George W. Bush's AIDS relief plan showed how conservatives can run foreign aid

Ask a hundred Republicans whether they like foreign aid and you will hear a very particular noise. It is the sound of a man remembering a story about a government that took a billion dollars, built a palace, and sent a thank-you card. We have all heard the story. Some of it is true. A good deal of American aid over the decades has gone to governments that stole it, to programs that never measured anything, and to consultants who wrote reports about the reports. When a conservative says "cut it," that is usually where he is coming from, and honestly, he has a point.

So here is the oddity. One of the biggest foreign aid programs in American history was launched by a Republican President, in a State of the Union speech, and it has kept its support in the party for more than twenty years. It is called the President's Emergency Plan for AIDS Relief, or PEPFAR. If you want to know how a conservative should think about spending taxpayer money overseas, this is the program to study. Not because every part of it is perfect, and not because I want to tell you what to think about the budget, but because it was built on a different design from the one that gives foreign aid its bad name.

What the President announced in January 2003

On January 28, 2003, in his State of the Union address, President George W. Bush announced a plan to fight HIV/AIDS in Africa and the Caribbean. The number he gave was $15 billion over five years. He pointed out that in sub-Saharan Africa, where the disease was devastating whole communities, only a tiny fraction of the people who needed antiretroviral medicine were getting it. He framed it as a moral obligation and as a matter of American interest, because a collapsing society in a region full of unstable governments is not a place from which security or trade can grow.

Notice the way the program was put together, because it matters to the argument. This was not a vague promise of "support" for "development." It had numerical goals. The 2003 plan aimed to put two million people on treatment, to prevent seven million new infections, and to provide care for ten million people affected by the disease, including orphans. Those are targets. You can count against a target. You can say, at the end of the year, whether the money did what it was supposed to do. That is already a different animal from the usual foreign aid.

The law behind it

Congress turned the announcement into law quickly. The United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 was signed on May 27, 2003. It authorized the five-year commitment, created a Global AIDS Coordinator at the State Department to run the effort (the first was Randall Tobias), and concentrated money on a short list of focus countries. The initial list was fifteen: twelve in Africa, plus Guyana, Haiti and Vietnam. Concentrating the money on a limited set of places was another conservative design choice. Spreading a dollar thin across a hundred countries lets you claim credit everywhere and be accountable nowhere.

The law has been renewed more than once. In 2008, with Bush still in office, Congress reauthorized the program with a much larger authorization, up to $48 billion over five years, and Congress has extended the framework since then. If you want to read the actual text, Congress.gov carries the 2003 and 2008 laws, and the State Department publishes the program's annual reports. Go to the primary documents. Never let anybody, including me, tell you what is in a bill without letting you read it.

Why it is a different design: four features

Let me lay out the argument the way I see it. There are four features of PEPFAR that conservatives can defend on conservative principles.

1. A defined mission. The program had one job: fight a specific disease. That makes it easier to judge and harder to turn into a slush fund. The fewer the goals, the fewer the places to hide.
2. Counting. The plan's targets gave Congress and the public something to check. How many people are on treatment? How many tests have been run? How many babies were born free of the virus because their mothers got medicine? Questions like these have answers, and the answers can be audited. Spending that is measured gets better, and spending that is not measured gets worse.
3. Local and faith-based partners. A great deal of the work was carried out through clinics, hospitals and community organizations already on the ground, including church-run hospitals and missions with decades of local trust. Many of the best health networks in rural Africa were built by churches long before Washington thought about it. Bush's team understood that sending money through partners who knew the villages and had a reputation to protect was better than building a new bureaucracy from scratch.
4. Treatment as a promise, not a pilot. Once you put someone on antiretroviral therapy you are committing to keep going, because stopping lets the virus come roaring back. That is a real long-term obligation, and it cuts both ways. It is a reason the program has outlasted the administration that created it. It is also a reason to demand a plan for the day other governments can take over more of the cost.

The best version of the case against it

Now the step where I give you the strongest version of the opposing argument, in terms its defenders would accept. It goes like this.

One. The United States has a national debt that no family would tolerate in its own household. Every dollar spent abroad is a dollar borrowed, in effect, from our children.

Two. Our government has no constitutional duty to heal foreign populations. Charity is a private virtue. Churches, foundations and families can give to African clinics without the Treasury being involved.

Three. Foreign aid can prop up bad governments and crowd out local institutions. If an outsider pays for the doctors, the local ministry has less reason to build its own system.

Four. A program, once started, never ends. Look at the permanent constituencies that grow around every federal stream of money.

I take every one of those points seriously. The first is a fair fiscal argument, and it is the best reason to say that no program, including this one, gets a blank check. The second is a legitimate statement of limited government. The third is a real risk, and the fourth is nearly a law of nature in Washington.

The answer

Here is why I still think PEPFAR passes the test, and why the right can defend it without compromising principle.

First, on the question of cost, the program has always been a small slice of the federal budget, and its price tag was set in advance by Congress. That is the ordinary appropriations process, described in How a budget becomes law, from the President's request to the checks. A line item that is voted on every year, with stated targets, is a more accountable thing than the open-ended entitlements that really drive the debt. If you want to fight the deficit, there are far bigger places to look.

Second, on the constitutional question, the Constitution gives Congress the power to spend for the general welfare and gives the President broad authority over foreign affairs. Reasonable conservatives have always disagreed about how wide that is. But the argument that foreign policy includes the health of a region where a pandemic can destabilize governments is not a stretch. A disease that kills young adults hollows out a country's teachers, soldiers and farmers. The result is failed states, and failed states cost Americans a great deal more than clinics do.

Third, on the risk of propping up bad governments, this is where the design matters. Money that flows through a focused program with counting and with non-governmental partners is less likely to disappear into a ministry. That does not eliminate corruption. Nothing does. But it changes the odds.

Fourth, on the permanence of programs, the right answer is not to refuse to start. It is to write sunsets, benchmarks and transition plans into the law. Congress did build in reauthorization periods, and each reauthorization is a chance to ask hard questions, to demand audits and to tell partner countries to carry a bigger share. That is exactly the kind of oversight conservatives claim to want.

The controversies, stated plainly

It would be dishonest to tell the story as if it were free of fights. The 2003 law included a requirement that a portion of prevention money go to programs promoting abstinence, and critics, including some public health experts, argued that this tied the hands of people on the ground. Supporters said the approach, often summarized as abstain, be faithful, and use condoms where appropriate, reflected the best evidence from some countries and the values of the communities served. The 2008 reauthorization loosened that earmark. You can come down wherever you like on that debate, and I would simply ask you to notice that it was argued in public, in the legislative process, by elected officials. That is how it should work.

There was also a fight over the conscience of faith-based groups, over whether groups that took federal money had to take positions that violated their beliefs. The details are tangled, and the point is that the program tried to work with religious organizations rather than around them. For the broader story of how conscience protections attach to federal money, see The Hyde Amendment rider and the conscience laws that keep taxpayers out.

What the program teaches about the rest of foreign aid

Here is the broader lesson, and it is the reason I wanted you to read this post. Every conservative critique of foreign aid, from the idea that it is waste to the idea that it props up dictators, is a critique of a design, not of the impulse to help. Bush's AIDS plan fixed several of those design problems. It had a goal, it was measured, it used trusted local partners, and it kept a clear line from the taxpayer to the result.

That suggests a standard you can apply to any aid proposal that crosses your desk. Ask four questions. What exactly is the goal, in a sentence? How will we know if it worked? Who is actually delivering the help, and what is their record? And what is the exit plan? A program that cannot answer those questions does not deserve a dime. A program that can answer them deserves a hearing, even from a skeptic.

The same logic, by the way, runs through the economics of trade and growth. The deepest antipoverty force the world has ever seen has been commerce, a point made in The Best Antipoverty Program Ever Tried Was Letting People Trade, and the economist Thomas Sowell's famous reminder that there are no solutions, only trade-offs, captured in Thomas Sowell Asks What Happens After the Policy Passes, applies here too. Every dollar spent on health abroad is a dollar not spent somewhere else. The honest conservative position is to say so out loud and to pick programs that earn their place.

Where this leaves the debate

Some conservatives look at PEPFAR and say it proves foreign aid can work if it is built right. Others look at it and say it is the exception that proves the rule: the right design is rare, and the typical aid program will not have it. I think both sides are partly right, and I think the productive question is not "for or against," but "which programs, held to what standard, and with what end date?"

It is also fair to notice what Bush's own team did next. The same administration tied a separate aid effort, the Millennium Challenge Corporation, to a country's record on governance, which is the same principle again: pay for performance, not for promises. The lesson in both cases is that accountability is not an enemy of generosity. It is what makes generosity something a taxpayer can stand behind.

The bottom line

• The right way to judge any foreign aid program is by its design: a clear goal, counting, trusted local partners, and an exit plan. PEPFAR met that standard better than most.
• You can be a fiscal hawk and still support a program that Congress writes with targets, audits and renewal votes. What you should oppose is spending with no goal and no scorekeeping.
• Ask your representative four questions about any aid bill: what is the goal, how will we measure it, who delivers it, and when does it end?
• Read the primary documents. The 2003 and 2008 laws are on Congress.gov, and the program's annual reports are public.
• Do not accept the lazy line, from either side, that "foreign aid" is one thing. It is a hundred different programs, and some deserve a cut while others deserve a defense.