Mark Dybul warns aid sector it must fundamentally change its ways

In the wake of President Donald Trump’s broadside against U.S. foreign assistance, many aid advocates have voiced a familiar refrain: “Yes we know the system needs reform but …” It seems not a lot of self-reflection is going into the part before the “but.” Amid the current maelstrom, Mark Dybul — a renowned global health expert who helped usher in the landmark U.S. HIV/AIDS initiative known as PEPFAR — sought to present a more optimistic, yet self-critical, narrative for the aid community in a recent Devex Pro Briefing. Dybul has voiced many of these criticisms for over a decade, long before the current existential debate over the usefulness of foreign aid triggered by the Trump administration’s dismantling of the U.S. Agency for International Development. His vision: A far less siloed sector that collaborates with the private sector and governments not just to dole out money, but to create a self-sustaining development plan that drives economic growth, ensuring mutually beneficial success for both donor and recipient. That vision begins with a child in a village, the mother, and the family and radiates outward. “We start with that human person and people in a village, and then the community around them … and the country around them, and the region around them. Would we — if we were focused on that child and giving them every opportunity in life, health, education, job opportunity, economic growth — set up the current development institutions and structures that we have, or would we create something different? And to me, the answer has been obvious for 20 years. We would create something different. “And the Africans have been telling us this for 20 years,” Dybul continued. “They do not like the aid model. They never have liked the aid model. They want something different. They need something different. They need a system that focuses on that family, that focuses on economic growth and opportunity equitably distributed, so that their countries can grow and that their people have opportunity.” “And you can’t do that with 1,000 organizations all siloed within individual activities that aren’t connected, that burden the countries with an enormous weight of bureaucratic responsibility, where they’re called out of the country or to a meeting every third day from a different organization.” For example, in Eswatini, he was told by community health workers that they need a cohesive health system, noting that “different community health care workers, one for maternal child health, one for malaria, one for HIV, were going to the exact same household every week.” “And I’ve been saying this for 13 years, and I’ll say it again, we need, functionally, a Bretton Woods II to remake our development institutions, which is going to mean consolidation, collapse, closing and shifting and engaging the private sector in a fundamental way which has been anathema — we do marginal things — to support countries in what they’ve been telling us they need: Sustained economic growth and development,” Dybul said. He noted that funds such as Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria — where Dybul once served as executive director — are wary of talking about doing things differently lest their replenishments get cut. “Well, they’re gonna be cut, so do you want a world in which that child gets taken care of or not, and what are we going to do about it?” he said. “And it’s not just Gavi and the Global Fund — it’s a rethink, and then — and this is something we are terrible at — bringing in the DFIs and the private sector pieces, because in the end, unless there is economic growth, all the things that we’re doing … are not going to get us out of the fundamental development issue.” But getting private sector buy-in to invest in low-income countries — where risk and return on investment are viewed unfavorably — is notoriously difficult. Dybul said it’s possible, citing the promising area of clinical trials in Nigeria, where the government “put together an investment case for what it would look like to invest in building a clinical trials infrastructure over five years.” And what they found was that with an investment of several hundred million dollars, you could create 500,000 and $3.8 billion in revenue, plus a profit margin that was reinvested into the health system, according to Dybul. “That’s very doable in many countries,” he said. That’s also an example of a win-win because currently, most trials are done with a limited number of participants — mostly white men over 50 — in expensive settings, while Africa offers more genetic diversity, “which happens to link to a lot of diversity in the United States, so it’s a win for everyone, and good for the United States.” “And so we have to stop thinking about what’s just the humanitarian thing? If it’s not a win-win, it’s going to be very difficult to get people to participate.” Dybul pointed out that two-thirds of people in Africa are under the age of 35, and the unemployment rate among younger men is around 50% or 60%. But that could represent a tremendous growth opportunity if the investment comes in. “They are young, hungry, but they don’t have the access,” Dybul said. “The next vaccines, the next new entry point can be found by these young, dynamic kids who are just so hungry.” Already, companies are realizing this potential. Dybul recalled a meeting with Walmart “and I asked the CEO at the time, why are you doing this partnership with us? I’ve never seen a Walmart in Africa, and he was like, ‘You can’t see it, but I sub, sub, sub source a lot from Africa. So if I don’t have a healthy Africa, I’m going to lose a lot of my relatively inexpensive sourcing.’” “I can’t meet my 10-year forecast if there isn’t a growing Africa,” Dybul added, arguing that “there’s nothing wrong with it being a win for everyone.” That mindset shift could also resonate with U.S. audiences. Dybul said the aid community needs to support a restructuring “that focuses on development — not individual projects, not individual organizations, not individual diseases, not individual anything.” “And if we can do that together, I think the administration and certainly Congress will respond. But if we don’t, and if the arguments are we need things to be the way they were … you won’t just be furloughing. You’ll be closing the doors.”