Cablegate: Global Health Initative: Promoting Greater Awareness And

DE RUEHDS #2943/01 3500441
P 160441Z DEC 09




E.O. 12958: N/A

Reference: State 00/125761

1. The U.S. Mission to Ethiopia wishes to provide the following
comments in response to State cable 00125761 regarding the goals and
principles of the President's Global Health Initiative (GHI). The
broad goals around improving overall health outcomes and increasing
country capacity to improve prospects for sustainability are on
target and welcome. They provide an opportunity to tailor the GHI
to meet the country-specific burden of disease. Host governments,
multilateral, and bilateral partners will appreciate such
flexibility, which will improve their motivation to work with the

2. The approaches to achieving these broad goals (integrating USG
health programs, increasing country alignment, and deeper engagement
with other stakeholders) are also sound. We would like to emphasize
that strategic integration and coordination takes place at both the
intra-sectoral and inter-sectoral levels. Intra-sectoral approaches
provide opportunities for holistic health programs.
Inter-sectorally, health programs should link to programs in
business development, environment, alternative livelihoods,
agriculture, democracy and governance, emergency relief and
education to ensure that health issues are taken into account and
health messages promoted.

3. The women and girl-centered approach is of course valid and the
addressing of male norms under GHI is much appreciated. However,
women and girl-centered programs must do much more than simply
target women as beneficiaries for services but rather focus on
women's status in the community, their education levels, their
ability to earn and control income, and their ability to
successfully negotiate health outcomes for themselves, their
children and their communities. Women and girl-centered programming
must focus on the household and community levels, where most key
decisions regarding child and maternal health are made, while
continuing efforts to address key policy issues at higher levels.

4. The four specific areas of GHI, are also appropriate. However,
in order for these goals to generate traction at the country or
global level, they need to be quantified with clear and realistic
objectives and targets. Additionally the issue of balance is
applicable across all other GHI programs. For example, while
agreeing that HIV prevention needs to improve, we still need to
maintain balance with care, treatment and support programs.

5. The U.S. Mission to Ethiopia fully supports the seven proposed
GHI principles. As per para 3, we look forward to providing our
views on how these principles may best be applied in the follow-up
cables on GHI's strategy and plans for implementation. In the time
allocated for a response to this cable, we have not been able to
fully provide information on best practices, lessons learned and
opportunities. Ethiopia has rich experience to share in these and we
will communicate these as soon as possible.

6. The USG team and the Government of Ethiopia are well positioned
and highly motivated to initiate implementation of the GHI. Many of
the policies, plans and platforms for service delivery, donor
coordination, systems strengthening and building country ownership
are already in place. In all of these platforms, the USG is fully
involved and in a position to provide strong leadership in pursuit
of the goals and principles of GHI.

7. The strong emphasis on country leadership, program integration
and improved coordination among existing agencies and programs is
most welcome. The question around interagency coordination is of
course "how"? To be most effective, integration needs to be across
agencies and involve their respective partners, as appropriate.

8. Central support for providing guidance on an appropriate
division of labor in the field, taking comparative advantages of
agencies into account, is essential both at this stage of PEPFAR and
for moving forward with GHI. We have seen PEPFAR accomplish a great
deal over the past six years, but at a high transaction cost when it
comes to interagency relationships. Multiple factors may have
contributed to this, including modeling in the field the way
agencies relate to one another at headquarters, competition for
budget and credit going to agencies, differing agency cultures, lack
of clarity on division of labor, and lack of headquarters and
in-country leadership with managing the historical change that
PEPFAR introduced to achieve targets through interagency
coordination. However, the lack of a clear division of labor
between USG agencies within PEPFAR has clearly reduced the overall
effectiveness and efficiency of the USG program for HIV/AIDS

ADDIS ABAB 00002943 002 OF 002

9. Key to effective and efficient programming is a clear division
of labor in tandem with excellent coordination. There are several
ways in which to divide responsibilities, including by programmatic
area (HIV prevention, HIV care/treatment, neglected tropical
diseases, TB, malaria, family planning, maternal health, child
survival etc), health system component (supply chain, laboratory,
strategic information, human resources, infrastructure, financing
etc), and programmatic partnerships (private sector, public sector,
uniformed services, community, etc.). We believe that a management
model whereby an agency is assigned responsibility for a specific
area, component, population and/or partnership and is provided with
the authority and resources for implementation, on behalf of and
with the collaboration of all USG agencies, will ensure that GHI
produces better results at a lower cost.

10. The primary lesson learned from Ethiopia, and critical for the
eventual success of the GHI, is that clear lines of authority and an
appropriate division of labor between US agencies, based on each
agency's comparative strengths, needs to be established from the
beginning. In this way, USG agencies operating in Ethiopia will be
able to more effectively collaborate and implement GHI, improve
health status in a lasting way, and thus serve both the interests of
the people of Ethiopia and the US taxpayer.

11. In summary, the U.S. Mission to Ethiopia welcomes the
opportunity to work with all relevant agencies in designing and
implementing the GHI, and believes that in Ethiopia existing
platforms across the areas covered by GHI are extremely
well-positioned to support the Initiative. We look forward to the
opportunity to respond to the forthcoming cables on the draft GHI
strategy and plans for implementation.


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