George W. Bush and the President’s Emergency Plan for AIDS Relief
Forty million total cases. Three million deaths. One year. This was not the casualty of a bloody global conflict, but the state of the HIV/AIDS Crisis in 2003 when President George W. Bush launched the President’s Emergency Plan for Aids Relief (PEPFAR). Since the beginning of this program it has provided over $80 billion dollars for AIDS funding and saved an estimated 17 million lives.
In doing so, it also represented a rarity in today’s highly polarized environment: a bipartisan agreement from policymakers that the U.S. had a responsibility to help those in need.
Yet, while the results of PEPFAR seem indisputable, during its early years, many people doubted the efficacy of the program. Implementation problems on the ground, interagency conflicts, and public perception of the program were some of many issues the new initiative faced as it attempted to tackle the global AIDS crisis. In its first five years, the program focused on working directly with fifteen so-called “focus countries” that were considered to have both the highest rates of AIDS and the fewest resources to deal with the disease. After this initial five-year period expired, PEPFAR was reauthorized with a focus on developing long term partnerships with countries that would work to shift the leadership of the fight towards the partner nations.
Robert Clay joined the PEPFAR program as the director of the office of HIV/AIDS in the
United States Agency for International Development (USAID) Global Health Bureau in 2008 as this shift occurred. There he was responsible for 60 percent of PEPFAR’s budget in a program that was struggling to find a new sustainable direction. This came after a 25-year career fighting the AIDS epidemic on the ground in Zambia and India and experiencing the work of PEPFAR and its predecessors firsthand.
As director, he witnessed the struggles of a massively funded, but highly political, organization. From budget disputes to long term planning failures, Clay details the struggles he faced in the mission to combat the global AIDS crisis from the organizational side, and the unique successes and failures the United States achieved. In doing so he offers insights and a vision for how America can continue to improve its responses to global public health crises.
Robert Clay’s interview was conducted by John Pielemeier on April 12, 2018.
Read Robert Clay’s full oral history HERE.
Read more about the AIDS crisis on the ground in Africa HERE.
Drafted by Ty Ashton Ehuan
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“Holbrooke turned to me and he asked how many of these kids are here because of HIV/AIDS. I said, we don’t know for sure but probably seventy to eighty percent.”
Beginning of the Global Response: It’s interesting when you go to the Hill and ask people what was the entry point for them with HIV/AIDS. It was often orphans and vulnerable children. So both in Zambia and India, we had Staff delegations and Congressional delegations that would visit children’s programs and that was the way that they were able to start understanding and get to know the effects of HIV/AIDS. That was also true with Ambassador Holbrooke. This goes back to my time in Zambia. He came out to Zambia when he was the U.S. Ambassador to the U.N. He visited a project that we had in Zambia that was focused on orphans and vulnerable children. We had probably 200 kids that were in this area playing and doing all kinds of things. Holbrooke turned to me and he asked how many of these kids are here because of HIV/AIDS. I said, we don’t know for sure but probably seventy to eighty percent. Later on, in an interview that he did on the plane back from Africa, he said a light bulb went off and he began to understand the significance and the scope and enormity of the AIDS epidemic.
He visited a couple of other places but it was from that trip that he then worked to get the special session on HIV AIDS in the U.N. in January.
Q: January. What year was that?
CLAY: It was January 2000. Vice President Al Gore chaired the U.N. Security Council special session and that really was the start of the global response. In the late ‘90s and early 2000s, we in the field were crying out and asking where is the global response because we were seeing this disaster happening right in front of us. There was very little international outcry and we thought this should be on the front page of all the papers because of what we saw happening.
From the U.N. session, there was a big ramp up globally, and that eventually led to the Global Fund on AIDS, TB, and Malaria and it also had a huge impact on the support for PEPFAR. Everybody has their own version of events that transpired. I would venture to say it was that field exposure and understanding of the impact that Ambassador Holbrooke took away from his Africa trip that got him motivated and it was an effect that got others quite engaged in the whole issue. That reinforced what was happening around the world.
“At first I thought he was joking because PEPFAR had such a bad internal reputation.”
Starting at PEPFAR: I had the option of retiring while in India or staying on, and I definitely wanted to stay in India. Through the course of my tour, I actually extended one more year so I was in India for five years as I have mentioned. My last year, I was approached by Kent Hill (Assistant Administrator for the Global Bureau) to see whether I wanted to come back and lead the USAID/PEPFAR program.
At first I thought he was joking because PEPFAR had such a bad internal reputation. And I had been engaged in PEPFAR’s predecessor with the Life Initiative in Zambia and then with PEPFAR in India so I was aware of some of these challenges. I knew the tensions with the management of organizations, the pressure to move money, and the focus on reporting. At the same time, after Zambia and India, I knew the importance of the HIV/AIDS work. I also thought that it would be useful to be back in the U.S. after ten years overseas. At that time, USAID was enforcing the twelve year rule, so I would either have to come back now or in two years.
I had been engaged in PEPFAR’s predecessor with the Life Initiative in Zambia and then with PEPFAR in India so I was aware of some of these challenges. I knew the tensions with the management of organizations, the pressure to move money, and the focus on reporting. At the same time, after Zambia and India, I knew the importance of the HIV/AIDS work. I also thought that it would be useful to be back in the U.S. after ten years overseas. At that time, USAID was enforcing the twelve year rule, so I would either have to come back now or in two years.
I made the plunge and took the position as the Director of the Office of HIV/AIDS in the Global Health Bureau. It was an office of 140 staff and a budget of $3.3 billion (60% of PEPFAR at that time) It was a time of a lot of uncertainty. The PEPFAR program had been around for a while, but there were a lot of tensions between the different agencies, largely because USAID had traditionally been working in the space of HIV/AIDS and under PEPFAR it was a whole of government approach including CDC, but also DOD, Peace Corps, and HHS. USAID had the sense that everybody was trying to take away what they had been doing in the past. There was a real feeling of hunkering down, feeling of being attacked that was really prevalent within the office. So one of the things that I did when I first came back—after talking to all the staff, and doing my assessment—was to establish that we needed to have a two-track approach. One to pursue changes within the whole PEPFAR program and to see whether we could have a more equitable distribution and play more to our strength than we currently felt. There were some opportunities coming up including a change in the PEPFAR Ambassador. So that seemed like an opportune time where we might be able to address these broad concerns. That was one track—a higher track to try to change the model.
But I told the staff, we also have to have a track that said we’re going to be best-in-class for the current model because we can’t just be defensive. We can’t just think that they’re taking our football and therefore we’re not going to play. We have to be very actively engaged and until we have any changes at the broader level, we needed to really be focusing on delivering what we had been asked to do with good quality and sound technical assistance. So that’s how we started. I think it really helped the staff get to a much more positive position and attitude.
“…we didn’t have clarity between the two dominant players—CDC and USAID.”
Cooperation Difficulties: This was a very stressful environment with lots of issues. My time as the head of the USAID/PEPFAR program, which was three years, I would characterize as working in the grey zone.
The grey zone is where we didn’t have clarity between the two dominant players—CDC and USAID. So every day there would be these issues that would come up about who’s doing what. Why was CDC taking lead on this—or CDC would come and say why is USAID doing this.
There was just a lot of negotiation between the two agencies. Previously, CDC and USAID worked very well together because there were defined roles. CDC was the expert in surveillance, lab and epidemiology. In the past, oftentimes the missions would request CDC to come to their country to provide those services because they complemented what we did. But PEPFAR, because of the size of the money, gave huge increases in resources to all agencies. So, CDC’s role changed dramatically.
Over time CDC became a different organization within the PEPFAR program and in some ways they became a sister organization to USAID. In some countries like Zambia, they just divided the country in half and CDC did half the program and USAID did the other half. It meant that CDC was developing expertise and prevention programs and doing all kinds of things that traditionally they hadn’t done. And that became a real source of tension.
Dr. Debbie Birx was the head of the CDC/PEPFAR program in Atlanta and I was the head of the USAID/PEPFAR program in Washington. We both spent a lot of time negotiating and discussing issues between the two organizations. We also went on numerous joint field trips to be able to build the relationships necessary to manage this program.
“PEPFAR was and continues to be seen as one of the most successful programs in the U.S. government”
Leadership: PEPFAR had two main leadership bodies. The principals were the PEPFAR ambassador and the agencies political leadership. Then there were the deputy principals who led their programs in their agencies. I was the USAID deputy principal. During my tenure, deputy principals played a key role in terms of debating and discussing. I remember meeting every week for three, four, or five hours going through all the different programs, all the issues—excruciating meetings. And you know thinking back I wondered if we could have done that differently. But it did bring everybody together and forced us to really confront issues.
You got to see the potential when everyone worked together. You know the USG is a very powerful organization with all the wealth of expertise across the board. It is really phenomenal when we all work together. I would say that was not rare, but it was not a frequent occurrence. Oftentimes, we were working across purposes. And I think that the whole of government is good in theory but in practice it has real downsides, particularly if roles and responsibilities aren’t well defined as in PEPFAR.
The irony is, that because of the amount of money and the emotional issue of HIV/AIDS, and the visible progress that we had through the indicators, PEPFAR was and continues to be seen as one of the most successful programs in the U.S. government on the outside. It really is viewed as a way in which the government has really been able to tackle an area and make a huge difference.
And that’s true. That is correct. But inside the organization, and this is a story you don’t hear much outside of the organization—inside of the organization there are, as I mentioned earlier, a lot of hard feelings, there are people who basically would never work in another PEPFAR country because of the tensions that exist. There is also inefficiencies and duplication.
One of the biggest problem areas was the country budgets. What often happened the first year was that PEPFAR would announce a budget to the country and then let the country decide how they’re going to divide it up.
Basically the parties in country, largely CDC and USAID, would spend weeks and weeks arguing and fighting over who does what. At times, it got very, very childish and in the first year people really went to defend their own turf. It was not a good beginning on collaboration.
USAID had most of the HIV/AIDS activities before PEPFAR, so CDC was trying to increase their amount. This became very ugly in some places. The second year when this happened again people said, wait a minute, we’re going to have to go through this again? Some continued to fight but others just divided it in half. You do this and we will do that and then we go on our separate ways. It really wasn’t truly whole of government. It was just divided geographically or it could be technically divided. Or they just said let’s just do what we did last year. Let’s not revisit it. We’re going to do a straight line. That happened in a number of countries where things just continued as normal. And I always felt that this was one of the real shortcomings of the whole approach. There wasn’t a real in depth review of what had happened and then changes to the system. Strategic decision making was not happening around the budgets.
On the other hand, I know that there would have been thousands of people continuing to die if the services didn’t get out there. So it’s a debate and it’s a tension within the program.
“…there were some missions that would advertise their post was not a PEPFAR country and therefore you could come and not have to do PEPFAR.”
Information Collecting: I think the other thing that I felt from that time at PEPFAR is that when I came back from the field, I was really amazed that there was so much information that the field was providing to Washington through the PEPFAR management information system.
You know PEPFAR is famous for their reporting. It served them very well in terms of being able to respond to Congressional inquiries. We were able to turn around very quickly what was happening at PEPFAR whenever Congress asked for something. That was key to the continued bipartisan support on the Hill and was key to continued increase funding beginning in 2003 all the way to 2010, huge increases every year. I was amazed when I came back to see that a lot of that information the field provided was never being utilized or analyzed. There was a huge opportunity cost of the field collecting this information. They weren’t going out to see these programs: they were basically filling out forms at headquarters. So that was a key area that I championed when I was back. Trying to get more reasonable information collection differentiating between what was necessary in Washington and what could stay in the field. During that period there was a whole revision of the HMIS system. I think it became a little more rational though PEPFAR has always been very heavily focused on information collection.
Q: Right. I think from the early days PEPFAR set up its own information collection system unlike in other parts of USAID. It had the reputation of being a family killing assignment for people who would work in missions because you worked on weekends. They also as you mentioned were unable to get to the field as much as they wanted. It was very staff intensive.
CLAY: Correct. In fact, there were some missions that would advertise their post was not a PEPFAR country and therefore you could come and not have to do PEPFAR. So that became a selling point for attracting Foreign Service Officers.
“The caliber of the staff, the level the discussions and in some ways the interagency rivalries demanded the best.”
Successes and Failures: Thinking back, PEPFAR was a mixed bag. Yes, it was hugely intensive, there was widespread burnout. A lot of it I think could have been more streamlined and better managed and I think we actually would have achieved more. At the same time, largely because of those funds that we had, PEPFAR was able to do things that other programs weren’t able to do. The caliber of the staff, the level the discussions and in some ways the interagency rivalries demanded the best. I think USAID’s staff were always feeling like they were on the edge and having to really perform at a very high level in order to survive in the PEPFAR environment. So I think it was a strong incentive for USAID to do its best.
There are some practices I think that came out of PEPFAR that should be incorporated in other programs. Particularly the whole area of data and being able to explain what we’re doing and being able to analyze the data.
But there are other areas that we need to not repeat and learn from. PEPFAR was designed as an emergency program, so it started because we had drugs that needed to get to people. Whatever means were feasible at the time, which often meant parallel systems, PEPFAR used them. So it was not designed as a development approach because the development would take time and there were people that were dying.
USAID’s position at the table was that we should set up systems, sustainable processes, and we should work to bring others along. I think a lot of the other PEPFAR agencies around the table were looking mostly at treatment expansion.
“What is the end game here?”
Long-Term Approach: Over time, PEPFAR started to re-examine its approach. I would attribute this largely to the response to those in the Obama administration and the Hill when they saw how much money was mortgaged to the ARV (antiretroviral) treatment.
Once you put someone on ARVs, you can’t just take them off. So you’re basically obliged for the rest of their life to provide these services. Therefore, the mortgage of our resources is quite significant. The Hill kept asking, “What is the end game here? When are we actually going to be able to see some return, or not have this huge commitment because it really was undercutting so many other worthwhile global health programs with all this money going into the PEPFAR program.”
Q: Robert, this reminds me of a similar issue in the previous years with USAID’s program with contraceptives for family planning where we provided, we were the only donor providing contraceptives in many countries. And many countries were not providing their own. There was a lot of pressure over the years to move out of that, spending so much money on buying contraceptives and finding other ways of those being provided either by other donors or rather the host country themselves. And that has been relatively successful. AID did make that transition.
CLAY: You are right. The difficulty with PEPFAR was that there was so much money so quickly that it displaced virtually all the other donors. Also many ministries of health made the rational decision that if there’s so much coming into this sector, that they would move their resources over to cover other shortfalls they have. We had countries where 80 to 90 percent of the program was funded by the U.S. government. And if you do that for four, five, six years it is very difficult to get that changed around. What PEPFAR was trying to do is to reengineer the program midway and try to bring in sustainability to the program. They put big resources behind it. There were lots of different meetings and strategies. McKinsey came in and did all kinds of studies for us. They did move a lot towards the approach, but PEPFAR is still a long ways from becoming a sustainable program in that regard. So yes, I think it could have been designed up front as opposed to trying to retrofit it later on.
We saw that in Ethiopia where initial allocation of resources was for an epidemic that we thought was around 4 to 5 percent. So the amount of money was appropriate for that. But during the course of PEPFAR, after one or two years, there was a revision of the numbers based on current data that showed prevalence was much lower, largely concentrated in the urban areas and not in the rural. Because of this tension, the amount of money continued to be at the level of the previous assessment. There weren’t any changes to the funds to match the epidemic and that created huge pipelines. When we got to 2011/2012, our review showed massive pipelines in some of these countries where the epidemic didn’t match the amount of money that was being sent.
In some ways that pipeline helped those countries because that’s what saved them when the funding became flat lined in 2010. We had exponential growth up to 2010 and then we had a flat line in funding. But after 2010 the expenditures continued because of the pipeline that existed. We continued to be able to ramp up the program but then eventually that pipeline ran out so eventually people had to start looking at reductions of their work or more cost effective programming.
TABLE OF CONTENTS HIGHLIGHTS
BS in Molecular Biology, University of Texas 1972–1976
MA in Public Health, University of California, Los Angeles 1981–1982
Joined the Foreign Service 1984
USAID/Zambia Population, Health, and Nutrition Office Director 1998–2003
USAID/India Dir. Of Population, Health, and Nutrition Office 2003–2008
Return to USAID/Washington as Director of Office of HIV/AIDS 2008–2011
Deputy Assistant Administrator for Bureau for Global Health 2011–2014