GLOBAL HEALTH INITIATIVE: MADAGASCAR COMMENT

UNCLAS SECTION 01 OF 02 ANTANANARIVO 000863

DEPARTMENT FOR AF/E MBEYZEROV
PLEASE PASS TO USAID/AFR AMARCUS, GH/HIDN CBONNER

SIPDIS

E.O. 12958: N/A
TAGS: EAID KHIV KWMN KOCI MA
SUBJECT: GLOBAL HEALTH INITIATIVE: MADAGASCAR COMMENT

REF: 09 STATE 125761


1. SUMMARY: This cable is in response to reftel, "Global Health
Initiative: Promoting Greater Awareness and Participation". Post
welcomes the opportunity to provide input on the Global Health
Initiative (GHI). Post supports the GHI Principles as they bring
attention to key elements of health programming that will enhance
the impact of the USG's support, further strengthen USG leadership
in the health sector in Madagascar, and, most importantly, improve
the health of Madagascar's population. The new high-level emphasis
on country-led ownership and strengthening health systems are
extremely welcome advances in the USG approach to foreign
assistance. Critically, Post urges that the principle of "Increase
Impact Through Strategic Integration and Coordination" be applied to
the GHI structure and strategy so that inter-agency coordination can
focus on enhancing health programming rather than dividing the
budget and that Missions lead the strategic process in country. END
SUMMARY.

OVERVIEW
--------------

2. Post welcomes the opportunity to provide formal input on the
Global Health Initiative (GHI). USAID Health Officers have been
actively participating in several of the Working Groups and sharing
perspectives from Madagascar. Post looks forward to providing
further comment on the GHI strategy and implementation plans when
requested.


3. The GHI brings much-needed attention to key areas for improving
health in developing countries. The focus on country ownership,
strengthening health systems, addressing maternal and child health
and family planning, and promoting integration and alignment
correctly addresses elements not present, or not sufficiently
strong, in the initial designs of the President's Emergency Plan for
AIDS Relief (PEPFAR) and the President's Malaria Initiative (PMI).


4. Post notes that comments below on activities and coordination
with the Government of Madagascar (GOM) reflect past, and hopefully
future, work. Due to the March 2009 military coup, the USG has
suspended all work with the de facto GOM. Nonetheless, the USG
remains the largest bilateral donor in the health sector, and the
second largest donor overall after the World Bank.

COMMENTS ON GHI PRINCIPLES
--------------

5. WOMEN AND GIRL-CENTERED APPROACH: GHI's emphasis on women and
girls is well-placed and appropriate and consistent with USG's
historical focus. Post is aware that GHI Working Groups have been
looking at the cultural determinants of health and identified the
importance of also reaching men, as they often control financial,
decision-making, cultural and other barriers to women and girls
accessing healthcare.


6. STRATEGIC INTEGRATION AND COORDINATION: Madagascar has been
working towards smart integration of public health services for
several years. The USG is active in advising and supporting this
process. There are many examples from Madagascar showing that
individual interventions, such as family planning, are more
successful when offered with other services, such as child
immunization and post-partum care.


7. Within the USG in Madagascar, USAID is the main agency
implementing health programs. HHS/CDC is also a vital partner in
PMI and in providing support for other infectious diseases such as
Rift Valley Fever. Furthermore, the Peace Corps has volunteers in
health, DOS supports community health initiatives through the
Ambassador's Self-Help fund, and DOD is involved in malaria and
water and sanitation activities in the Comoros and HIV/AIDS in
Madagascar. Within USAID's portfolio, integration across sectors
has been a Mission principle. Health programs foster collaboration
and capitalize on synergies with Title II Food Security, Paul Simon
Water for the Poor Act, environment and rural development, and
education program activities.


8. Post believes that it is extremely important to acknowledge
lessons learned during the initial implementation of other
whole-of-government approaches such as PEPFAR and PMI. Missions, in
coordination with host country governments and other donors, rather
than headquarters, should lead the assessments of country programs
and the design of the GHI in-country. This has worked extremely well
with PMI. However, Mission staff who have also served in PEPFAR
countries have experienced an overly prescriptive approach from
headquarters that did not adequately take into account the Mission's
knowledge, experience, and level of involvement on the ground.


9. Post also urges that the administrative and management structure
of GHI reflect lessons learned from PEPAR and PMI. Mission health
staff note that PMI is structured in a way that encourages positive
collaboration between USG agencies with a focus on the disease, not
inter-agency turf battles.

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10. STRENGTHEN AND LEVERAGE KEY MULTILATERAL INSTITUTIONS: While
this is important at the international level, Post suggests that GHI
also explicitly acknowledge the importance of USG involvement with
multilaterals at the country level. USG field staff successfully
work with counterparts from these institutions to implement global
partnerships (such as the GAVI Alliance) and leverage funds.


11. COUNTRY OWNERSHIP AND INVESTMENT: This is an extremely important
principle that is welcomed by Post and one that is certain to
enhance the effectiveness of USG assistance. In Madagascar, as in
many countries with robust USG health programs, the USG is an active
member of sector groups led by the host country Ministry of Health
(MOH). USG staff and USG-partner staff, along with other donors and
sector players, participate in the development of national plans and
strategies for the sector and for specific sub-sector areas (i.e.
malaria, family planning, etc.). When this effort is successful,
country plans reflect ownership from all stakeholders. Having a
specific USG strategy to work within host country plans will enhance
the USG's role as a collaborative partner and increase
sustainability.


12. HEALTH SYSTEM STRENGTHENING: Specific emphasis on strengthening
health systems is a critical element in fostering sustainability and
enhancing impact of USG interventions. In Madagascar, the USG has
been supporting the strengthening of the supply chain, health care
financing (particularly through community-led insurance schemes),
the national health information system, the national laboratory and
regional surveillance laboratories, and contraceptive security.
Additional resources and the recognition of this important principle
are extremely welcome.


13. Post suggests that community-based health programs should be
highlighted as part of health systems strengthening. Many of the
evidence-based, critical interventions for maternal, neonatal and
child health, family planning and nutrition, are actions that can
and should be taken in the community and in lowest-level health
facilities. Madagascar is one of the countries where community
health has been embraced as the best way to reach the most
underserved populations. With USG and other donor assistance,
community health workers provide a range of services from
information and communication for behavior change to provision of
injectable contraceptives. In the near future, they will also
diagnose and treat malaria and pneumonia.


14. METRICS, MONITORING AND EVALUATION: GHI's emphasis on aligning
USG indicators with those already in use in the country is very
important.


15. RESEARCH, DEVELOPMENT AND INNOVATION: Madagascar has had the
opportunity to help pilot a number of approaches to health service
delivery that have influenced other country programs. The most
recent example is USG support for evaluating and piloting
community-based distribution of injectable contraceptives. This
extremely successful initiative to make this popular family planning
method more readily available to rural women is being scaled-up
throughout the country and has served as a model for several other
African countries. Post welcomes the opportunity to play a
leadership role in other innovations. On the overall research goals
of GHI, Post particularly looks forward to work on identifying
methods for evaluating the added value of integration and
strengthening health systems.


16. COMMENT: The GHI offers an important opportunity for the USG to
increase the depth and scale of its foreign assistance in health
with the ultimate goal of improving the health of host country
populations. Post strongly suggests that the actual structure and
implementation of GHI at the country level incorporate
lessons-learned and best practices from other "whole-of-government"
approaches, particularly PEPFAR and PMI. Mission Madagascar looks
forward to being a part of this initiative. END COMMENT.

MARQUARDT