIV/AIDS)
2. Shift the emergency response to a sustainable responseManage the transition from an emergency to a sustainable response that involves the transfer of skills, expertise, technological know-how (see Following the Funding and The Numbers Behind the Stories: PEPFAR Funding for Fiscal Years 2004 to 2006) and financial sustainability (see Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and What to Do About It by my colleague Mead Over). In this financial downturn, budgets are getting tighter and tighter, as more and more global health priorities are considered every day. Dire warnings about ARV treatment interruption are circulating at the global and country levels.
3. Strengthen health systemsEnsure that health systems (including health information systems, supply chains for ARVs and essential drugs, and the health work force) are actually strengthened with support for the national AIDS response. (See Seizing the Opportunity on AIDS and Health Systems)
4. Publish measurable results of impact AND share PEPFAR dataDeliver measurable results for every fiscal year: those that also add up to real changes in the fight against HIV at the end of 5 years. i.e. that new infections decrease over time and that fewer people die from AIDS. (See The Numbers Behind the Stories: PEPFAR Funding for Fiscal Years 2004 to 2006). Share data about PEPFAR from its impressive database so that others can conduct useful analyses on program outcomes and impact. (See Memo to President Obama)
5. Address gender-based vulnerabilityEnsure that gender-based vulnerabilities and gender differences that drive infections and impede access to services are addressed and that measures to demonstrate gender-related outcomes are reported for prevention, treatment and care. (forthcoming analysis from CGD's HIV/AIDS Monitor and ICRW)

The world has been waiting for Goosby and he is here. Potentially strong leadership bolstered by technical know-how, strong political links, and domestic and global health policy skills should work to make PEPFAR shine in all directions, despite shrinking resources and loud calls to recalibrate funding for global health issues. Watch this spot as the new leader takes office, rolls up his sleeves and gets to work.