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President Obama's ambitious Global Health Initiative — announced to a receptive international community in 2009 — is faltering as budget constraints and shaky implementation limit the impact of the multibillion-dollar program.

In Kenya, a glimpse into GHI's future

GHI's strategy isn't new to Kenya, but will it help?

so that more is available in each location and let Kenyans know what care and treatment is available to them.

A key element is what aid workers call “sustainability,” which means projects should be able to continue after the foreign funding dries up. But with the US contributing around $650 million a year towards Kenya’s health system, is a handover to the Kenyan government ever going to be possible?

“You can ask that question,” Adrian conceded. “Where is the exit strategy with those kinds of budget figures? How is the government of Kenya going to finance, manage and sustain this level of service?”

She said that working more closely with officials from Kenya’s health ministry was a step towards preparing Kenya to bear the health burden itself.

Dr. Kayla Laserson, CDC’s Director of Research and Public Health Collaboration, insists that since the advent of GHI, the relationship with government officials is “completely different.”

“A lot of [health initiatives] are very donor driven, which isn’t how it should be, with [GHI] we have said, ‘This is yours. Take it. Let us help you.’ And they really have,” said Laserson.

She admitted that a patient using a clinic supported with U.S. money may not yet have noticed any major changes, but Laserson argues that GHI has brought about an atmosphere of greater reflection.

“A lot of our work has gone forward as it had but there’s been a change in the philosophical approach. Perhaps we’re still working on malaria and pregnancy but now we’re also part of GHI and we talk and think about it differently and we talk and think about the connections between that work and other work,” she said.

The various U.S. agencies are also required under GHI to talk to one another more and work more closely together. Again, this is something that has been happening for some time in Kenya, unlike in some other countries, although there are still some grumblings.

As one U.S. health worker who did not want to be named, put it: “GHI is just a bunch of new meetings with no new money.”

Perry, Kenya’s PEPFAR head, concedes there are more meetings but that they are worthwhile, not just time-consuming talking shops.

“Kenya has been forward thinking and out there… in terms of working together as an interagency team and also [in terms of] the relationship with the government and moving towards country ownership,” said Perry.

But before Kenya can begin to even think about taking over the health burden, it must first secure stronger and consistent economic growth.

“Ultimately no amount of investment or political reform is going to deliver long-term sustainability unless you have growth,” said Brudvig. “If you have growth the government has greater revenue streams and can take on a greater part of the burden. Right now saying we want the government [of Kenya] to do more because we want to do less is not feasible.”

GHI fits well with the post-financial crisis era of austerity because it is about being more efficient; using what you have, cutting out waste and, eventually, getting out altogether.

“Every bureaucracy, if left to their own devices, would prefer to rely upon their own resources and their own contractors and programs,” but Brudvig argued that this leads to a “stovepipe effect” that under GHI is to be replaced by integration.

Away from the Nairobi conference rooms, the impact of the U.S. investment in Kenya’s health system stops being a theoretical discussion and becomes a living reality.

A small program called ‘Mothers2Mothers,’ based in Kisumu hospital and funded by the U.S. since 2008, is creating and maintaining support networks for HIV positive new mothers. They need it.

Sitting beneath a tree that offered welcome shade from the scorching mid-afternoon heat, a small group of HIV positive mothers told how discovering the infection had altered their lives.

Like many others, Jacqui Odongo was thrown out of the house when she told her husband she was HIV positive. She was pregnant with their first child at the time.

“He renounced me, he said that when he was at work I was prostituting around. I was chased out of my homestead that very night.

“My husband shouted at me calling me all sorts of names, he threw my things all over the compound, my mother-in-law came out demanding why I was bringing disease to their home. The neighbours came out of their houses and looked at me as if I had brought death to that place. I really cried and when I left, I never went back,” she said.

Odongo believed HIV was a death sentence — for her and her unborn child — but at the Mothers2Mothers program she found solace in so-called ‘Mentor Mothers.' In the program, those who have gone through the process of discovering and disclosing their HIV status now help others do the same.

She was shocked to find women looking healthy. They were not “sick, with rashes all over their bodies,” as she had expected. Some of the new mothers were breastfeeding, and most had given birth to HIV negative babies.

“The Mentor Mothers consoled me and they told me that it is possible to give birth to a negative baby if I follow the doctor’s orders. That’s what gave me hope in life,” recalled Odongo, who is herself now one of the program’s coordinators, and is mother to a daughter who is HIV negative “as of her last test,” a caveat used by all the mothers in the group.

In the group, women learn about maternal health, child health, family planning, reproductive health and defending against and mitigating the effects of HIV/AIDS. They also learn to support one another in their fight to survive in the face of deeply ingrained prejudice and stigma towards those with HIV.

The problem for GHI is not so much the work, as the message, or lack of one, according to CSIS’ Morrison. “People are still asking, what is GHI? Is it PEPFAR redux? Is it PEPFAR with new packaging? It’s not, it’s much more than that, but GHI has not done a good job of branding itself.

“GHI can do much better in explaining its goals and achievements but that does not belie places like Kenya, where real progress is being made,” he said.

http://www.globalpost.com/dispatch/news/health/110916/kenya-ghi-future-pepfar-aids