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RR RUEHBZ RUEHDU RUEHGI RUEHJO RUEHMA RUEHMR RUEHPA RUEHRN RUEHTRO
DE RUEHAN #0863/01 3491440
ZNR UUUUU ZZH
R 151440Z DEC 09
FM AMEMBASSY ANTANANARIVO
TO RUEHC/SECSTATE WASHDC 3140
INFO RUEHZO/AFRICAN UNION COLLECTIVE

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. 
 
ANTANANARI 00000863  002 OF 002 
 
 
 
¶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