|Youth in the Global Health Initiative|
The Urgent Need for Partnership
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The Global Health Initiative (GHI) is an innovative and pragmatic approach to eliminating inefficiency and waste in U.S. global health programs. But in order to maximize its potential to save lives and improve health, and to guarantee the rights of young people in countries receiving funds, it must be more explicit in making youth a priority. Young people have the right to accurate and complete information and access to services, and to a voice in decisions that affect their health and lives, as well as the future of their countries. This document provides some background on youth issues in the Global Health Initiative, and provides recommendations as to how the GHI can best empower young people to protect their health and to become health advocates in their own right.
What is the Global health initiative?
The GHI is a new U.S. Government (USG) initiative designed to strategically restructure U.S. global health programs.[1,2] Announced by President Obama in 2009, the GHI attempts to correct inefficiencies and invest in sustainable approaches in global health funding. Under the GHI, the USG’s many disease- and program-specific funding streams (HIV/AIDS—the largest component of the GHI; tuberculosis; malaria; maternal, newborn and child health; family planning and reproductive health; nutrition; and neglected tropical diseases), will be implemented in a coordinated manner, measuring almost all results as a single set of achievements.
United States global health programs funded by the USG have achieved significant gains in public health, providing many in need with food aid and assistance with child survival and family planning (among others). But these programs have been hampered by inefficiency and “red tape.” [3,4,5,6,7] Under the GHI, it is hoped that in-country consumers will be better aided with USG foreign assistance funds.
a shift toWard Performance incentives
The “paramount objective” of the GHI is the achievement of “major improvements in health outcomes.” As such, the GHI provides “performance-based” incentives, whereby donor countries/institutions identify their desired outcomes, and allow partners (recipient countries/institutions) to determine the best way to use available resources to achieve those particular targets (guided by the rubric in Table 1). In theory, what differentiates the GHI from historical USG global health programs is that while it will still be driven by quantitative targets (what the GHI accomplishes), it will also prioritize processes that maximize resource use both for short-term achievement and long-term sustainability (how the GHI accomplishes its goals).
Table 1: Targets, Principles And Implementation Components of the GHI
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existinG Youth PolicY in Ghi Plus countries
GHI operates in all 80 countries where the USG offers health development assistance. As part of the focus on evaluation, research, and innovation, known as the GHI’s “Learning Agenda,” some countries will be selected to receive additional resources for GHI implementation and data collection. Serving as “learning laboratories,” these countries will provide some of the GHI’s first data and “lessons learned.” In 2011, the GHI chose eight Plus countries: Bangladesh, Ethiopia, Guatemala, Kenya, Malawi, Mali, Nepal, and Rwanda, each of which has (or will have) its own GHI Partnership Strategy outlining the ways in which U.S. global health programs can support country priorities and existing national health plans. According to a recent study on GHI resource distribution, the current eight GHI Plus countries account for 25 percent of all GHI spending. Table 2 (page 4) offers brief summaries of existing youth policy in the current GHI strategies of the eight GHI Plus countries. While youth priorities and interventions range widely across the strategies, all the documents share the same core weaknesses:
1) none employ comprehensive sex education for youth, even when targeting reductions in adolescent pregnancy and HIV prevalence;
2) none focus on their large pools of unemployed youth as part of a sustainable solution to their health workforce crises; and
3) none specifically guarantee data collection disaggregated by age to reveal health data unique to their youth populations, a major missed opportunity.
PrioritizinG Youth in the Ghi: What’s missinG
The GHI represents an important opportunity to improve health programs, increase youth participation, and spur progress in economic development and good governance due to strategic achievements in public health. However, young people have not been sufficiently prioritized wit in the GHI.
1. An emphasis on girls and gender equality, one of the core principles of the GHI, is a significant step forward for U.S. global health programs. But additional efforts must be put in place to support a partnership with women and girls rather than simply viewing them as the passive end- users of programs.
2. Despite the GHI’s directive to “Do more of what works,” no GHI document mentions comprehensive sex education programs, which have repeatedly been proven effective at helping young people lower their risk of HIV, unintended pregnancy, and sexually transmitted infections.
3. The GHI’s “Learning Agenda” makes a stride towards better data collection and improved programs, but does not guarantee the disaggregation of data by age to show unique experiences of adolescents.
4. Attention to child health is crucial for long-term sustainability, but little is achieved if children survive to adolescence without sufficient support to guide them into adulthood.
5.While giving countries ownership over USG funded public health initiatives is a change for the better, the GHI should identify specific youth outcomes and include as a core principle youth participation, and should protect vulnerable young people from partner governments who ignore or disenfranchise them.
achievinG health outcomes throuGh PartnerinG With Youth: recommendations for the Ghi
In order to ensure the success of the GHI, it is imperative that the USG and GHI country govern- ments implement the following recommendations. The USG and partner countries should:
1. Revise core principles to include: “Partner with Youth.” Young people are integral to the success of the GHI, and as such, partnership with youth should be reflected in the initiative’s core principles, including training American ambassadors, GHI Teams, Field Mission Staffs, and health care providers in all countries in youth-adult partnerships and fundamentally organizing GHI country plans and targets to include a focus on youth as part of the solution to national health challenges.
2. Do more of what works:
a. Fully integrate comprehensive sex education into all GHI programs. The GHI emphasis on evidence-based programming, research, and innovation offers an unprecedented opportunity to prioritize comprehensive sex education in country plans – education which has been proven to help young people delay sexual initiation and to use protection when they do have sex.[10,11] The GHI’s complementary focus on supporting changes in public policy for public health outcomes should encourage partner countries to develop comprehensive sex education curricula for their educational systems.
b. Improve youth access to affordable, youth friendly sexual health services, including family planning and STD/HIV testing and treatment. Significant barriers, including laws/policies, provider attitudes, convenience, and cost frequently deter youth from obtaining urgently needed sexual health services. But programs exist which can help better serve young people and help protect their health and lives.
3. Transform knowledge of global adolescent health through the GHI Learning Agenda: Explicitly require the collection and disaggregation of data by age that separates 10-14, 15-19 and 20-24 year olds from children and adults in all GHI countries. The GHI learning agenda is an unprecedented opportunity to place adolescents on the “demographic map,” offering invaluable data for the improvement of developmentally appropriate programming and health services.
4.Empower the next generation of government watchdogs: Invest specifically in youth advocacy and guarantee youth participation in GHI planning, implementation, and evaluation. This requires, at a minimum, investment in youth-led civil society organizations, technical assistance to develop advocacy capacity, and pressure on partner governments to not only permit, but support, youth civic engagement. In addition, the GHI must develop specific mechanisms for youth participation within GHI teams in country and guarantee youth access to the American ambassador.
5. Build local capacity and sustainability: Prioritize the education and employment of young people in the expansion of health workforce training. Almost every GHI country, and all GHI Plus countries are focused on developing the viability and sustainability of their health workforces. At the same time, across the same countries, young people lack access to higher educational opportunities and decent employment. Empowerment through investments in health care employment for youth creates a dual dividend of an educated and employed youth population, and a sustainable health workforce.
To achieve its quantitative goals and targets, and to execute programs according to its core principles and standard components of implementation, youth must be a priority in the GHI. Worldwide, 1.2 billion people are aged 10-19, 90 percent of whom live in the developing world. Even more, today’s generation of young people is the largest in history—nearly half the world’s population (almost 3 billion people) is under the age of 25. Their access to information and resources will determine their ability to prevent HIV infections, unintended pregnancies, and sexually transmitted infections, and will determine whether or not countries have the health workforce and health care advocates to protect generations to come. Will the GHI commit to evidence-based practices and full partnership with young people - or ignore youth, and miss out on realizing its full potential?
Written by Brian Ackerman, Advocates for Youth © June 2011
Table 2: Summary of Youth Policy Provisions Within GHI Plus Country Strategies
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1. Global health programs include bilateral programs such as The President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative, Congressional funding for international family planning, maternal and child health, food security and nutrition, and accounts for polio, blind children, and vulnerable children, among others; multilateral programs such as support for the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria; UNFPA; UNICEF; and the World Health Organization. They are defined by their links to specific health conditions and to specific programs/ institutions, not to health outcomes.
2. “The United States Government Global Health Initiative Strategy Document,” The U.S. Department of State, Washington, DC, 2011.
3. Droggittis, Christina and Oomman, Nandini. “Think long term: How Global AIDS Donors Can Strengthen the Health Workforce in Africa” Center for Global Development, Washington, 2010. http://www.cgdev.org/content/publications/detail/1424416. Accessed on 15 May 2011.
4. While not specifically citing U.S. health programs, this pa- per describes the problems which arise in the pre-GHI type of health programming that was the standard for large donors, including the U.S. government, citing the need to allow for local organizations and governments to do the pub- lic health problem-solving with resource assistance from donors in order to achieve sustainability. Eichler, Rena; Levine, Ruth “Performance Incentives for Global Health: Potential and Pitfalls.” Center for Global Development, Washington, DC, 2009, pp. 11-22. http://www.cgdev.org/content/publications/detail/1422178. Accessed on 15 May 2011.
5. Even food aid, which does successfully supply food to many of those facing hunger in low and middle income countries,was largely procured by exporting food from donor coun- tries to poor countries, effectively undermining local agricultural production. Johnson, Toni. “Analysis Brief: The Food Aid Dilemma,” Council on Foreign Relations, New York, 2008. http://www.cfr.org/haiti/food-aid-dilemma/p16761 . Accessed on 15 May 2011.
6. The actual GHI Strategy Document cites a fictitious narrative about the challenges an individual woman faces in seeking out diverse healthcare services in an environment where physical clinics are separated based on the condition they serve to illustrate these consumer inefficiencies.
7. Fidler, David. “The Challenge of Global Health Gover- nance.” Council on Foreign Relations International Institutions and Global Governance Program. New York, 2010, p. 2, 14-16. http://www.cfr.org/global-governance/challenges-global-health-governance/p22202. Accessed on 15 May 2011.
8. Eichler, Rena; Levine, Ruth “Performance Incentives for Global Health: Potential and Pitfalls.” Center for Global De- velopment, Washington, DC, 2009, pp. 11-22. http://www. cgdev.org/content/publications/detail/1422178 . Accessed on 15 May 2011.
9. Michaud, Josh and Jen Kates. “U.S. Global Health Policy: The U.S. Global Health Initiative: A Country Analysis” Kaiser Family Foundation, February 2011.
10. Agha S. A quasi-experimental study to assess the impact of four adolescent sexual health interventions in sub-Saharan Africa. International Family Planning Perspectives 2002; 28:67-70, 113-118.
11. Alford S, Cheetham N. Hauser D. Science and Success in Developing Countries: Holistic Programs that Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections. Washington, DC: Advocates for Youth, 2005.
12. Moya C. Creating Youth Friendly Sexual Health Services in Sub-Saharan Africa. Advocates for Youth, 2002. http:// www.advocatesforyouth.org/publications/549?task=view . Accessed on May 26, 2011.
13. United Nations, Department of Economic and Social Affairs, Population Division, World Population Prospects : The 2008 Revision. http://www.esa.un.or/undp/wpp2008/index.htm, Accessed October 2010, cited in United Nations Children’s Fund (UNICEF), State of the World’s Children 2011 : Adolescence : An Age of Opportunity, New York, 2011, pp. iii, 2, 20.
14. United Nations Population Fund (UNFPA), State of the World Population 2005, New York, 2005. http://www.unfpa.org/swp/2005/presskit/factsheets/facts_adoles cents.htm#ftn2. Accessed on 15 May 2011.
15. UNICEF. “At a Glance: Bangladesh: Statistics” UNICEF, New York,2009. http://www.unicef.org/infobycountry/bangladesh _bangladesh_statistics.html#83. Accessed on 15 May 2011.
16. “U.S. Global Health Initiative: Bangladesh: Interagency Program Strategy 2011-2015” Dhaka/Washington, DC, 2011. http://www.ghi.gov/documents/organization/158922.pdf . Accessed on 1 June 2011.
17. UNICEF. “At a Glance: Ethiopia: Statistics” UNICEF, New York, 2009. http://www.unicef.org/infobycountry/ethiopia_ statistics.html#83 . Accessed on 15 May 2011.
18. “Report on Progress towards implementation of the UN Declaration of Commitment on HIV/AIDS 2010” Federal Democratic Republic of Ethiopia Federal HIV/AIDS Prevention and Control Office. Addis Ababa, 2010. http://www.unaids. org/en/.../ethiopia_2010_country_progress_report_en.pdf. Accessed on 16 May 2011.
19.“The United States Global Health Initiative: Ethiopia Global Health Initiative Strategy” Addis Ababa/Washington, DC, 2011. http://www.ghi.gov/documents/organization/158918.pdf . Accessed on 1 June 2011.
20. UNICEF. “At a Glance: Guatemala: Statistics” UNICEF, New York, 2009. http://www.unicef.org/infobycountry/guatemala_statistics.html#83 . Accessed on 15 May 2011.
21. “The United States Global Health Initiative: Guatemala Strategy” Tegucigalpa/Washington, DC, 2010. http://www.ghi.gov/documents/organization/158909.pdf . Accessed on 1 June 2011.
22. “Ministerial Declaration: Preventing through Education” Signed by all Ministers of Health in the countries of Latin America and the Caribbean. Mexico City, 2008.
23. UNICEF. “At a Glance: Kenya: Statistics” UNICEF, New York, 2009. http://www.unicef.org/infobycountry/kenya_ statistics.html. Accessed on 15 May 2011.
24. “Global Health Initiative: Kenya Strategy 2011-2014” Nairobi/Washington, DC, 2011. http://www.ghi.gov/documents/organization/158455.pdf . Accessed on 1 June 2011.
25. UNICEF. “At a Glance: Malawi: Statistics” UNICEF, New York, 2009. http://www.unicef.org/infobycountry/malawi_ statistics.html#83. Accessed on 15 May 2011.
26. “Malawi Global Health Initiative Strategy” Lilongwe/Washington, DC, 2011. http://www.ghi.gov/documents/organization/158919.pdf . Accessed on 1 June 2011.
27. UNICEF. “At a Glance : Mali : Statistics” UNICEF, New York, 2009. http://www.unicef.org/infobycountry/mali_statistics.html#83. Accessed on 15 May 2011.
28. “Mali Global Health Initiative Strategy” Bamako/Washington, DC, 2010. http://www.ghi.gov/documents/ organization/158920.pdf . Accessed on 1 June 2011.
29. UNICEF. “At a Glance: Nepal: Statistics” UNICEF, New York, 2009. http://www.unicef.org/infobycountry/nepal_ nepal_statistics.html#83. Accessed on 15 May 2011.
30. “Nepal Global Health Initiative Strategy” Kathmandu/Washington, DC, 2010. http://www.ghi.gov/documents/ organization/158921.pdf . Accessed on 1 June 2011.
31. UNICEF “At a Glance: Rwanda: Statistics” UNICEF, New York, 2009. http://www.unicef.org/infobycountry/rwanda _statistics.html#83. Accessed on 15 May 2011.
32. “Democracy and Governance.” USAID, Washington, DC, November 2009. http://www.usaid.gov/rw/our_work/programs/docs/factsheets/twopagerdemocracyandgovernance.pdf. Accessed on 1 June 2011.