USAID: an agency without leader and direction

Abstract

Last week, the rumours that Paul Farmer was no longer in the running to take over the US Agency for International Development (USAID) became all but certain. The reasons are unclear, but one explanation mooted persistently is that he was offered the position but was dismayed by the prolonged vetting procedure and withdrew. After 7 months without a leader, the USAID staff's morale has plummeted, and a vacuum has been created to be filled by others with vested interests. In July, at a town hall meeting at USAID, Secretary of State Hillary Clinton aired her frustration with the process when asked about the problems with the appointment. The agency is currently run by Jack Lew, the Deputy Secretary of State for Management and Resources, who has no background in health or development. Staff are spending much time providing him with technical explanations and briefings. Clinton is embarking on a Quadrennial Diplomacy and Development Review as a blueprint for how the State Department and USAID can together set priorities. With such deep involvement by the State Department and without a strong leader at USAID in place, the justifiable fear is that programmes will be directed to achieve short-term political gain rather than governed by need and science-based advice. Initial expectations ran high, with US President Barack Obama making foreign aid and development, and in particular health for development, some of his key priorities. His Global Health Initiative outlined not only commitment to HIV/AIDS, malaria, and tuberculosis but also a welcome new emphasis on maternal and child health and neglected diseases. USAID had a much increased budget of US$13·2 billion in 2008. In July, Senators John Kerry and Richard Lugar, with others, proposed a new Bill, the Foreign Assistance Revitalization and Accountability Act of 2009, which gave a strengthened, more transparent, and independent role for USAID. All the building blocks are in place. Obama's preoccupation with US health-care reform must not distract him from urgently and speedily finding and appointing a strong candidate to competently lead USAID—one of his greatest assets to advance trust in US commitment to global health.