Consultation Document

Through the Global Health Initiative (GHI), the U.S. government is pursuing a comprehensive whole-of-government approach to global health. The Initiative promotes a new business model to deliver its dual objectives of achieving significant health improvements and creating an effective, efficient and country-led platform for the sustainable delivery of essential health care and public health programs. In the coming months this implementation roadmap will be refined and finalized, through consultation with Congress, partner countries, civil society organizations, other donors and governments, the private sector, and multilateral and international institutions.

THE CONTEXT

Health is at the heart of human progress. It determines whether parents can work to support their families, children can attend school, mothers can survive childbirth to nurture their children, and infants can grow and thrive. Where health services are strong, families and communities flourish. Where health services are weak or nonexistent - where the spread of diseases is unchecked, illnesses are untreated, and women give birth alone - families suffer, breadwinners die prematurely, and communities unravel.

The Obama Administration is emphasizing global health in its diplomacy and development work around the world. With strategic investments in global health, we will spur progress in economic development, job creation, education, agricultural development, gender equity, and political stability. These are goals with a global impact; the health and stability of countries around the world have a direct impact on the security and prosperity of the United States.

We start with a recognition of the enormous contributions this nation has made to improve health outcomes worldwide. We have helped save millions of lives through immunizations and made oral rehydration therapy available globally, greatly reducing infant deaths. We have helped eradicate smallpox and reduce polio and river blindness. And, most recently, we have led the world in addressing infectious disease, bringing hope and life-saving treatments to millions with our highly successful programs in HIV/AIDS, tuberculosis (TB) and malaria. Americans can and do take pride in these global achievements, which have contributed greatly to the lives of so many people, projected U.S. values, and strengthened U.S. leadership in the world. The challenge of the next decade and beyond is to take these impressive accomplishments to the next level by helping countries achieve long-term sustainability in their health services. If we succeed in our efforts, we will help improve the lives of millions, limit the long-term cost to U.S. taxpayers, and contribute to a stronger future for American citizens.

THE NEED

The growing health needs in the developing world are well-documented. What these reports do not typically capture is the experience of individuals served by the programs and systems currently in place.

Consider an HIV-positive pregnant woman who lives in drought-stricken rural Africa. She has walked several miles with a child on her back to arrive at the nearest health post. Here, her child will receive immunizations and basic primary care. Because this facility is small and provides only limited services, the woman will be unable to receive either antenatal care or basic obstetric care at this post when she is ready to deliver her next child.

To receive these services, she must travel to a different clinic in a separate village, where she will spend hours or days waiting outside, as there is no reliable transportation between her village and the clinic. This clinic can provide the treatment necessary to prevent transmission of HIV to her unborn child. It is not equipped, however, to address the many complications of delivery that result in maternal death or disability. Those services would require a much longer journey - and money she does not have - so the woman takes her chances at the site that offers some promise of assistance.

Her baby is born HIV-free, thanks to assistance provided through the President's Emergency Plan for AIDS Relief (PEPFAR). Once back home, the mother tries to feed her family in a year when crop yields are low. Her children will not receive the Vitamin A supplements needed to thrive, and she herself will suffer from anemia. Friends and relatives have told her of health workers that can help monitor the baby's progress and provide medicine, guidance and family planning, but no workers serve the rural village in which she lives, and once again the journey is too long.

THE VISION

The all-too-common conditions faced by this woman and her children illustrate how health programs and weak systems in many developing countries are not meeting the needs of their population. While health services may be available, too often they exist in an uncoordinated or ad hoc manner - aligned around funding sources or diseases - rather than the broader needs of the populations they seek to serve.

President Obama's Global Health Initiative addresses the challenges faced by this woman and her family - and millions of others in similar circumstances. The GHI will help partner countries improve health outcomes through strengthened health systems, with a particular focus on improving the health of women, newborns and children through programs including infectious disease, nutrition, maternal and child health, and safe water. Achieving major improvements in health outcomes is the paramount objective of the Initiative. To that end, the GHI supports the following goals and targets:

• HIV/AIDS: PEPFAR will: (1) support the prevention of more than 12 million new HIV infections; (2) provide direct support for more than 4 million people on treatment; and (3) support care for more than 12 million people, including 5 million orphans and vulnerable children.
• Malaria: Reduce the burden of malaria by 50 percent for 450 million people, representing 70 percent of the at-risk population in Africa. This effort will include the expansion of malaria efforts into Nigeria and the Democratic Republic of Congo.
• Tuberculosis (TB): Save approximately 1.3 million lives by reducing TB prevalence by 50 percent. This will involve treating 2.6 million new TB cases and 57,200 multi-drug resistant (MDR) cases of TB.
• Maternal Health: Save approximately 360,000 women's lives by reducing maternal mortality by 30 percent across assisted countries.
• Child Health: Save approximately 3 million children's lives, including 1.5 million newborns, by reducing under-5 mortality rates by 35 percent across assisted countries.
• Nutrition: Reduce child undernutrition by 30 percent across assisted food insecure countries in conjunction with the President's Feed the Future Initiative.
• Family Planning and Reproductive Health: Prevent 54 million unintended pregnancies. This will be accomplished by reaching a modern contraceptive prevalence rate of 35 percent across assisted countries, reflecting an average 2 percentage point increase annually, and reducing to 20 percent the number of first births by women under 18.
• Neglected Tropical Diseases (NTDs): Reduce the prevalence of 7 NTDs by 50 percent among 70 percent of the affected population, contributing to: (1) the elimination of onchocerciasis in Latin America by 2016; (2) the elimination of lymphatic filariasis globally by 2017; and (3) the elimination of leprosy.

These are only some of the outcomes that will be achieved through the Initiative. For a complete list of GHI targets and outcomes, see Annex A.

Achieving these health outcomes requires a purposeful effort to improve health systems in the developing world. GHI will work with partner governments to develop, strengthen and expand platforms that assure the financing and delivery of priority health interventions. Building functioning systems will, in some cases, require a new way of thinking about health investments, with increased attention to the appropriate deployment of health professionals, improved distribution of medical supplies and improved functioning of information and logistics systems - all while maintaining a focus on delivering results. In the end, success will be measured not by the robustness of the health system itself, but by a country's ability to meet the needs of key populations and improve health conditions.

Improving health outcomes through strengthened platforms and systems is at the core of the Initiative. This vision of sustainable progress is only made possible by the improvements in the health sector over the past decade. Less than ten years ago neither the woman nor her two children would have stood a chance of survival. At that time, a mother in this circumstance could not have hoped to access life-sustaining HIV treatment, let alone the services that would prevent her child from being infected by HIV. Even if her children would have been born HIV-free, they would have been at increased risk of dying from pneumonia, malaria, or from another preventable disease. Life-saving interventions in HIV/AIDS, TB, malaria and childhood diseases were made possible in large measure by U.S. government global health programs launched and supported over the past decade by the Bush Administration, with the full support of Congress. The GHI will build on this tremendous record of success and take these remarkable achievements to the next level by further accelerating progress and investing in sustainable health delivery systems for the future.

THE NEW APPROACH

To meet this vision, the GHI will dedicate substantial new resources and unprecedented funding levels - totaling $63 billion over six years - and will use a new business model for U.S. government global health assistance. Beginning in 2010, this business model will be applied in all countries, regions, and programs receiving U.S. government global health funding. Indeed, many of these measures are already underway. Last December, PEPFAR released a five-year strategy that outlines its contributions to the GHI, and focuses on transitioning the program from an emergency response to a sustainable, country-owned effort. (See PEPFAR's Contributions to the Global Health Initiative http://www.pepfar.gov/strategy/index.htm). Likewise, in FY 2010, the U.S. government is strengthening the integration of family planning, maternal and child health, and malaria programs in many African communities, including providing training for local health care workers and volunteers.

The GHI aims to maximize the sustainable health impact the U.S. government achieves for every dollar invested. It is that simple. The Initiative will deliver on that commitment through a business model based on GHI's core principles (see box), drawn from the principles of effective development partnership announced by President Obama at the G-8 meeting in L'Aquila:

Implementing a woman- and girl-centered approach: A core objective of the GHI is to improve health outcomes among women and girls, both for their own sake and because of the centrality of women to the health of their families and communities.

Because of their roles in child rearing, providing and seeking care, and managing water and nutrition, the ability of women to access health-related knowledge and services is fundamental to the health of their babies, older children and other family members. Over the long term, the health of women enhances their productivity and social and economic participation and also acts as a positive multiplier, benefitting social and economic development through the health of future generations.

Moreover, both because of their reproductive role and patterns of gender discrimination, girls and women are particularly vulnerable to ill health, and are comparatively underserved by health services. According to the World Health Organization, AIDS is the leading cause of death among women aged 15-44 worldwide, and nearly 60% of those living with HIV in sub-Saharan Africa are women. It is therefore essential that PEPFAR and other programs ensure that services for women are linked to, and expand access for, their primary health care needs. The GHI will support long-term systemic changes to remove barriers and increase access to quality health services including, for example, by improving monitoring and evaluation of the health of women, adolescents and young girls; supporting integrated health services; involving men and boys in addressing gender equity; improving training of health providers on gender issues; ensuring meaningful participation of women and girls in decision-making; and engaging civil society in partner countries to address gender equity in health care.

Coordination, collaboration and integration - at all levels: Coordinating and integrating the delivery of health interventions is essential for improving health outcomes. Under the GHI "integration" has both downstream benefits at the point of contact as well as upstream benefits in the structure of U.S. government assistance. Integrating health services at the point of contact ensures the delivery system is designed to meet the holistic needs of an individual when they go to a health facility. Upstream integration ensures the joint programming among U.S. government agencies, other donors and partner country governments, and other institutions to increase efficiency and effectiveness. For example, clinics providing family planning and antenatal services can deliver interventions that prevent mother-to-child transmission of HIV (PMTCT), and strong PMTCT programs can be broadened to deliver family planning and antenatal care. Such integration will help ensure that more pregnant women - including those living with HIV - have access to high quality prenatal care and attended delivery services. In addition, the outreach used to distribute insecticide-treated bednets can be used for health education and delivery of other essential tools of care such as chlorine and soap for clean water and sanitation; supply chains and distribution channels for established immunization programs can also provide basic supplies needed for clean, safe deliveries; and the vast unmet demand for family planning services can be addressed by facilities and community-based workers that provide child health and immunization services and treat children who are severely malnourished. The improved care established through the integration of these and other services will produce lasting progress for the entire community.

Strengthening and leveraging other efforts: The GHI is built on the recognition that improving global health outcomes is a shared responsibility. The needs are too vast and the challenges too great for any one country or organization to address alone. The U.S. government will join multilateral efforts involving the United Nations and others to make progress toward achieving Millennium Development Goals 4, 5 and 6. Indeed, a key principle of the GHI is to strengthen and leverage key multilateral organizations, global health partnerships, and private sector efforts (see box on page 6). For example, the GHI will build on U.S. government support for the GAVI Alliance to expand the comprehensive immunization of children, increasing the number of vaccines provided to include those that protect children against pneumococcal disease and rotavirus. Similarly, the GHI will strengthen the U.S. government's already close collaboration with the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) as well as its leadership in the Global Polio Eradication Initiative (GPEI). In each of these collaborations, the GHI will emphasize accountability for achieving substantive outcomes and rigorously monitor impact without increasing the reporting and administrative burdens on partner countries. Indeed, harmonizing and reducing these reporting requirements is a key element of the GHI's approach to monitoring and evaluation.

Partnership with countries: It is ultimately those within countries - the governments, non-governmental organizations (NGOs), the private sector and others - who are responsible for making and sustaining progress. They must be accountable to those served by their own health systems. Accordingly, a core principle of the GHI is to encourage country ownership and invest in country-led plans. In implementing this principle, the U.S. government will support partner countries in managing, overseeing, and operating the functions of their national health systems. The GHI will work closely with partner governments, as well as civil society organizations in-country, to ensure that investments are aligned with national priorities, and to support partner government's commitment and capacity so that investments are maintained in the future. The partnership will be based on support for country-level processes of policy development and planning, along with the provision of technical assistance through a model of mutual respect, responsiveness to demand, and dedication to capacity development.

Learning and accountability: The performance of a health service delivery platform is ultimately measured in outcomes, or indicators closely linked to outcomes. The GHI will support innovations that promote a results-oriented rather than expenditure- or input-based approach to system strengthening. To address supply- and demand-side barriers and bottlenecks, the GHI will support innovative means - including the use of results-based financing and performance incentives at a variety of levels - that stimulate both utilization of services and provision of high quality care, while respecting voluntarism and informed choice. Ultimately, a functioning health system includes linked health system elements - such that the trained health worker is in the right place, with the right skills, incentives, equipment, and medical supplies to deliver the services people need.

Learning also requires leadership in the discovery of research-based knowledge, which leads to innovation. Monitoring, evaluation, research, learning, and innovation are integral to all aspects of the Initiative and critical to its success. The research and evaluation agenda of the GHI will address important questions that are immediately relevant to both GHI and partner country goals and objectives, including persistent questions about how to stimulate and maintain quality of service delivery, how to reach marginalized populations, and more. Operational or implementation research supported with rigorous monitoring and evaluation and an emphasis on using the data will help identify critical problems and improvements, including sustainable and cost-effective service delivery approaches; obstacles to rapid system scale-up and approaches to reduce such obstacles; and strategies to help improve health service delivery models. GHI research and evaluation approaches and findings will be shared within and across countries and with all GHI partners to facilitate wider learning, systems strengthening, and continuous quality improvement through innovation.

THE OPERATIONAL PLAN

Partnering Globally for Better Health

The U.S. government is already the world's leading provider of global health assistance, with a diverse set of programs and investments in approximately 80 countries worldwide. All of the countries in which the U.S. government invests health resources are essential partners for achieving the ambitious outcomes envisaged in the Initiative, including those in Annex A.

The Initiative provides strategic funding increases to programmatic areas where large health gains can be achieved. These programmatic areas include: HIV/AIDS, malaria, TB, family planning, nutrition, maternal, newborn, and child health (MCH), and NTDs. The majority of GHI resources will be devoted to implementation and expansion of proven interventions through a strengthened delivery platform, with a particular focus on adopting a woman- and girl- centered approach. Coordination, integration, and partnership with governments and local NGOs will be a hallmark of GHI work.

While specific disease and system priorities will vary by country, GHI implementation has four main components:

• Do more of what works: Identify, integrate, take to scale, and evaluate proven approaches in family planning, nutrition, HIV/AIDS, malaria, TB, MCH, NTDs, safe water, sanitation and hygiene, and other health programs to improve the health of women, newborns, children and their families and communities. Encourage phasing out strategies that have not produced positive impact on health outcomes;
• Build on and expand existing platforms to foster stronger systems and sustainable results: Build on and expand the platforms supported through U.S. government and other investments, including those in HIV/AIDS, malaria, MCH, and family planning; strengthen health systems functions to ensure the quality and reach of health services and public health programs in the short and long term; and work with governments to incorporate sustainability into health programming;
• Innovate for results: Identify, implement, and rigorously evaluate new approaches that reward efficiency, effectiveness, and sustainability. Focus particular attention on promising approaches to service integration and delivery, community-based approaches, private sector participation, the introduction of performance incentives, promotion of health behaviors, and other strategies that have potential to increase value for money; and
• Collaborate for impact: Promote country ownership through support for country-led national health plans; improve coordination across U.S. government agencies and with other donors; expand technical assistance with the aim of "working ourselves out of a job"; leverage and help partner governments coordinate and integrate investments by other donors; and create and use systems for feedback about program successes and challenges, in order to focus resources most effectively.

Annex B provides an illustrative list of GHI interventions and activities related to each of these focus areas.

In each country receiving global health assistance, U.S. government experts will work with partner governments and other country counterparts to strengthen and support country-led national health plans. The process of implementation will begin with an assessment of existing national health plans, health systems, current financing gaps, and the capacity to use additional resources effectively. Based on this assessment, the GHI will work with partner governments and other development partners to identify goals, strategies, and approaches to which the GHI can contribute, including identification of a plan to build an evidence base and capture progress. Primary goals of this process will be to tightly align U.S. government support under the GHI with each country's national plan and strategies and to highlight performance objectives articulated in both process and outcome measures. Agreed-upon decisions and understandings related to U.S. government health assistance under the GHI will incorporate already existing health sector agreements such as USAID Strategic Objectives Agreements, PEPFAR Partnership Framework Agreements, and other bilateral agreements.

Accelerating Impact: GHI Plus

While the GHI program will apply everywhere U.S. government global health dollars are at work, GHI will launch an intensified effort in a subset of up to 20 "GHI Plus" countries that provide significant opportunities for impact, evaluation, and partnership with governments. These countries will receive additional technical, management and financial resources to accelerate the implementation of GHI's innovative approach, including integrated programmatic interventions and investments across infectious disease, MCH, family planning, and health systems activities. GHI Plus countries will provide opportunities to learn how to build upon existing platforms and best use programmatic inputs to deliver results, and how to work in close collaboration with partner governments, across U.S. government agencies, and with global partners. Central to the generation of this knowledge will be robust monitoring and evaluation efforts. Knowledge gained will be shared with other GHI countries, inform future decision-making, and fulfill the imperative of accountability. These activities will be carried out with close collaboration and coordination with country governments, local civil society, international organizations, and other donors.

A particular focus in GHI Plus countries will be assessing the effectiveness of the GHI business model. For example, new models of technical assistance to GHI Plus countries will be judged by the extent to which sustainable capacity is created or strengthened in-country. Technical assistance will focus on building and supporting the capacity to integrate and accelerate priority interventions, develop innovations, conduct rigorous monitoring and evaluations, and strengthen health systems functions (strategic planning, financing, information systems, laboratory capacity, surveillance, and health worker training and retention). Annexes C and D illustrate how an accelerated program of GHI interventions and activities could operate in two countries - Bangladesh and Ethiopia.

The accelerated program of GHI Plus countries will be supported in FY 2011 by a GHI Strategic Reserve Fund (GHI Fund). The GHI Fund will provide catalytic resources to the GHI Plus countries above and beyond their growing baseline allocations from programs such as PEPFAR, the President's Malaria Initiative (PMI), MCH, family planning, and others.

The GHI Fund will be drawn from a combination of global health programs across USAID and the Department of State. The integrity of the funding sources will be maintained for reporting and accounting purposes, and a system will be developed to link program outputs to those sources. The resources comprising the GHI Fund will be dedicated to achieving a portfolio of outcomes across the programs and supporting the systems necessary to achieve those outcomes. Shared ownership of common performance goals will fuel the creativity and motivation of national and global health partners and U.S. government agencies toward "systems thinking" and efficient and effective collaboration at all levels.

The starting point for deployment of GHI Fund resources will be a review of national health plans, including health system policies and investments and current financing gaps. Based upon this review, the U.S. government will provide significant technical assistance as well as inputs for programs to design and implement strategies aimed at strengthening the health system functions essential for improving outcomes. In addition, GHI Fund resources in FY 2011 and FY 2012 will be used to accelerate the scale-up of proven cost-effective interventions across MCH and infectious disease to improve the health of women, newborns, and children and cover the start-up costs associated with integrating interventions. Depending on local circumstances, other donor contributions, and country monitoring and evaluation plans, approximately 10% of the GHI Fund resources in FY 2011 and beyond will be used to design and implement an intensive monitoring and evaluation effort, and to broadly disseminate findings for the benefit of both the countries involved, and, more importantly, others facing challenges in reaching underserved populations and delivering quality services.

Once agreement is reached on the details of the GHI Plus program, a simple Memorandum of Understanding (MOU) will be signed to reflect the commitments of the partner government and the U.S. government. This MOU will build on existing health sector agreements between the U.S. government and partner governments.

In later years of the Initiative (FY 2013 - FY 2014), a portion of GHI Plus allocations will depend on partner progress against an agreed-upon set of critical indicators. This portfolio of indicators will cut across program areas and will be negotiated and agreed to by partner governments. The selection of indicators and targets will be based on applicability in the particular setting, ability to integrate and build upon existing monitoring and evaluation systems, measurability, and potential for improvement over the period of implementation. Given the need to choose indicators that are sensitive and measurable in the short periods under consideration, indicators might include, for example, coverage of PMTCT, delivery and/or use of bednets, immunization coverage, coverage of institutional deliveries, and access to family planning counseling and services. If possible, depending on plans for data collection, more direct measures of changes in health status will be used.

Selecting GHI Plus Countries

The selection of GHI Plus countries will occur in two phases. In the initial phase, FYs 2011 and 2012, up to 10 GHI Plus countries will be selected. In FY 2011, a $200 million GHI Fund will support an accelerated implementation approach in these countries. The GHI Fund is expected to increase in FY 2012 and beyond, based on early results and learning. Beginning in FY 2013, a second wave of up to 10 GHI Plus countries will be selected. These countries will also receive an accelerated program of implementation - resourced in part by allocations from the GHI Fund - and informed by the learning and experience of the program in Phase I. Thus, by FY 2014, as many as 20 countries will participate as GHI Plus countries. The criteria for selection of GHI Plus countries will include:

• Partner country interest in participation, including commitments regarding monitoring and evaluation, as well as transparent reporting;
• Engagement of partners in collaborative health systems strengthening and support of national health plans;
• Existence of health information system with basic functionality;
• Presence in country of health programs in at least three of the following areas: MCH, family planning, nutrition, TB, HIV/AIDS, malaria, NTDs, and safe water and sanitation;
• Magnitude and severity of the health problems to be addressed;
• Potential to leverage bilateral, multilateral, and foundation investments;
• Potential to leverage other U.S. government development investments, such as the Feed the Future Initiative;
• Regional diversity to maximize learning opportunities; and
• A focus on low-income countries.

The GHI recognizes, through the creation of the GHI Fund, the significance of designating resources that are not allocated to countries ex ante and are distributed as a result of a collaborative process with partner countries. To promote country ownership and ensure meaningful engagement in the additional and intensive effort required for transformational change in health conditions, each national authority participating as a GHI Plus country must demonstrate interest and commitment to these concepts, and must be fully part of discussions, planning, and negotiations from the outset. Recognizing that the Initiative must be fully accountable to Congress and the American taxpayer, the flexibility of the GHI Fund and country selection process is circumscribed by the following requirements:

• The list of potential GHI Plus countries will be determined by March 1, 2010, following consultations with Congress, U.S. government agencies, partner and other donor governments, and other stakeholders;
• Phase I GHI Plus countries will be selected from the list. Congress will be consulted during the selection process and briefed on the details of the country reviews;
• The selection of Phase I GHI Plus countries will be completed by April 30, 2010; and
• No GHI Plus country will receive more than an additional $50 million annually in program funding associated with its GHI Plus status.

Conclusion

Building on a long tradition of U.S. government global health leadership and the unprecedented level of commitment manifested in recent years, the Obama Administration's Global Health Initiative has the opportunity to move global health to a new level of effectiveness, with a vision of long-term sustainability led by partner countries. Seizing that opportunity requires new investments in programs that recognize the centrality of women and girls to long-term health and well-being of families, communities, and countries, and that foster the development and expansion of high-performing and sustainable platforms for service delivery and the implementation of public health programs. This is an ambitious endeavor that requires a full measure of commitment and collaboration across U.S. government agencies and with our global and national partners. It is one that the Obama Administration embraces as the leading edge of a comprehensive, future-oriented vision of this country's contributions to global development.