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After growing impatient with the U.S Global Health Initiative’s (GHI) lack of transparency about progress in the field, my interest piqued once again with a flurry of spring time releases—the final GHI strategy and seven GHI plus country strategies (Rwanda’s strategy pending) on an all new GHI website. While these documents contain ample information (stay tuned for future posts as we digest this content), there are also undocumented signs of progress about the GHI principles.  For example, I learned yesterday at an Aspen Institute event featuring Health Minister Dr. Tedros Adhanom Ghebreyesus, that two key GHI principles—country ownership and integration—are taking shape in Ethiopia. Here is a snapshot of what I learned, lingering questions I have about the GHI principles, and suggestions for the GHI’s learning agenda.

Country Ownership

According to Minister Tedros, Ethiopia is leading the way for the GHI implementation plan, ensuring that U.S. Government (USG) investments are aligned with national priorities in the GHI operating plan, or OP. As Amie Batson, USAID Deputy Assistant Administrator for Global Health, explained, in the long term, there will just be one sectoral strategy that details USG support of country priorities, but in the short term, the OP will be the overarching strategy that links PEPFAR’s Country Operational Plan (COP), PMI’s Malaria Operational Plans (MOP,) and other USG global health operational plans, aligning them with country led priorities.  It is reassuring and not so surprising (see here for a CGD event on country ownership that featured Minister Tedros’ comments on why and how countries need to lead the way for donors) to hear from a Minister of Health that the GHI is taking shape in alignment with a country’s health goals and objectives. While this sounds encouraging in concept, a few questions linger about this GHI principle.  For example, while this is an example of country ownership, or at least government ownership in Ethiopia, is this happening in other countries?  Will country ownership include other (private and/or public) stakeholders or be limited to governments only?

Granted, it will be difficult to measure country ownership when we don’t have a defined standardized measure for such a construct, but the GHI team might consider systematic documentation of evidence from countries on these hard-to-measure GHI principles (please, not as success stories already highlighted). For example, evidence about stakeholder participation (in addition to government in negotiations), alignment of GHI targets with country goals, and alignment of USG activities with national policies and systems could all serve as criteria to systematically track progress on country ownership. If we are trying to establish a new way of providing U.S. foreign aid for global health, let’s do a good job of documenting it so that we learn about what’s working and what isn’t in different contexts.

Integration

Another key GHI principle is to ensure that a broad range of health services are delivered via integrated service delivery platforms. In simple English, a woman arriving at a clinic for child immunizations should be able to access other health services, for example family planning, antiretroviral therapy, or getting plain old Oral Rehydration Salts (ORS) for her child who has diarrhea, at the same site.  Based on Minister Tedros’ comments, under the GHI, Ethiopia is poised to integrate maternal and child health with AIDS related services via its prevention of mother-to-child transmission (PMTCT) program.  As the Minister noted, PMTCT coverage is low in Ethiopia, so service integration will help to increase these numbers, and lead to greater impact of AIDS treatment programs.  But I have many concerns about integration, especially for reproductive health services.  Will integration be limited to PMTCT programs—a bridge between maternal and child health and AIDS services?  Where will family planning, reproductive health services, and other health services fit in? How will different funding streams with different targets enable integration of services beyond PMTCT programs?

The biggest constraint to integrated service delivery is the way in which USG funding for global health is channeled to countries. Specific GHI targets will drive programs for AIDS, TB, Malaria, maternal and child heath (MCH), family planning (FP), neglected tropical diseases (NTDs), and nutrition under separate funding streams. I raised this question at the Aspen event (see here for video coverage—start at 73:07 for my question and their responses), hoping to learn more about this challenge: How will integrated services be funded given different funding streams and obligations for GHI teams to report progress to Congress against specific GHI targets? Amie Batson explained that GHI teams are finding ways on the ground to integrate programs for greater impact, while being faithful to reporting requirements at home, but I’m still left wondering what that means in practice with separate vertical funding streams by program.

I’m currently working on a paper that shows how the different USG funding streams over the past decade has been one of the biggest barriers to integration of AIDS and reproductive health programs on the ground. I’m learning that vertical funding for different health programs (AIDS, MCH, FP etc.) constrain health facility managers’ ability to use resources for integrated service delivery. It isn’t “simple management of resources,” as the third panelist Ambassador Mark Dybul responded rather defensively (with a revisionist recap of PEPFAR 1’s integrated service delivery approach!) in a clear misreading of my question. Integrated service delivery doesn’t mean you can’t report specific results. Of course you can, but how you design integrated delivery programs, allocate resources, and then define, measure, and report results under different funding streams (some more dominant than others—read PEPFAR) isn’t crystal clear to me.

Signs of integrated services, at least for MCH and AIDS via the PMTCT bridge, are emerging from Ethiopia, but I’m looking forward to learning more from the GHI team about how this principle might be applied in a range of country contexts to ensure that other GHI outcomes (family planning, NTDs, etc.) are also benefitting from this integrated approach. Regular documentation and sharing about different integration models and their outcomes as they develop in different countries is a MUST for a learning agenda for the GHI.

Share your ideas for questions and issues that the GHI Learning Agenda should tackle!