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Cablegate: Global Health Initiative: Kenya Comment


DE RUEHNR #2628/01 3550530
R 210529Z DEC 09



E.O. 12958: N/A

REF: 09 STATE 125761

1. Post appreciates the opportunity to comment on
goals and principles of President Obama?s Global Health
Initiative. As stated, individual government agencies
involved in defining practices, implementation, and
governance have been actively involved in discussions
(e.g. HHS/CDC, USAID, STATE), and have engaged with the
field. Note: Post was visited by S/GAC?s A. Gavaghan
on November 10, 2009; she facilitated a GHI Listening
Session where inputs from all agencies were solicited.

2. Kenya currently has the largest USG health
portfolio globally (approximately $600 million/year),
with major financial support from PEPFAR and the
President?s Malaria Initiative (PMI). USG health
programs in Kenya are implemented by four agencies:
USAID, HHS/CDC, USAMRU, and the US Peace Corps. Beyond
HIV and malaria interventions, USAID also is authorized
to provide technical and financial support for family
planning, maternal/child health, and tuberculosis.
Both HHS/CDC and USAMRU provide substantial support for
public health research, surveillance, and national
surveys, and both have substantial research capacity
through large field sites. HHS/CDC research focuses on
malaria, HIV/AIDS, and emerging infectious diseases,
and its programmatic work also extends to outbreak
investigations, refugee health, and influenza in a
strong partnership with the Ministries of Health. The
robust combined USG bilateral program aims to improve
specific health outcomes, and to build capacity of the
host country to assume key functions while promoting an
increase to the GOK budget line item for health.

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3. The principles of GHI ? a women-centered approach,
strategic integration, leverage multi-lateral
institutions, country ownership, sustainability,
improve M&E, promote research development and
innovation ? exist now in Kenya as pillars of the
current program. For this reason, much attention has
been given to the health program in Kenya.
Specifically, integration of vertical disease
interventions has resulted in comprehensive,
?horizontal? services delivered as a package to
clients. An example of a best practice, USAID has
?blended? resources resulting in substantial health
improvements in technical areas receiving relatively
small funding (e.g. child health). 2008/09 Demographic
and Health Survey (DHS) saw a welcome drop in the under
five mortality rate from 114 to 74, thanks in large
part to increased use of malaria bednets and childhood
immunizations. Integrated or ?wrap around? programs
have been implemented in Kenya at large scales, with
wide-spread HIV counseling and testing services also
reaching family planning needs of all clients. Some
implementing partners are conducting door-to-door HIV
testing, bringing a key package of health services into
the privacy of one?s home. Historically, Kenya has
embraced the GHI principle of integration and
demonstrated measurable results from this strategic

4. USG agencies have also been keenly aware of
development issues related to sustainability.
Programming over $.5billion annually, USG is challenged
to continue achieving great success while moving the
country towards more sustainable health services.
Capacity building, in the form of provider training,
has helped produce a cadre of skilled health workers.
Training in basic management and leadership skills is
greatly improving the country?s ability to manage and
supervise programs in the public and private sectors.
HHS/CDC supports a Field Epidemiology and Laboratory
Training Program that has greatly enhanced indigenous
capacity for outbreak response and surveillance, and
USG-supported research has contributed to dozens of
Kenyan scientists obtaining higher degrees.
Institutional capacity building in Kenya has allowed
for some young NGOs to grow and mature, becoming
eligible to raise funds and manage health programming
at a standard respected by the international community.
While sustainability challenges are great, Kenya is
maximizing efforts to build the capacity of both
individuals and institutions for long term health
sector improvements.

5. The Kenya program places the client at the center
of all health interventions. While this has proven to
help bring comprehensive services to mothers, children

and their families, recent data has suggested that more
could be done to focus on the health of mothers.
Specifically, 2008/9 DHS data demonstrate that while
major improvements are happening elsewhere in the
country, maternal mortality is on the rise. This has
produced a national response, calling for greater
emphasis on women as targets of primary health care.
Safe motherhood programs will need to be expanded into
rural regions to help reduce the risks associated with
pregnancy and delivery. Such programs should be
integrated with current and future efforts to prevent
mother-to-child transmission of HIV. In keeping with
the GHI women-centered principle, Kenya programs will
re-commit to investing in life-saving interventions
that impact mothers and their newborns.

6. Other opportunities relevant to GHI include the
principle of country ownership. Large health
portfolios, like that in Kenya, must face country
ownership as an element of sustainability. GHI will
need to emphasize GOK institutions ? Ministries,
Universities, Regulatory Bodies and others, ? in
addition to continuing support civil society and
public-private partnerships. Benchmarking of proxy
indicators among host country governments will become
increasingly important as part of the development
assistance program. For example, countries like Kenya
could be encouraged to build annual increases into
budget line items (e.g. anti retroviral procurement)
with the aim of eventually supporting the majority of
HIV patient drug needs. Similarly, support for
expanding access to social health insurance for the
poor will remove financial barriers to care. Research
around market segmentation or private sector analysis
of client preferences can help shift paying clients to
private services and reduce the burden now placed on
public facilities. All of these proposed finance
schemes reflect the need to shift ownership from
international donors to the host country.

7. As expressed during the November Listening Session,
USG agencies were unified in their belief that labor-
intensive reporting requirements need to be better
balanced against time needed to oversee the design,
implementation, monitoring, and evaluation of on-going
activities. PEPFAR has not benefited as much as it
could have from operational research and the processes
for learning quickly from implementation experience
will have to be made simpler than the currently
cumbersome Public Health Evaluation system.

8. In sum, Kenya?s large health program already aims
to meet many of the GHI goals and principles. With
multiple USG agencies engaged in Kenya, in-country
governance structures are well-established at both the
policy and project levels (for HIV and malaria). New
structures might duplicate already highly functioning
systems in countries where the health portfolio is
stable, and mature. Overall, GHI principles are firmly
reflected in Kenya?s strong bilateral health program.

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