Guidance for Global Health Initiative Country Strategies

I. INTRODUCTION
Global Health Initiative Summary
Global Health Initiative Health Outcomes
Global Health Initiative Core Principles
The Global Health Initiative Country Strategy
Casual Relationship between GHI Principles and GHI Goals
Governance of GHI
Budget Authorities and Planning
Other Considerations
Reporting on GHI

II. GHI COUNTRY STRATEGY
Purpose and Characteristics of a GHI Strategy
Deliverables Expected from the Country Team
GHI Country Strategy Review Criteria and Process

III. IMPLEMENTATION OF GHI
Field Organizing Structure
Elements of Inclusive Process
Headquarters Organizing Structure

ACRONYMS
 

INTRODUCTION

Purpose

The purpose of this document is to provide guidance to U.S. Government country teams for developing, implementing, monitoring, and reporting on a multi-year strategy to implement the Global Health Initiative (GHI). ¹ The intended recipients of the guidance are the approximately 80 countries in which the U.S. Government invests foreign assistance funding in the health sector. The guidance defines and clarifies expectations about the GHI strategy, including its relationship with the impressive array of existing U.S. Government health and development programs spread throughout the world, and sets forth the parameters and content of a GHI strategy. In addition, it provides guidance on how the field will structure itself to deliver on a key tenet of GHI—adopting a "whole-of-government" approach2 aimed at improving national health outcomes. Finally, it discusses monitoring and reporting on progress in achieving the goals and objectives of a GHI Country Strategy.

Global Health Initiative Summary

GHI sets an ambitious agenda and signals a commitment to fundamentally improve the way the U.S. Government does business to achieve greater impact. GHI is an overarching umbrella that encompasses U.S. Government health-related programs on HIV/AIDS, malaria, tuberculosis, maternal, newborn and child health (MNCH), neglected tropical diseases (NTDs), family planning (FP) and nutrition. It links closely to other U.S. Presidential development initiatives including Feed the Future (FtF) and Global Climate Change, where synergies with GHI may be possible and should be pursued. To achieve its goals, GHI will also reach beyond the health sector to areas that link with health, such as safe water, sanitation, health financing and education for girls.

GHI seeks to achieve more "value for money" by:

• Promoting better alignment between U.S. Government investments and country-level priorities, thereby fostering country-ownership and sustainability;
• Promoting smart integration among U.S. Government-supported disease-specific programs, with an emphasis on leveraging and building on existing platforms and strengthening systems that reach across the health sector, thereby creating greater efficiencies and improving outcomes;
• Reforming the way the U.S. Government supports countries in delivering health services by increasing the number and types of local partners (e.g., non-profit organizations, private businesses, civil society, faith-based organizations, partner governments) and strengthening national capacity to lead, manage and oversee health programs.

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1 Full details of the Global Health Initiative can be found at www.ghi.gov
2 A whole-of-government approach is characterized by an inclusive process that involves all U.S. Government agencies and offices with expertise in global health activities and assets that can be leveraged to achieve common goals and targets. This includes, among others, U.S. Agency for International Development (USAID); Department of State, including the Office of the Global AIDS Coordinator (S/GAC); Department of Health and Human Services (HHS), including the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH), Food and Drug Administration (FDA), and the Office of Global Health Affairs (OGHA); Department of Agriculture (USDA); Department of Defense (DOD); Department of Treasury; Millennium Challenge Corporation (MCC); Peace Corps; the Office of Management and Budget, the White House National Security Staff (NSS), and the White House Office of Science and Technology Policy (OSTP).
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Global Health Initiative – Sustainable Health Outcomes

The paramount objective of GHI is to achieve major improvements in health outcomes through sustainable approaches and increased country ownership. In line with partner government priorities and in partnership with multilateral efforts, GHI supports critical goals and targets which confirm the U.S. commitment to the health-related Millennium Development Goals, and provides a useful framework for our GHI investments. The targets and outcomes for GHI³ are listed below:

• HIV/AIDS: Through the President’s Emergency Plan for AIDS Relief (PEPFAR), support the prevention of more than 12 million new HIV infections; provide direct support for more than 4 million people on treatment; and support care for more than 12 million people, including 5 million orphans and vulnerable children.
• Malaria: Through the President’s Malaria Initiative (PMI), halve the burden of malaria for 450 million people, representing 70 percent of the at-risk population in Africa. Malaria efforts will expand into Nigeria and the Democratic Republic of Congo.
• Tuberculosis (TB): Contribute to the treatment of a minimum of 2.6 million new sputum smear positive TB cases and 57,200 multi-drug resistant (MDR) cases of TB, and contribute to a 50 percent reduction in TB deaths and disease burden relative to the 1990 baseline.⁴
• Maternal Health: Reduce maternal mortality by 30 percent across assisted countries.
• Child Health: Reduce under-five 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 (FTF).
• 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; and reducing from 24 to 20 percent the proportion of women aged 18-24 who have their first birth before age 18.
• Neglected Tropical Diseases (NTDs): Reduce the prevalence of 7 NTDs by 50 percent among 70 percent of the affected population, contributing to: the elimination of onchocerciasis in Latin America; the elimination of lymphatic filariasis globally; the elimination of blinding trachoma by 2020; and the elimination of leprosy.

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3 For more detailed information on the targets and outcomes of GHI including linkages to current strategies, please consult the Global Health Initiative Strategy Document (Annex I), available on www.ghi.gov.
4 The Lantos-Hyde Reauthorization Act (P.L. 110-293) calls for the USG to support the objectives of the Global Plan to STOP TB, including the achievement of the Global Plan goals to reduce by half the TB death and disease burden from the 1990 baseline.
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Global Health Initiative Core Principles

GHI is rooted in the seven core principles outlined below.⁵ U.S. Government programs are expected to align their health programs with these broad principles and strengthen the knowledge base for how these principles advance health goals.

1. Focus on Women, Girls, and Gender Equality: A core objective of 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. Over the long term, improving the health of women enhances their productivity and social and economic participation. Improving women’s health also benefits, now and in the future, the social and economic development of families, communities and nations.
2. Encourage country ownership and invest in country-led plans: GHI will help build the capacity of partner countries to develop, manage, oversee, and implement their national health plans. GHI will build from existing government health plans, as a framework for common investment, demonstrating commitment to country priorities, and will work to ensure that civil society and the private sector are engaged.
3. Strengthen and leverage other efforts: Ultimately, improving global health outcomes is a shared responsibility. Through GHI the U.S. Government will work to leverage the investment of other bilateral and multilateral donors, foundations, partnerships, and the private sector to improve health outcomes.
4. Increase impact through strategic coordination and integration: GHI will promote health delivery systems that focus on comprehensive primary health care and prevention. It will promote joint programming among U.S. Government agencies, other donors (bilateral, multilateral, and foundations), partner country governments, and other institutions.
5. Build sustainability through health systems strengthening: Through GHI, existing health systems will be strengthened to enable efficient, effective and sustained provision of health care services and public health programs. GHI will adopt metrics to assess the robustness of health systems, and promote both improved access to and utilization of quality health services, particularly for marginalized and disadvantaged populations, in order to improve key health outcomes.
6. Promote learning and accountability through monitoring and evaluation: GHI will emphasize data-driven decision-making to track progress, resolve critical problems, and promote cost-effective service delivery approaches. The U.S. Government will work with partners to prioritize sets of indicators aligned to national reporting systems and timelines that permit cross-country analysis and minimize reporting burdens.

7. Accelerate results through research and innovation: GHI will foster research to address key questions with immediate relevance to both GHI and partner country goals and objectives. GHI will spur the discovery, development, translation and implementation of new interventions and technologies, thus enhancing program effectiveness while strengthening country-based research capacity.

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5 For a complete description of these principles, please consult the Global Health Initiative Strategy Document, available on www.ghi.gov. In addition, a supporting document for implementing the Principle of Women, Girls, and Gender Equality is available on https://max.omb.gov/maxportal/. Teams will be guided on registration procedures in order to access the MAX site. Additional supporting documents for the other GHI principles will be forthcoming.
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The Global Health Initiative Country Strategy

The GHI Country Strategy is the over-arching framework which outlines the vision for how GHI will utilize U.S. Government health investments by ensuring the integration of GHI principles into existing and future country programs. Articulated as a multi-year strategy which can be updated annually, the GHI Country Strategy document describes the application of these principles in two or three cross-cutting focus areas which represent opportunities where multiple programs, and/or agencies, and/or other collaborations can accelerate achievement of GHI targets and health objectives. The GHI Country Strategy should demonstrate how the U.S. Government can save resources, improve outcomes and increase efficiencies through investment in these areas. The strategy should acknowledge the challenges of enhancing country-owned systems by setting short-, medium- and long-term benchmarks.

The GHI Country Strategy is not intended to replace existing operational plans, but rather to complement and connect these activities with the cross-cutting focus areas. The implementation modalities of GHI are the country operational plans for HIV/AIDS (COP), malaria (MOP), and foreign assistance (OP). These yearly or biennial operational plans should reflect both GHI principles and accelerated progress toward the health targets of GHI resulting from the GHI Country Strategies. This strategy will also serve as a road map for how GHI is implemented within all U.S. Government GHI program plans.

The annual Performance Plan and Report (PPR) ⁶ will be used to report on progress towards achieving GHI goals. All GHI health outcome indicators are currently collected through this data reporting system. Under the Program Area Narratives, the "health" section will be used to report broadly on GHI, while the Program Area Elements and Key Issues Narrative will be used to report on specific health outcomes and cross-cutting areas respectively, as is currently done. The PPR is a report generated through FACTS Info, the planning and reporting database of the

U.S. Department of State F Bureau. The FACTS Info database collects both quantitative and qualitative data and will be the tool used to report on progress achieved in applying GHI principles. By October 2011 modifications to the system will ensure open access by U.S. Government agencies reporting on programs funded through the Foreign Assistance account.

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6 The annual Performance Plan and Report (PPR) provides information on the performance of State and USAID foreign assistance programs. Performance information supports annual budget requests to Congress. The PPR will be submitted to the Office of the Director of U.S. Foreign Assistance (F) using the Foreign Assistance Coordination and Tracking System Information (FACTS Info). All U.S. Government investments funded through the foreign affairs account are to be reported through FACTS Info. Plans are underway to place FACTS Info servers outside State and USAID firewalls to ensure access by HHS and other agencies. For global health investments by HHS, DOD, Treasury, and others made that are not from the foreign assistance fund, there is ongoing dialogue as to how best to ensure these additional investments inform progress of GHI.
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Causal Relationship between GHI Principles and GHI Goals⁷

Underlying the seven GHI principles is the premise that concerted application of them will result in significant and sustained health improvements. The GHI Causal Pathways diagram shown below provides a pictorial representation of this relationship, serving as a guide as to how GHI works and not a template to be completed by each country (See guidance in Section II on the accompanying Results Framework).

Figure I

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7 Additional interagency M&E TA will be available to interagency field teams for related M&E portions of the GHI Strategy (e.g. GHI Strategy Matrix, Reporting, Results Framework, Causal pathway),
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• Greater country ownership is supported by continued engagement with partner governments, civil society, and private sector stakeholders as they develop, implement and support country health plans and health strategies. Aligning U.S. Government investments with country priorities and plans increases the likelihood that progress is owned by local stakeholders and maintained in the future.
• In supporting country plans, U.S. Government will leverage improved health partnerships, other investments and expertise to ensure that U.S. Government investments complement and strengthen the efforts of government, local and international organizations, other bilateral and multilateral donors, foundations, and the private sector.
• Increased country ownership and improved partnerships create opportunities to strengthen health systems. GHI fosters collaboration with country partners to jointly identify and address bottlenecks and barriers in their health systems. GHI focuses on improving system components in a manner that supports efforts across the health sector, where it is cost-effective and consistent with the nationally-defined priorities.
• The functioning of health systems, in turn, influences demand for and supply of health services. Improved health knowledge, attitudes, and norms (demand) result from promoting interventions that value women and girls, support healthy behaviors, and increase individuals’ health literacy. Expanded, coordinated/integrated, gender-equitable services (supply) encompass service quality, availability, accessibility, and affordability.
• Sustained improvements in health behaviors and care and treatment coverage are the assumed outcome of the interaction of supply and demand and greater country ownership of the health sector. Improved efficiencies in health programs and systems are also expected outcomes as a result of GHI. These programmatic outcomes lead, ultimately, to improved health status. The integral nature of monitoring, evaluation, research, and innovation to all aspects of GHI is shown on the vertical rectangle on the right side of the document. In particular, evaluation under GHI is expected to improve understanding of the relationships conveyed by the vertical and horizontal arrows in the main body of the diagram

Overall Governance of the Global Health Initiative

Currently, GHI is led by an Operations Committee (the USAID Administrator, the Global AIDS Coordinator, and the Director of the CDC). In early 2011, the Secretary of State appointed an Executive Director for GHI at the State Department reporting to the Secretary of State and the GHI Operations Committee, to facilitate heightened coordination of U.S. programs to meet the goals and objectives of GHI, and to transition leadership of GHI to USAID at the end of FY 2012 pending the completion of a set of defined benchmarks. The responsibility for leading PEPFAR, following current practice and its governing statute, will remain with the Office of the Global AIDS Coordinator (OGAC) at the State Department. As the State Department and USAID work to implement QDDR and other key initiatives, posts should expect further guidance. All U.S. agencies are nonetheless expected to foster a culture supportive of interagency collaboration in implementing GHI.
 

Budget Authorities and Planning

The President and the Secretary of State have established significant United States objectives on global health, through the creation of the Global Health Initiative, and provided a coherent set of steps for implementing these in the State Department’s Quadrennial Diplomacy and Development Review (QDDR) and the Presidential Policy Directive on Development. In order to fulfill these objectives, the Secretary of State created the Office of the Executive Director of the Global Health Initiative (S/GHI) in January 2011 to work with USAID, S/GAC and HHS/CDC on operational implementation.

GHI seeks to bring greater coherence between U.S. Government agencies and host country partners by improving on the processes through which country health teams collaboratively set priorities and develop optimal work plans. Collaboration allows the U.S. Government to present a unified, coordinated face to Ministries of Health as well as other key Ministries and stakeholders that are essential for improved health outcomes in partner countries. The purpose in doing so is to allow countries to take more effective ownership of these programs, and to eliminate inefficiency from duplication or other factors. Collaboration is always challenging, despite the evident benefits, and will require agency headquarters in Washington and Atlanta to receive feedback from the field in order make these practices work most effectively.

Working together as part of a single U.S. Government effort optimizes effective interactions for all parties involved. Country teams are requested to develop a single GHI Country Strategy, which will serve as a guidepost to achieve greater efficiencies and contribute to health targets through crosscutting goals and objectives such as health systems strengthening, country ownership and improved outcomes for women and girls.

Agencies recognize that there are differences in how services and products are procured and commit to harmonizing these activities in order to increase the effectiveness and efficiency of these programs and ensure value for money for U.S. government investments. All agencies are committed to increasing use of local partners, particularly host governments; increasing efficiency and effectiveness; and strengthening partnership and collaboration with bilateral and multilateral donors and international organizations.

Budget Authorities

GHI builds on existing U.S. Government investments in health-related programs on HIV/AIDS, malaria, tuberculosis, MNCH, NTDs, FP and nutrition. Therefore resource planning for GHI country strategies will take place consistent with the existing authorities of U.S. Government global health programs.

In the domain of HIV/AIDS, S/GAC will continue to exercise budget responsibility and oversight, strategic planning, policy coordination and representation of the PEPFAR program on behalf of the U.S. Government and the interagency process. As a part of the State Department’s streamlining efforts, S/GAC will work to revamp the Country operational Plan (COP) process in order to allow country teams to spend more time on program implementation and monitoring.

Outside of PEPFAR, GHI will be implemented in accordance with the authorities and appropriations granted USAID and other implementing agencies. For USAID, this authority includes budgets to implement the global health programs in MNCH, FP, malaria, TB, nutrition, water and sanitation and NTDs. For HHS/CDC, this authority includes budgets to implement programs and activities related to these priority GHI areas. In doing so, USAID and HHS/CDC will actively seek ways to work together more effectively on behalf of U.S. Government objectives at headquarters and in-country, in ways consistent with their legislative and regulatory requirements.

Planning

Working with the Office of the Executive Director of the Global Health Initiative in the Secretary of State’s Office, USAID, HHS/CDC, and S/GAC all commit to inclusive planning, implementation and monitoring of GHI and to do so in accordance with the QDDR and the President’s Policy Directive on Development. The organizations at headquarters and in the field commit to achieving excellence in whole-of-government global health planning and will encourage and reward staff for adopting the leadership practices and organizational processes in order to do so. In addition, GHI will be diligent in seeking input from in-country field offices to improve the effectiveness and efficiency of these practices and resolve areas where lack of clarity inhibits success.
 

Other Considerations

GHI acknowledges that several countries will need to identify unique platforms and foundations on which to plan and implement the GHI approach. These include countries that have single programs such as MNCH/ FP only, HIV only, or have no USAID mission or CDC presence. Platforms such as the President’s Malaria Initiative (PMI) and FP are also significant U.S. Government efforts from which GHI can and should be built. Some countries have exceptional circumstances that make fulfilling all the requirements of the GHI Country Strategy challenging. These include a single in-country U.S. Government program (e.g. PEPFAR only, or a single agency); operate through regional programs; or countries with relatively small budgets (<$5,000,000). Under such circumstances the country team may negotiate with headquarters for an exception to the requirements of the GHI Guidance that cannot be met. In such instances, it is expected that country teams will search for innovative ways to apply the GHI principles toward achievement of health outcomes, work in an inclusive interagency manner where applicable, and identify focus areas for more intense engagement with the partner country government, civil society and bilateral and multilateral partners.

Reporting on GHI

GHI performance metrics will be reported to headquarters through the Performance Plan and Report (PPR) submitted each December through FACTS Info. In the 2010 PPR, a new set of required indicators has been introduced. Many of the new indicators should be easily obtained from Demographic and Health Surveys (DHS) or other nationally representative surveys (e.g. the AIDS Indicator Survey) or surveillance systems. Other indicators can be obtained from publicly accessible sources, such as the World Health Organization databases.

In addition, since 2010, PEPFAR’s Next Generation Indicators which replaced all its previous performance indicators were reported through FACTS Info. Definitions and information about data sources can be found in the PPR indicators handbook distributed by the F Bureau. It is anticipated that in 2011 a limited number of additional GHI-related indicators may be introduced for the PPR.

 

GHI COUNTRY STRATEGY
 

Purpose and Characteristics of a GHI Country Strategy

U.S. Government teams⁸ are responsible for developing a brief multi-year GHI Country Strategy through 2015 that articulates a holistic approach for how U.S. Government investments in health and other development efforts will support national plans and move key GHI principles and objectives forward. Development of these strategies will be achieved through ongoing and continued dialogue with governments as partners, as well as through an inclusive whole-ofgovernment process.

The guidance acknowledges that many countries have recently developed BEST⁹ Action Plans, PEPFAR Partnership Frameworks and Partnership Framework Implementation Plans; PEPFAR Country Operational Plans (COPs); President’s Malaria Initiative (PMI) Malaria Operational Plans (MOPs); U.S. Department of State, Office of the Director of Foreign Assistance Operational Plans (OPs); USAID Country Development Cooperation Strategies (CDCS); U.S. Department of State Mission Strategic Resource Plans (MSRPs); and other relevant plans and/or agreements. The GHI Country Strategy does not replace these strategic plans but provides the vehicle through which they are linked for planning in the health sector, and can complement each other.

A bedrock assumption of GHI is that there are efficiencies to be gained by looking and planning across disease-specific programs. Thus U.S. Government country teams should identify areas of shared investment and activities across programs when developing a GHI Country Strategy, and identify opportunities for synergy. Financing for new approaches under the GHI Country Strategy will be determined by country teams using the existing budgets and planning authorities under PMI, PEPFAR and USAID for the OP. This does not exclude interagency planning for new approaches within these plans to support GHI, but defines where the available resources will be sought. These new approaches may also include other funds and concomitant planning authorities such as U.S. Government assistance through HHS, DOD and other applicable budgets.

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8 All countries will be requested to develop GHI strategies due by December 2011; Round II country strategies will be due by June, 2011. A total of up to twenty countries will be designated as GHI Plus countries by 2013. These countries will receive additional management and technical support for learning, with the best practices shared globally. Eight GHI Plus countries were identified in 2010; others will be selected in 2013.
9 Best Practices at Scale in the Home, Community and Facilities: An Action Plan for Smart Integrated Programming in Family Planning, Maternal and Child Health, and Nutrition under the Global Health Initiative.
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The following are key objectives and characteristics of a GHI Country Strategy:

• Builds upon existing health plans and agreements with countries (e.g., BEST Action Plans, Partnership Frameworks, COPs, MOPs, Cooperative Agreements, and Strategic Objective Agreements) and draws on strengths of all agencies;
• Applies the GHI principles to identify modified/new priorities, policies or activities that are designed to accelerate achievement of GHI targets and objectives;
• Identifies two or three cross-cutting strategic areas of focus where application of the GHI principles can result in synergies and efficiencies in programming that improve the efficiency and effectiveness of U.S. Government health investments in programs under GHI;
• Reflects the strategies, activities, and indicators outlined in the country’s national health plan and is formulated through ongoing engagement with the partner government;
• Strengthens government, civil society and private sector capacity to plan, lead, and manage their national health programs;
• Establishes country targets that are nationally-owned and aligned with GHI health targets and objectives;
• Reinforces collaboration and participation with bilateral and multilateral partners;
• Is not specifically designed to significantly increase the U.S. Government footprint in the country;
• Promotes processes and mechanisms to (1) ensure the efficient and effective use of U.S. Government resources; (2) increase alignment of planning, procurement and M&E activities with partner country government; and (3) enhance best practices in procurement to make appropriate use of the competitive process for the benefit of a range of large and small implementing partners including civil society and faith-based organizations.

Deliverables Expected from the Country Team

o Data Slide Set – This is considered the first step for all countries in the GHI Country Strategy development
o 10-15 page GHI Country Strategy Document
o Results Framework
o GHI Country Strategy Matrix
o Research and Evaluation Questions (optional)

Under the leadership of the Ambassador/Deputy Chief of Mission (DCM) and a designated GHI Planning Lead (PL-further explained below), an interagency field team will engage in an inclusive and coordinated planning process to develop a comprehensive high-level GHI Country Strategy. The time frame of the strategy, from 2011 to 2015¹⁰, will coincide with achievement of the Millennium Development Goal (MDG) targets of 2015.

The GHI Country Strategy should be grounded in the partner country’s health goals and objectives and be responsive to the priority needs identified by the country health-sector policies and plans. The strategy should be designed in a participatory and inclusive manner, engaging partner country counterparts, U.S. Government personnel on the ground, health and other sector development partners, and civil society. While such a process takes time, it is a visible demonstration of commitment to country ownership and improved partnerships and is likely to lead to a more complete and realistic strategy with better harmonization of program activities with other stakeholders. The choice of two or three cross-cutting strategic focus areas should reflect the comparative advantage of the U.S. Government in the context of the country situation and capitalize on the strengths of the different U.S. Government partners.

Teams should expect to have multiple conversations with government and civil society over the strategy development period to ensure host partner government understands the GHI approach and local civil society has a voice in the strategy. In addition, Health teams should collaborate with U.S. Government non-health sectors of democracy and governance, economic growth and others, to help foster innovation to achieve health outcomes.
 

DATA SLIDE SET

The first step in the development of the GHI Country Strategy will be a thorough assessment of the current health context by the country team. This will include reviewing and analyzing the current epidemiologic data, existing health statistics (understanding some of these will need to be further validated), the national health system, the national health plan, the scope of U.S. Government-supported activities and existing mechanisms, and current GHI health outcome areas, as well as issues related to the GHI principles. This information will be gathered into a Data Slide Set to be shared with HQ.¹¹ This analysis will serve as a core element for bringing field teams together to design the country GHI Country Strategy and will form the basis for initial discussion with HQ on the proposed strategy.

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10 The GHI time frame may differ for some countries.
11 Country teams can download the GHI Data Slide Set template on the GHI intranet site (https://max.omb.gov/maxportal/). Completed slide sets along with copies of the National Health Plan and any relevant disease- or issue-specific plans from the National government should be loaded on to the intranet site under the country folder coordinated through the Planning Lead.
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GHI COUNTRY STRATEGY DOCUMENT (10-15 PAGES)

Each GHI Country Strategy document should include the following elements:

1. GHI Vision (`1 page) – Summary statement of what will be achieved under GHI.
2. GHI Partner Country Priorities and Context (`2-3 pages) Provide a summary of the current status of GHI health outcome goals and principles in country, including challenges affecting health, drawing on existing studies and data to the maximum extent. Much of this information will have been collected for the Data Slide Set.
   • Summarize the partner country National Health Plan, or equivalent, and health response, including priorities and gaps.
   • Identify areas of overlap between the priorities of the partner country’s National Health Plan and GHI.
   • Identify barriers to achieving country priorities and GHI goals and implementing principles. These barriers may include:
     • lack of relevant data;
     • programming gaps;
     • policy concerns;
     • financial gaps;
     • significant bottlenecks;
     • limited human resources; and
     • lack of partner country engagement.
   • Identify strengths and opportunities, which may include:
     • possibilities for implementation of evidence-based interventions;
     • scaling up successful best pratices; and
     • strengthening of health system elements that would benefit multiple disease areas or health conditions.
   • Identify existing systems and service delivery platforms (between U.S. agencies and programs, with partner governments and the non-public sector, and with other collaborating partners (multilaterals, other bilaterals, foundations) where services or systems can be expanded, integrated or better coordinated to improve access and quality of care, including preventive services.
3. GHI Objectives, Program Structure, and Implementation (`6-9 page)
   The GHI Country Strategy should reflect a multi-year (2011- 2015) road map demonstrating how application of the GHI principles will save resources, increase efficiencies and accelerate or sustain health outcomes. The strategy should:
   • Select and agree upon two or three cross-cutting areas in which an intensified focus can rapidly impact health outcomes. For example within a shared area, teams may consider innovative ways to consolidate inputs into human resources or the supply chain to strengthen country capacity to achieve health objectives in new and sustainable ways.
   • Demonstrate "smart integration" ¹² to maximize synergies and efficiencies in programming and/or better ways to deliver services using all available resources (U.S. Government, donor and government);
   • Strengthen health systems, including those within public sector, private sector and civil society, to promote sustainability;
   • Identify new or revised priorities, policies, or activities that will ensure achievement of GHI's targets and objectives;
   • Harness U.S. Government, partner country and others’ expertise and resources;
   • Develop new or innovative ways to sustainably scale up proven interventions;
   • Promote processes and mechanisms to increase alignment of planning, procurement and M&E activities with partner country government and engagement of local partners;
   • Support new reforms aimed at optimizing the number, types, and quality of performance of local partners.
4. Monitoring and Evaluation and Learning (~1-2 pages)
   • Submit a Results Framework and Strategy Matrix as described below which include indicators that are aligned with partner country indicators, reporting systems and timelines.
   • Country teams are encouraged to identify priority, policy-relevant research and evaluation questions to inform learning under GHI.
5. Communications and Management Plan (~1 page)
   • Describe a management and communication approach that promotes partner government ownership and ensures engagement by all relevant stakeholders including donor community and civil society.
   • Briefly describe the interagency management and communication process, utilizing existing country systems as appropriate and include illustrative examples of how the health teams will engage each other around inclusive procurement, budget, and planning processes.
6. Linking high-level goals to programs (~1 page)
   To demonstrate how the GHI Country Strategy will be implemented through U.S. Government programming, teams should provide a high-level overview that links existing program areas and reporting, to GHI objectives, health outcomes and principles. In less than one page, teams should give a brief overview that:
   • Identifies high level activities critical to implementing the GHI Country Strategy that draw upon and will be incorporated into COP, MOP, OP, or other plans. For example: "by the end of 2011, the Country Team will coordinate a U.S. government effort that will provide support to the partner government’s human resource strategy, with a focus on training and retention, with PEPFAR proposing to do (list specifics) and PMI proposing to do (list specifics) and USAID/MCH proposing to do (list specifics)".
   • Identifies high-level milestones that will be used to track progress in applying GHI principles articulated in the GHI Country Strategy. For example: "by June 2011, the Country Team will work with the partner government, and other partners as needed, to establish the development of a technical working group devoted to women, girls and gender equality. By the end of 2011, the Country Team will identify support for at least three activities that the technical working group would like to pursue within new or existing national health strategy".

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12 Per the World Health Organization: Integration means that multiple activities and resources are organized, coordinated and managed to ensure the delivery of more efficient and coherent services in relation to cost, output, impact and use (acceptability). U.S. Government uses the term "smart integration" to emphasize integration where it makes technical, financial and cultural sense. Integration is not an end in itself and should be pursued where it results in improved services for a gamut of health needs. It often makes sense to integrate incrementally by building on a strong vertical program.
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The GHI Country Strategy Matrix below should be used to link the country GHI objectives, health outcomes and principles as they align to the in-country COP, MOP and OP plans to avoid undue additional reporting burdens on the field. The brief overview can refer to the matrix in describing the links in the in-country plans.

RESULTS FRAMEWORK

Designing a Results Framework is a key step in developing and implementing the GHI Country Strategy. A Results Framework is the starting point for strong monitoring and evaluation and embodies key hypotheses about causal relationships between proposed activities and expected results and impact. The Results Framework takes the GHI Causal Pathways diagram described on page 8 and transforms it into a pictorial representation for how the country team will deliver on their GHI Country Strategy. An illustrative GHI Results Framework template is provided in Fig. 2. Country teams may choose to organize their framework differently; however, the key elements of the framework- health impact (goal), outcome (strategic objective), program outputs (intermediate results) and proposed activities- should be included, along with a discussion of critical assumptions. Countries are expected to produce their own results frameworks and are not expected to fit their results framework into the Causal Pathways document. In choosing indicators, country teams should consult the Performance Plan and Reporting indicators handbook distributed by the F Bureau, which compiles indicators included in FACTS Info that are relevant to the GHI.

Figure 2

Template for Country-level GHI Results Framework

• The Health Impact and Outcome: Goals are the long-term end state or health impact that is to be achieved. The two to three focus areas articulated in the GHI Country Strategy should relate directly to the country’s own goals in the health sector and to one or more of the GHI’s overarching goals for sustained improvements in health status. It is important to keep in mind that health impact may be the result of both program effort and other non-program variables.
  The programmatic outcome or strategic objective represents the higher-level result that the U.S. Government team, along with its partners, is willing to be held accountable for achieving within a given time frame and available resources. The programmatic outcome should be clear, precise and objectively measurable. It should be clearly and causally linked to the results framework goal and to relevant national priorities.
• Intermediate Results (Outputs) and Proposed Activities: Intermediate Results are key lower-level program outputs that must occur for the strategic objective to be achieved. Traditionally, in the health sector, intermediate results relate to demand for, availability of, access to and quality of services. In the context of the GHI, a strengthened health system is also a key intermediate result. Country teams should propose a set of activities that will lead to the achievement of the intermediate results or program outputs.
  The contribution of the Country Strategy to achievement of the GHI principles should be evident throughout the results framework, but most prominently at the intermediate result and activity levels, as these are the levels at which GHI resources are directly targeted.
• Critical Assumptions: When developing the framework, U.S. Government teams should work together with other partners in country to identify the set of critical assumptions upon which achievement of the results in the framework depend. Critical assumptions are conditions outside the control of the U.S. Government and implementing partners, including factors outside the health sector. If a critical assumption is identified that has a low chance of holding true over the duration of the strategy (i.e., it poses a significant risk to the achievement of the strategy), the Team should identify realistic means to address the constraint and incorporate those approaches into the framework as results. For example, perhaps the policy environment in country is not supportive of private sector participation in the health sector. Rather than identifying a supportive policy environment as a critical assumption, the team might consider including policy activities in its results framework.
   

GHI COUNTRY STRATEGY MATRIX

Country teams should also complete and submit a GHI Country Strategy Matrix—a tool to create a succinct diagram of the GHI Country Strategy and its expected results on health outcomes^13. The GHI Country Strategy Matrix should be completed for at least two or three cross-cutting strategic areas of focus identified in the GHI Country Strategy, and reference the documents where remaining targets are cited.

In completing the matrix, country teams should relate GHI Global and Country Strategy-specific goals (column 1) to both national health priorities/initiatives (column 2) and to U.S. Government-supported activities (column 3) identified by the team in the GHI Country Strategy. The matrix should also include indicators, country specific baselines, and targets for key health impacts, outcomes, program outputs and proposed activities identified in the results framework (column 4). In setting targets for the indicators, teams should take into account the GHI global targets, country progress to date, and expected progress at the country level over the lifetime of the GHI (progress to be achieved through 2015). The way(s) in which the GHI principles are being applied to reach the GHI targets also should be briefly described in column 5. Finally, key partners in these activities should be identified in column 6.

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13 Country teams can download the GHI Strategy Matrix template and a sample Results Framework on the GHI intranet site (https://max.omb.gov/maxportal/). The completed matrix should be loaded on to the intranet site under the designated country folder coordinated through the Planning Lead (see page 22 on the PL).
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Figure 3

GHI COUNTRY STRATEGY MATRIX
1:	2:	3:	4:	5:	6:
GHI Health Goals	Relevant Key National Priorities/ Initiatives	Key Priority Actions/Activit ies Likely to Have Largest Impact	Baseline info/countryspecific GHI targets	Key GHI Principles	Key Partners
List the GHI overarching and country specific goal(s) where U.S. Government investments in the two or three focus areas will make a contribution.	Drawing from the National Health Plan, list key country priorities, goals and indicators.	List key U.S. Government activities that will be supported by the GHI Country Strategy.	List outcomes, intermediate results, and proposed activities, including baselines, for tracking GHI Country Strategy progress.	Country ownership Woman/girl-centered approach Strategic integration Strengthen/leverage partner engagement Health systems strengthening Metrics/M&E Research and innovation	List key partners
EXAMPLE: GHI Overarching Goal: Reduce maternal mortality by 30% across assisted countries Country-Specific Goal: Decrease maternal mortality ratio from 673 per 100,000 live births to 267 per 100,000
EXAMPLE: Key priorities from the Health Sector Development Plan IV (2011 -2016): Decrease teenage pregnancy from 17% to 5% Increase Focused ANC 1+ visits from 66% to 90% and ANC 4+ from 31% to 86% Increase Delivery Service attended by skilled birth attendants from 18% to 60% Increase postnatal care service from 34% to 78%
EXAMPLE: Key priority actions and initiatives: Support the Health Extension Program (HEP) to deliver family planning (FP) and clean delivery services in community Improve access to quality ANC and maternity and neonatal services to create community demand Support health facilities to meet criteria for emergency obstetrical and neonatal services
EXAMPLE: Key indicators and milestones: Outcomes: Increase ANC 4+ from 31% to 86% in U.S. Government supported facilities Intermediate results: FP/RH services will be provided by over 13,000 HEWs in 5,000 health posts in over 300 districts (32 million people) and integrated into HCT, PMTCT, ARV services in 1,103 sites Integration of PMTCT, ANC and maternal, neonatal, and child health services will be improved in over 1,000 health centers and 150 hospitals Labor and delivery services will be expanded and quality improved, including emergency obstetrical and neonatal services in 200 facilities and pre-service training of 3,000 midwives and 200 emergency surgical officers will be supported
EXAMPLE: Key principles: In a new activity, the U.S. Government team will support GHI principles by addressing key HRH bottlenecks to achieving MNCH goals. A particular focus will be on improving the supply and quality of midwives using a systems approach.
EXAMPLE: Key partners: MOH, RHBs, UNICEF, UNFPA, Integrated Family Health Program, CU/ICAP, UW/ITECH, Red Cross, Christian Health Association

GHI RESEARCH AND EVALUATION QUESTIONS (optional)

All GHI country teams are encouraged to identify priority, policy-relevant research and evaluation questions for the two or three areas of focus, that have the greatest potential to contribute new knowledge relevant to national, U.S. Government and global programming and policymaking, and which could be addressed through implementation of GHI country strategies. Potential evaluation studies and research projects will be shared with other relevant U.S. Government programs to shape broader investments toward country-identified learning priorities. Two particular areas of interest are (1) evaluation studies with a focus on cross-cutting issues relevant to GHI principles and health systems. (For example, What changes have been introduced to increase responsiveness to health needs of adolescent girls, and what are the results in terms of service utilization and key outcomes?); and (2) implementation research on condition- or disease-specific issues that would accelerate achievement of GHI targets (For example, use of community health worker-administered treatments in preventing and reducing maternal deaths).
 

GHI Country Strategy Review Criteria and Process

Once complete, initial draft GHI country strategies will be submitted to HQ for review. The objective of the review is to provide independent input on the two or three cross-cutting strategic areas; the GHI review does not replace operational planning reviews of the COP, MOP, and OP. Review panels will be convened with representation from headquarters staff of HHS/CDC, S/GAC, USAID, and other GHI Strategic Council (GSC) agencies¹⁴, as well as senior field staff from other GHI country teams. The review is an iterative process, allowing for further strengthening of the strategy document through a dialogue between the country and review teams on any identified issues, prior to its final submission.

The review panel will assess each Country GHI Country Strategy based on three general criteria:

1. Does the strategy present a strong argument for how the two or three strategic focus areas will:

• Accelerate achievement of GHI targets
• Take into consideration the GHI principles
• Include an approach to doing business that emphasizes whole-of-government and country partnership

2. Does the strategy describe how this will occur?

• Are new or revised policies, processes or procurements described?
• Are barriers to achieving objectives and proposed solutions defined?

3. Does the strategy demonstrate how progress will be measured?

• Is a logical causal pathway between the strategic focus areas and achievement of GHI objectives demonstrated?
• Are expected outcomes defined and benchmarks set to measure progress?
• Are areas for improved learning and opportunities to evaluate what works (and why) evident?

Once the Country Team at post and Review Panel (headquarters and other field staff) have completed their dialogue, the final submission will be presented to the Operations Committee for approval.

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14 For more information on the GHI Strategic Council and cited Operations Committee, go to https://max.omb.gov/maxportal/
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IMPLEMENTATION OF GHI

Implementation of GHI requires an evolution in how both field and HQ teams organize themselves and collaborate to foster greater strategic coordination and maximize strengths to achieve GHI results. The section below addresses GHI organization of country support at the headquarters and in-country levels. At headquarters there will be an Interagency Country Support Team to provide assistance to country teams for GHI. At the country level the GHI process will be led by the U.S. Ambassador in collaboration with partner government leaders.¹⁵ This leadership will be supported by strong interagency leadership from core agencies (USAID, HHS/CDC and State) applying a whole-of-government approach inclusive of all agencies at headquarters and in the field. Further information will be maintained at https://max.omb.gov/maxportal/.
 

Field Organizational Structure

Under the leadership of the U.S. Ambassador, country teams will organize themselves to ensure effective leadership and coordination of GHI. There is no "one size fits all" model; the platforms for interventions and comparative strengths vary from country to country, depending on both agency presence and areas of intervention. Some countries are already effectively functioning with an interagency model and should continue to do so. The Planning Lead role is described below.

• Planning Leads for GHI Coordination: The Operations Committee will consult with the Chief of Mission to designate a Planning Lead for each country. Planning Leads are responsible for facilitating the in-country processes required to develop, implement and monitor/report a GHI Country Strategy, including communications to a HQ convening lead (convener of HQ communication and support, from country support structures). Planning Leads do not have any exceptional budget authority. The Planning Lead is responsible for ensuring inclusive processes (elements of an inclusive process are listed below) to deliver both a quality GHI Country Strategy and annual progress summaries. The designation of a Planning Lead to convene processes to move GHI forward will take into account the existing in-country structures to avoid duplicative processes. Designation of Planning Leads will take place when countries are requested to prepare and submit a GHI Country Strategy.

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15 Multi-sectoral involvement is expected, including but not limited to the Health Minister.
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Elements of Inclusive Process

GHI supports inclusive and meaningful interagency planning, implementation, monitoring and reporting processes and will take necessary steps to assure that their employees at both headquarters and in the field act accordingly. Inclusiveness is critical for GHI. The following are elements of inclusive planning, implementation and monitoring:

• Agencies engage with all interested/relevant U.S. Government agencies in planning, and design discussions to develop the best GHI Country Strategy based upon agency capacities and activities.
• Agencies share and confer on relevant Funding Opportunity Announcements (FOAs), Requests for Applications (RFAs)/ Request for Proposals (RFPs) and Cooperative Agreements, and invite input on key elements.
• Agencies give notice of, and if appropriate, invite colleagues to participate in meetings of significance with key partner country government officials and other partners and/or provide a summary of the discussion to keep colleagues informed of key issues and ensure consistent U.S. Government voice with all partners. Major negotiations or discussions with the host government related to GHI should be carried out per inter-agency agreed modalities for interfacing with partner governments shared with all affected agencies.
• Agencies share all relevant data regarding planned activities and partners, research, partner performance and other activities in-country with each other, including program aspects of planned procurements (on a confidential basis if required).
• Agencies inform each other of important upcoming conferences, TDYs and high level visitors and include each other in in-briefs and out-briefs and activities/site visits where appropriate.
• Agencies contribute to a high-quality, technically rigorous GHI Country Strategy that draws on the unique expertise and contributions of each agency.

If disputes arise because an agency/office believes their expertise, technical recommendations, or ability to contribute is being compromised or excluded, the agency should first consult with the U.S. Ambassador. Should the issue not be resolved at post, the agency should alert the Operations Committee for assistance.
 

Headquarters Organizational Structure

Interagency Support Teams composed of staff currently exercising this interagency function in each of the three Agencies and/or others who are familiar with the country and its GHI plans, will be established for each country. Additional technical experts from HHS/CDC, S/GAC and USAID, as well as representatives from the GSC agencies, may be asked to participate on an ad-hoc basis given country needs and agency expertise. Each Interagency Support Team will have a Convening Lead (CL) who is expected to serve a convening function for the HQ team and coordinate interagency communications with the field. The CL and the in-country Planning Lead will work closely on communications between HQ and the field. The Interagency Support Team will:

• Support the field GHI interagency health team in planning for the review and Implementation of their GHI Country Strategy, and for reporting on progress and performance across all relevant programs under GHI;
• Create an HQ-level forum through which all agencies implementing GHI in a given country share information, communications to the field, updates, and technical support to the in-country GHI interagency health team.
   

ACRONYMS

AIDS Acquired Immune Deficiency Syndrome
BEST Best Practices at Scale in the Home, Community and Facilities: An Action Plan for Smart Integrated Programming in Family Planning, Maternal and Child Health, and Nutrition under the Global Health Initiative
CDC Centers for Disease Control and Prevention
CDCS USAID Country Development Cooperation Strategies Convening Lead
COP Country Operational Plan
DCM Deputy Chief of Mission
DHS Demographic and Health Surveys
F Foreign Assistance Office of the Department of State
FACTS Foreign Assistance Coordination and Tracking System - a data collection system designed for the annual Foreign Assistance Operational Plan and the annual Performance Plan and Report
FACTS Info Foreign Assistance Coordination and Tracking System Information- a data repository designed to provide a variety of information – including the Operational Plan and Performance Plan and Report data from FACTS; the Mission Strategic Resource Plan (MSRP) data related to foreign assistance from the MSRP system
FOA Funding Opportunity Announcement
FP Family Planning
FtF Feed the Future
GHI Global Health Initiative
GSC GHI Strategic Council
HHS U.S. Department of Health and Human Services
HIV Human Immunodeficiency Virus
HQ Headquarters
M&E Monitoring and Evaluation
MNCH Maternal, Newborn, and Child Health
MOP Malaria Operational Plan
MSRP U.S. Department of State Mission Strategic Resource Plans
NTDs Neglected Tropical Diseases
OP Office of the Director of Foreign Assistance Operational Plans
PEPFAR President’s Emergency Plan for AIDS Relief
PL Planning Lead
PMI President’s Malaria Initiative
PPR Performance Plan and Report
QDDR Quadrennial Diplomacy and Development Review
RFA Request for Applications
RFP Request for Proposals
RH Reproductive Health
S/GAC U.S. State Department, Office of the Global AIDS Coordinator
S/GHI U.S. State Department, Office of the Global Health Initiative
TB Tuberculosis
TDY Temporary Duty
USAID United States Agency for International Development