Oxfam America congratulates you on your inauguration as the 44th president of the United States. This historic moment provides an occasion to reestablish the role of the US as a global leader in fighting poverty and social injustice. And we believe you will make the most of this opportunity.

We ask that you take decisive and early action to shape how we engage in the international community. At a time when the US economy is in trouble and Americans are understandably concerned about their own economic well-being, we must not forget the needs of vulnerable populations around the world. If the US leads in the fight against global poverty, we can create positive long-term change that will result in a more just, prosperous, and secure world for all.

As your administration moves forward, you face an excellent opportunity to restructure US Foreign Assistance. Our current aid system is broken, which undermines American leadership and standing in the world. We ask that you work with foreign policy leaders in Congress to fix US foreign aid—a move that will fight poverty more effectively with no additional cost to taxpayers.

We encourage you to take bold action on climate change. The world?s poorest people—who are least responsible for climate change—are often the hardest hit by its consequences. Climate change is likely to increase economic and social instability, migration and refugee crises, and conflict over natural resources, and is quickly becoming a major driver of poverty and instability around the world. It is essential that your administration re-engage in international negotiations for a post-2012 agreement that includes significant cuts in emissions and additional funds to assist developing countries adapt to climate change. World leaders cannot create the next international climate agreement without US leadership. We also urge you to help bring about strong US legislation that not only dramatically cuts US emissions, but also provides significant assistance to poor and vulnerable communities.

Internationally, numerous conflicts continue to ravage civilian populations. We ask that you serve as a leader in prioritizing the protection of civilians in foreign assistance programs and cooperating with allies to remove obstacles to peace and stability. Yours is a unique opportunity: to build a 21st-century State Department by doubling the number of core diplomatic personnel and moving more personnel to potential and ongoing conflict zones. We know that we can rely on you to work closely with Secretary of State Clinton to achieve this vision.

In the US, we encourage you to turn your attention to the failed recovery of the Gulf Coast following Hurricanes Katrina and Rita. The inadequate US response to the desperate calls of her own citizens must not continue. Your administration can restore faith in government by helping to provide quality jobs and affordable housing for the low- and moderate-income families still unable to return to their former lives.

We look forward to working with you and members of your administration. We firmly believe that your leadership can help to improve the plight of millions of people who suffer from hunger, injustice, and violence around the world.

Sincerely,

Raymond C. Offenheiser
President, Oxfam America

Oxfam visited the densely populated and poor northern province of Zambezia in Mozambique recently to see how PEPFAR and other US agencies work on the ground. At the sites we visited, we found a close level of collaboration between PEPFAR and the Mozambique Ministry of Health. Over the past two years, the Mozambican government has worked to integrate all donors into its national development plans. Donors like PEPFAR have been asked to make some changes in the way they operate. PEPFAR aid to Zambezia province reflects PEPFAR’s ensuing move to integrate AIDS care into the long-term health system. To fight HIV/AIDS in Zambezia, Population Services International (PSI) implements PEPFAR programs ranging from those preventing the transmission of HIV from mothers to babies during pregnancy, to providing HIV counseling and testing, to preventing HIV through theatre and classroom presentations.

The need

Sixteen percent of the adult population of Mozambique is HIV positive. In some areas, infection rates are as high as 20 percent. In 2000, only 1,000 Mozambicans were on anti-retroviral therapy. PEPFAR programs have increased those numbers to nearly 160,000. PEPFAR funds have also financed care and support for about 800,000 people living with HIV and their families.

The debate

Development experts worry that PEPFAR may not be the kind of program that leads to long-term health and development. PEPFAR is often criticized as the textbook "vertical fund," which bypasses the government and creates a parallel health care system. Critics of these so-called vertical funds have pointed out that foreign aid donors sometimes pour all of their health funding into treatment of one disease. This can have the unintended result of neglecting basic care for the general population and hiring away health care workers from general medicine clinics to HIV clinics, leaving the general medicine clinics understaffed.

Donor resources for HIV have outpaced support for basic health care for all Mozambicans. In 2007, only 3 percent of US foreign aid to Mozambique was for child and maternal health, while 61 percent went to HIV/AIDS. But more people in Mozambique are affected by child and maternal mortality than by HIV, since 15 percent of Mozambican children do not reach their fifth birthday and the mother dies in one out of every 100 births in Mozambique.

Evidence: PEPFAR funds screening for other diseases

In the small town of Maganja da Costa, there is a PSI building next to the government health clinic that used to offer free counseling and testing to people who suspect they have HIV. The building bears a freshly painted sign. The sign used to read "HIV Counseling and Testing," and now it reads "Health Testing Center." At the request of the Mozambique Ministry of Health, PSI has expanded services offered there to include cancer, diabetes, and tuberculosis screenings. The change is a result of a recent Ministry of Health policy of integrating stand-alone HIV "day clinics" into the general health system, including centers funded by donors. Integrating these HIV day clinics into the general health system reduces the stigma attached to getting tested, since it's no longer obvious that if you walk into that building, you are there to test for HIV and HIV only. Making the building a generic testing facility, and not just an HIV one, provides new testing capacity for the government health clinic.

Evidence: PEPFAR places its staff in public clinics

PEPFAR is also working to integrate health care workers into government clinics, rather than hiring away the best staff for separate clinics. PSI has implemented this change on the front lines: its nurses are embedded within government clinics, wearing the same uniforms as government employees and providing the same services.

In the district hospital in urban Quelimane, PEPFAR's contributions to basic health are also on display. There, PSI uses PEPFAR money to fund two nurses and a physician's aide—a big addition to the original staff of eight. PSI also renovated the maternity ward, and Columbia University (using PEPFAR funds) transports blood samples to the lab, which is hours away. Support like this from PEPFAR makes it easier for the clinic to serve the more than 260,000 people depending on it for all their health care needs.

"PEPFAR support actually benefits other areas in the clinic. We now have pre-counseling in addition to testing, which we didn't have before, and we can now test for other sexually transmitted diseases as part of antenatal care because we have additional money for other testing." — Director of Government Clinic, Maganja da Costa

Evidence: It's the Mozambique Ministry of Health calling the shots

When we arrived in one town, PSI insisted that our first destination be the government clinic, where we asked the clinic's director for permission to visit. Visitors can be disruptive, preventing doctors, nurses, and health workers from seeing patients. Asking permission also reminds visitors and nongovernmental organizations that this is the government's clinic and that even though PSI may have outside money, its role is to help the government of Mozambique provide health care and not the other way around.

The lessons

While we heard concerns from international donors based in Maputo that PEPFAR is not fully integrated into the Mozambique Ministry of Health and National AIDS Council, the experience of health care workers in the field appeared to be one of close collaboration and integration. The change is due to two key innovations:

• The Mozambican government has insisted that donors better integrate their programs into the national health system.
• PEPFAR has become more willing to integrate its programs into the Mozambican health system, rather than create parallel systems.

PEPFAR's evolving role in Mozambique is a model for other PEPFAR focus countries, particularly the countries that have only just begun to hold donors like PEPFAR accountable to their national health priorities.

"In the southern part of Mozambique, HIV prevalence is going up, in part because of the traditional practice of having more than one long-term partner. So, the government of Mozambique, besides promoting condom use in a large scale, it is planning to promote a massive campaign on multiple and concurrent sexual partnerships. Now, concerning the scaling up of condom promotion, some partners, mainly PEPFAR, have not picked this up among their priorities. Rather, they preach abstinence and faithfulness. Meanwhile, support for procurement of medicines has been to push us towards the use of brand name drugs. I've been listening to the donors over the last 15 years telling us they want to listen to what the government wants—is this true or is it just rhetoric?

"We can plan by ourselves, we know our HIV priorities. When it comes to best practices, listen to us. You cannot just read the books that are written elsewhere in Europe or America, you have to experience what we do on a daily basis. You have to be integrated into the socio-anthropological mindset of people in order to make sure that the messages that you leave in the community pass through the generations."

On PEPFAR & donor coordination: "Sometimes we only know something is happening when they ask us to just endorse whatever they want to do."

"Sometimes it's difficult for all the donors to coordinate—they agree to do so, and then they just continue to follow the same practices as before. The Global Fund has signed the MOU [Memorandum of Understanding], but they insist on keeping bilateral contracts with both the Ministry of Health and the CNCS, so the Mozambican government has to do duplicative reporting to the Global Fund.

"What the US's PEPFAR has done does make sense in some ways. The capacity building process with PEPFAR is good, and there are also programs that I would say are very good, like the CDC's support to the Ministry of Health for prevention of mother-to-child transmission. However, here in Mozambique we have the Memorandum of Understanding and a general code of conduct for HIV work. Most partners have signed both, while the US has only signed the code of conduct. PEPFAR is about 70% of donor funding for HIV/AIDS in Mozambique. The other donors who signed the MOU represent only about 30% of aid to HIV in Mozambique. PEPFAR is a huge funding stream that doesn't align with the MOU.

"If better coordinated, I think PEPFAR's results could be more visible and better. PEPFAR's particular weakness as far as I am concerned resides in sharing information. Sometimes we only know something is happening when they ask us to just endorse whatever they want to do. Until they send us a letter or even a phone call: "Diogo, you know, there is another amendment in our support, an increase in our funding for HIV/AIDS. Could you liaise with the Ministry of Foreign Affair so as to see this process signed up..." I definitely have to do that, because at the end of the day, the money benefits our community and my people. But in doing that, I'm not saying that we are better coordinated, no, I still complain."

On how to improve: "Come into my planning cycle"

"There's another way that things should be: you have to come into my planning cycle and tell me that, look, I'll be intervening here and there, and therefore, if you have some priorities here, tell me, so that I don't put emphasis on those type of areas where the Americans or whomever are already working.

"Several governments championed steps to tackle the crucial issues sitting on the G8 agenda, but in the end this summit did not deliver the breakthroughs that are so urgently needed. The consensus reached was shallow at best, especially on climate," said Oxfam International Executive Director Jeremy Hobbs.

Some key results from the summit

• On climate change, the G8 endorsed a commitment to halve global carbon emissions by 2050, but with no agreed baseline year or mid-term targets. The G8 also endorsed a $6 billion pledge to the World Bank for climate investment funds that will come out of existing aid budgets.
• On the food crisis, the G8 promised to reverse the decline in aid to agriculture—but without any numbers—and to support the UN's plans to tackle the crisis. It also pledged to ensure that biofuels would be produced in a way that would be compatible with food security and to accelerate the development of second-generation biofuels.
• On Africa and development aid, the G8 reaffirmed previous promised to provide $50 billion in new assistance, half to Africa, by 2010—although it offered no details on who would do what to reverse the decline in aid since 2006. It also repeated the promise it made 12 months ago to spend $60 billion for health, however, the timing was not specified and the clarity of purpose remained vague.

Oxfam is now calling for leadership at key UN meetings on poverty in September and on climate in December.