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The Global Health Initiative in Malawi New Approaches and Challenges to Reaching Women and Girls

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The Global Health Initiative in Malawi New Approaches and Challenges to Reaching Women and Girls a report of the csis global health policy center The Global Health Initiative in Malawi new approaches and challenges to reaching women and girls 1800 K Street, NW | Washington, DC 20006 Tel: (202) 887-0200 | Fax: (202) 775-3199 Author E-mail: [email protected] | Web: www.csis.org Janet Fleischman December 2011 a report of the csis global health policy center The Global Health Initiative in Malawi new approaches and challenges to reaching women and girls Author Janet Fleischman December 2011 About CSIS At a time of new global opportunities and challenges, the Center for Strategic and International Studies (CSIS) provides strategic insights and bipartisan policy solutions to decisionmakers in government, international institutions, the private sector, and civil society. A bipartisan, nonprofit organization headquartered in Washington, D.C., CSIS conducts research and analysis and develops policy initiatives that look into the future and anticipate change. Founded by David M. Abshire and Admiral Arleigh Burke at the height of the Cold War, CSIS was dedicated to finding ways for America to sustain its prominence and prosperity as a force for good in the world. Since 1962, CSIS has grown to become one of the world’s preeminent international policy institutions, with more than 220 full-time staff and a large network of affiliated scholars focused on defense and security, regional stability, and transnational challenges ranging from energy and climate to global development and economic integration. Former U.S. senator Sam Nunn became chairman of the CSIS Board of Trustees in 1999, and John J. Hamre has led CSIS as its president and chief executive officer since 2000. CSIS does not take specific policy positions; accordingly, all views expressed herein should be understood to be solely those of the author(s). © 2011 by the Center for Strategic and International Studies. All rights reserved. Cover photo credit: Woman carries water from the village pump, Khulungira, Malawi, May 18, 2009; http://www.flickr.com/photos/ilri/4573801279/. Center for Strategic and International Studies 1800 K Street, NW, Washington, DC 20006 Tel: (202) 887-0200 Fax: (202) 775-3199 Web: www.csis.org embedd the global health initiative in malawi new approaches and challenges to reaching women and girls Janet Fleischman1 Introduction The Obama administration designated Malawi as a GHI Plus country in June 2010, one of the first eight countries selected to implement the Global Health Initiative’s (GHI) more comprehensive approach to global health and serve as learning labs for other GHI country programs.2 The GHI team in Malawi has identified the health of women and girls, including HIV and family planning (FP)/reproductive health (RH) services, as critical, promising areas for GHI success. Though still in early stages of implementation, new approaches are emerging in Malawi that leverage resources from the President’s Emergency Plan for AIDS Relief (PEPFAR) to develop greater program synergies for women and girls. Yet Malawi’s weak health system, combined with ever more serious concerns about governance and human rights issues that are undermining donor support, present challenges that may threaten GHI’s ability to achieve sustainable results. Although over half of U.S. funding to Malawi is focused on HIV/AIDS, Malawi was not one of the original PEPFAR focus countries.3 The U.S. government has relatively balanced health and development funding in Malawi, which gives the GHI comparatively greater potential for impact than in neighboring countries where U.S. flexibility is limited because funding is effectively tied to 1 Janet Fleischman is a senior associate with the CSIS Global Health Policy Center. This report was supported by a grant from the David and Lucille Packard Foundation. 2 The Obama administration’s Global Health Initiative (GHI) was announced in May 2009 as a six-year, $63-billion program. The GHI Plus countries are: Bangladesh, Ethiopia, Guatemala, Kenya, Malawi, Mali, Nepal, and Rwanda. The purpose is to help partner countries improve health outcomes, guided by seven core principles: focus on women, girls, and gender equality; encourage country ownership and invest in country-led plans; build sustainability through health systems strengthening; strengthen and leverage key multilaterals and other partnerships; increase impact through strategic coordination and integration; improve metrics, monitoring, and evaluation; promote research and innovation. See GHI, “U.S. Global Health Initiative,” http://www.ghi.gov/newsroom/factsheets/2011/161412.htm. 3 The 15 focus countries were: Botswana, Côte d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Uganda, Tanzania, Vietnam, and Zambia. | 1 PEPFAR.4 Granted, many questions remain about how GHI will add value, deliver results, and create space for innovative approaches, especially without new money.5 Nevertheless, GHI has encouraged an attitude of active collaboration within the U.S. government interagency team in Malawi and has introduced new expectations about the importance of program synergies to guide U.S. programs. The value and impact of GHI’s new business model may ultimately be evaluated based on its outcomes for women and girls, given the prominence of the women, girls, and gender equality principle in GHI and the importance of cross-sectoral approaches to address their health and non-health needs. This will not be an easy task, since women and girls face serious health challenges in Malawi. The HIV-prevalence rate is Malawi is almost 12 percent, with women disproportionately affected, accounting for some 60 percent of those living with HIV. Malawi also has extremely high levels of maternal mortality, reported to be somewhere between 510/100,000 and 1,100/100,000, which is related to poor access to health services.6 According to the preliminary results from the 2010 Demographic and Health Survey in Malawi, the modern contraceptive prevalence rate is 42 percent, and the total fertility rate is 5.7. In addition, the realities of violence against women and other abuses of women’s rights, limited access to education and productive resources for women and girls, and harmful gender norms, all serve to perpetuate poor health outcomes for women and girls and broader gender inequalities. Policy Options This is a critical yet perilous time for GHI in Malawi. Because Malawi is a GHI Plus country, U.S. supported programs will be subject to considerable scrutiny by U.S. government agencies and others evaluating GHI about whether they deliver results for the health of women and girls. At this same time, the national government has engaged in violent, repressive actions that threaten the willingness of donor governments to continue their investments in health and other arenas, prompting several to suspend assistance. The United States can use this opportunity to demonstrate that the program synergies inherent in GHI represent a useful and strategic way to achieve improved health outcomes for women and girls, and that such investments can be carefully managed while addressing the ongoing concerns about governance and respect for 4 In FY 2010, the U.S. government provided $145 million in development assistance to Malawi, and in April 2011, the Millennium Challenge Corporation (MCC) signed a $350-million compact with Malawi, focusing on the energy sector. However, the MCC agreement was put on hold in July 2011, due to governance concerns. 5 GHI does not include new money; rather, it is a compilation of other U.S. global health and development funding streams, including PEPFAR, the President’s Malaria Initiative (PMI), maternal, newborn and child health (MNCH), nutrition, and family planning/reproductive health. 6 Global Health Initiative, “Malawi Global Health Initiative Strategy Document,” http://www.ghi.gov/ documents/organization/158919.pdf. 2 | the global health initiative in malawi human rights. To accomplish this, the U.S. government in Washington and Malawi should consider the following policy options: 1. Demonstrate progress by enhancing coordination of women’s health programing under GHI: . Create technical working groups under GHI as well as with other external donors, focusing on issues such as maternal child health (MCH)-FP/RH linkages, and HIV- PMTCT (prevention of mother-to-child-transmission) and FP/RH linkages. Facilitate ease of integrating U.S. government funding streams in integrated programs, so that the program planning, implementation, and reporting processes can be more efficient and effective, less burdensome to partners, and have greater impact. Promote enhanced linkages between U.S. government programming and other development partner programs in Malawi, especially those focusing on family planning and reproductive health. 2. Address human resource constraints, health system challenges, and the policy environment to meet the needs of women and girls: . Use PEPFAR funds to train and supervise health care workers on providing integrated HIV-PMTCT and FP/RH services. Provide management support to increase accountability for cost-effective and quality programs on women and girls, and support the development of policy guidelines for integration. Enhance opportunities for cooperation and collaboration between the U.S. and other partners—the national government, multilateral organizations, nongovernmental organizations (NGOs), and faith-based organizations (FBOs)—to support programs focusing on increasing access to comprehensive health services for
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