7 Questions with Dr. Rajiv Shah

KARL HOFMANN: Dr. Shah, you are working to make sure USAID projects are moving toward an endpoint; essentially hoping to put USAID out of business in the long run. Is one of the ways in which countries will move toward self-sufficiency in health care provision by increased provision of health products and services through the private sector?

DR. RAJIV SHAH: Absolutely. I believe that global health investments, and development investments overall, are a critical part of keeping our country safe and secure and building an interconnected world that functions well and trades with each other and affords more and more people real opportunities. Because that mission is so important, we’ve really done an exhaustive review and identified an aggressive reform agenda that we call USAID Forward. It defines a set of principles for how we should do development assistance so we can achieve development objectives and, as you put it, put ourselves out of business. Really core to that is this understanding that ultimately our development investments should be replaced by vibrant civil societies, strong private sector activity, and effective, good governance and public service management. In health, a lot of what should follow major development activities is a vibrant private sector that provides health care services in a high-quality, verifiable way to low-income communities, and strong public sector systems that can continue to finance, resource, prioritize and train enough people so that you have a real vibrant and integrated health care system that can stand on its own going forward.

KH: You’ve stressed the need for USAID countries to drive economic development through “added-value” activities. Do you consider disease prevention programs to be added-value?

RS: Economic growth should increasingly be the central goal of all of our development efforts because that’s the engine of social improvement that brings better services and better quality of life to the poorest around the world. In health in particular, the investments made to reduce the burden and inequities in global health have huge impacts on economic growth and development.

We have a large amount of data that show, for example, investing in malaria not only reduces all-cause child mortality but it frees up hospitals and health systems to treat and serve other patients. Over and above that, it has meaningful impact against economic growth as resources and people are free to engage in more productive activities than of course being sick or ill. What I think is less discussed is the huge toll of malnutrition and child stunting on economic development. We know that 3 percent of GDP in low-income countries is essentially lost to child malnutrition. Then there’s all the unmeasured impact of kids who are never fully able to realize their economic, intellectual and human potential because they suffered from hunger, malnutrition and disease as a child.

When you start saving kids lives and especially young kids, and you reduce child mortality, people then start having less children because they have a higher confidence that their children are going to survive and they start investing more in the health, education, well-being and unlocking the human potential of those fewer children. That’s really the real virtuous cycle that links improved child health to improved economic development.

KH: PSI’s affiliate in Nigeria, the Society for Family Health, became the first locally held Nigerian nongovernmental organization (NGO) to qualify for direct USAID funding. In many countries, that transition from local NGO to receiving direct funding from USAID can take a long time, often due to hurdles like lack of local capacity, insufficient infrastructure and even corruption. How can USAID best address this issue?

RS: Let me first congratulate you and PSI in Nigeria for achieving that distinction because it’s very important and it’s very much the actual vision of success: having strong local institutions that have these broad capabilities. USAID has a proud history around the world of investing directly in local institutions from Bangladesh Rural Advancement Committee in Bangladesh to NGOs in Guatemala and El Salvador, which I just visited. But it is not enough to congratulate ourselves for our past. We are being really aggressive about changing our procurement system so that we can make more direct investments in local institutions right now, everywhere. In Pakistan for example we’ve moved up from 8 to 49 percent of the total assistance portfolio going to local institutions and the Pakistani government. We’re trying to replicate that in many other parts of the world.

KH: USAID celebrates its 50th Anniversary this year. What would you like to see enduring out of the next 50 years?

RS: When President Kennedy created USAID in a letter to Congress, he talked about how development assistance had become disorganized and multifaceted, and we weren’t really living up to our potential to share American ingenuity and innovation, science and technology with the poorest communities and countries in the world. In creating the Agency, he really did launch a great run – those early decades in particular had USAID well-resourced, making real investments in infrastructure and growth, focusing on bringing science and technology to the poorest parts of the world. And we saw huge impact.

We believe that we have a similar opportunity today, and looking forward we want to do many of the same things. This Administration’s very committed to investing in growth, focusing on science and technology, addressing the crisis we currently face in food and hunger, and realizing the next frontier of global health, which I think is linked to immunization, malaria, and new more innovative approaches to both tuberculosis and HIV prevention. Across those areas of work we can save millions of lives, protect and reduce maternal mortality quite significantly, and prevent more than 50 million unintended pregnancies. So we have this huge opportunity to achieve dramatic, quantitatively measurable results, and I just hope we seize that and do everything we can to make those achievements real.

KH: In the past, siloed funding for global health projects has been fairly standard but now the Administration under President Obama has moved forward with the Global Health Initiative (GHI), which talks more about comprehensive health programs and integration and the need to strengthen countries' own health systems. How do you see reconciling that need to integrate with the need to show real measurable success?

RS: At the end of the day when I think of the GHI, I’m most proud of the fact that in Kenya we have integrated family planning and maternal health services into the AIDS treatment platform of the U.S. President's Emergency Plan for AIDS Relief. At essentially no extra cost, we’ve expanded services to a large number of women in all parts of the country. I’m proud of the fact that in Mali we’ve brought together six or seven different disease campaigns, reduced the cost of executing them, expanded their reach and improved health outcomes particularly for children. And I’m really excited that in Malawi and Zambia we’re working to build a common drug procurement system that can be run and managed by the government but in a transparent and open way so that you don’t have a different drug procurement system for every disease. Doing those things allows people to take a longer-term view and invest in training human resources like nurses, midwives and community health workers, and it allows them to reach more people who would not otherwise get life-saving care at lower cost. But the real opportunity is to then invest those savings into the areas where we can have the health “buys” for the dollars that we invest. We can be very results-oriented in doing that. By introducing new vaccines against pneumonia and diarrhea, we can save 3 to 4 million lives in the next five years; by introducing new diagnostic technology and tuberculosis (TB) case management, we can potentially lower the cost of treating TB and reach many more people; by improving our ability to continue to be successful with the President’s Malaria Initiative, we can see another 50 percent reduction in all-cause child mortality in sub-Saharan Africa, which can essentially over a few years eliminate malaria from being a major cause of child death in sub-Saharan Africa.

So at the end of the day GHI is about efficiency, but it’s also about results. In fact the two go hand in hand. The results that are now standing at our doorstep are literally the things that we’ve been working on for decades to make possible, and we have to see it through.

KH: Your new evaluation policy emphasizes transparency, monitoring and reporting on lessons learned. How will we hold local organizations accountable in the same way that we hold organizations accountable at the more macro level?

RS: We need to make sure that whenever we’re spending resources we’re learning something about the impact that spending is having, and we’re getting better based on that learning. Everything doesn’t need to be a big scientific study to observe success or failure; learn from it, and move forward. That is why we’ve made a commitment that all of our projects would be subject to evaluation. Those evaluations, no matter what they say, will be publicly available and from them, we will collectively learn and get better.

KH: You’ve said that USAID plans to graduate at least seven countries from U.S. assistance by 2015. What are the qualifications you anticipate for graduation?

RS: The main graduation criteria has to do with economic growth and development, the evolution of good governance, the ability to connect into a society of partner countries where trade, investment and the ability to tackle complex problems is more active. Also, it will be in countries where we know the USAID assistance relationship can transition from a traditional development assistance relationship to one that’s really more about technical cooperation, bilateral learning and partnership and multilateral engagement. In global health, we’ve had a process of graduating countries from contraceptive access to family planning efforts. We only do that when countries reach 50 percent modern contraceptive prevalence and a total fertility rate under three children per women. It’s that kind of results-based graduation that we’re ultimately seeking because the goal of assistance is to help countries stand on their own, not to be perpetually needed.

KH: Raj, the challenges that you face are truly momentous but, as you pointed out, the opportunities are also terrific. I know I speak for many colleagues in the implementing partner sphere that we’re delighted that someone with your energy and fresh approach is at the helm.

RS: Thank you. USAID is a wonderful organization. I’m honored to be a part of it, and honored to get to work with PSI and so many other great partners that are literally changing the world.