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9
Strengthening Health Systems for an Effective HIV/AIDS Response
Main Messages
Health systems strengthening efforts were largely ad-hoc in PEPFAR I. Congressional
reauthorization created opportunities for formal support of strategies in partner countries
including integration of HIV services into existing country programs and systems. In
PEPFAR II, OGAC adopted the six-building block framework articulated by WHO, around
which the following main messages have been organized:
Leadership and Governance
Many stakeholders affirmed that there is strong leadership in partner countries for the
HIV/AIDS response, within both government and in nongovernmental sectors. However, in
some countries there are still challenges related to governance and management capacity
for the maintenance and sustainability of the HIV/AIDS response.
Intergovernmental planning among partner country governments, other local stakeholders,
and external donors is a critical activity that is needed for the current and future responses
to HIV/AIDS. For the USG support for PEPFAR countries, it is the primary tool for ensuring
leadership and governance, as well as a vehicle for joint planning efforts that support the
principles of ownership, mutual transparency, and mutual responsibility and accountability.
PEPFAR has increasingly provided stronger support for partner country planning and
development of national frameworks, policies, and strategic plans over time. There is
variable alignment or harmonization with partner country planning processes that are
primarily driven by national government priorities. It is reasonable that the USG, like all
donors, have its own considerations and requirements for funding decisions. Nonetheless,
PEPFAR has made progress in making its considerations a part of a joint planning process
rather than a displacement of country priorities.
PEPFAR has supported training for management and leadership to build capacity for
improved functioning of health systems with a variety of activities including curriculum
development, mentorship, and shorter-term trainings and workshops. However, the focus
and outputs of these training efforts are varied and it was difficult determine the impact of
these efforts from the data currently available.
PEPFAR’s capacity building approach has been “holistic” and includes developing human
resources; strengthening financial management; and building organizational capacity at
national, provincial, district levels and across government, private, and civil society sectors.
Despite these efforts, leadership and financial management capacity were frequently
mentioned as challenges to effective HIV/AIDS responses.
Financing
Data on partner country government expenditures for HIV/AIDS responses from National
Health Accounts and National AIDS Spending Assessments for the 31 countries that are the
focus of this evaluation were unavailable for many countries and years, making it difficult to
examine trends in HIV/AIDS funding.
Although there are nascent efforts in PEPFAR for costing of services and projecting of
needs to help countries develop a costed HIV/AIDS response, PEPFAR has not yet
systematically implemented assistance for partner countries to develop resource
development plans, resource projections, costing, and identifying funding needs.
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Information Systems
Despite initial PEPFAR-specific systems for program monitoring data, PEPFAR has worked
with partner country governments to integrate and strengthen Health Information Systems,
including achievements in strengthening partner country Laboratory Management
Information Systems. However, ongoing support to strengthen partner country health
information systems, and better alignment and integration with those systems, is needed to
enhance timely data availability and quality for strategic program planning, resource
allocation, and commodities procurement.
Medical Products and Technologies
PEPFAR has improved the capacity of partner country governments to quantify, forecast,
procure, store/warehouse, distribute, and track commodities; but challenges to assure
consistent and reliable supply chain functioning remain in many countries. These challenges
are a common issue across countries and are not PEPFAR-specific. Reliable supply chains
will be critical for sustainable and cost-efficient HIV/AIDS responses and avoid disruptions to
clinical care and treatment of people living with HIV/AIDS.
PEPFAR’s laboratory efforts have had a fundamental and substantial impact on laboratory
capacity in countries. This laboratory infrastructure and capacity has been, and can continue
to be, leveraged to improve the functioning of countries’ entire health systems.
Workforce
PEPFAR’s contribution to health workforces in partner countries has over time been more
appropriately directed to more pre-service production. Nonetheless, partner countries
continue to have considerable need for health workforce development and retention.
PEPFAR can contribute to that need by leveraging and maximizing its investments in
collaborative efforts to build the capacity of health professional training schools, which would
benefit the ability of countries to address not just HIV but the dual burden of infectious and
non-communicable diseases that many high-burden countries increasingly face. Adherence
by partner countries to the Global Code of Recruitment and follow-through on commitments
to the Abuja Declaration could both support sustainability of their own health workforces and
country ownership.
Service Delivery
PEPFAR’s impressive achievements in service delivery represent the success of a largely
disease-specific approach, which had both positive and negative effects on partner country
health systems. In some countries, an early emphasis on increasing volume of services to
meet targets for service delivery resulted in vertical programming, which did not always
facilitate service integration. PEPFAR has articulated the goal of increased integration of
services and has had some success. Many stakeholders in partner countries have identified
an interest and/or need for greater integration of HIV services into the general health
system. The best practices for integrating services, such as HIV and TB, reproductive
health, and primary care, need to be identified, evaluated, and scaled up.
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Recommendation Presented in This Chapter
Recommendation 9-1: To support the delivery of HIV-related services, make progress
toward sustainable management of the HIV response, and contribute to other health
needs, PEPFAR should continue to implement and leverage efforts that have had
positive effects within partner country health systems. PEPFAR should maintain efforts
in all six building blocks but have a concerted focus on areas that will be most critical for
sustaining the HIV response, especially workforce, supply chain, and financing.
Further considerations for implementation of this recommendation:
An important focus for PEPFAR’s future activities and policies should be support
for partner country capacity to locally produce and retain clinical, nonclinical, and
management professionals whose training and scope of practice are appropriate
and optimized for the tasks needed. MEPI and NEPI have provided a starting
point for the training of physicians and nurses; however the training of associate
clinician providers and other cadres will also be critical to sustainable
management of the response. In addition, PEPFAR needs to augment its efforts
to build partner country capacity to track the placement of trained workers, to
promote retention, and to develop long term human resources plans (see also
the discussion and recommendation for capacity building in Chapter 10 on
Progress Toward a Sustainable Response).
Building on the progress made through the public-private partnership with SCMS,
PEPFAR should enhance and expand efforts with a greater focus on capacity
building for accountable supply chain management in partner countries. The aim
of this improved capacity should be to gradually shift to local or regional
leadership, coordination, and management to ensure a reliable supply chain for
essential medicines and commodities.
Financing and leadership and governance are particularly critical for sustainable
management of the HIV response; this area is addressed in Recommendation
10-1 (see Chapter 10).
To contribute to the knowledge base for health systems strengthening, PEPFAR
should include this area in its research and evaluation agenda and its knowledge
dissemination efforts (see also recommendations for PEPFAR’s Knowledge
Management in Chapter 11).
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9
Strengthening Health Systems for an Effective HIV/AIDS
Response
BACKGROUND AND CONTEXT FOR SYSTEMS DEVELOPMENT AND
FUNCTIONING FOR HEALTH
A health system includes “all the organizations, institutions, and resources that are
devoted to producing health actions. A health action is any effort, whether in personal health
care, public health services or through intersectoral initiatives, whose primary purpose is to
improve health” (WHO, 2000, p. xi). The primary objective of a health system is to improve
health by achieving the best attainable average level of population health and minimizing the
differences between individuals and groups. National governments are ultimately responsible
for the performance of health systems and ensuring the wellbeing of their populations (WHO,
2000). To meet the ambitious goal of equitable access to health, member states of the World
Health Organization (WHO) have committed to providing universal health coverage, defined as
“access to key promotive, preventive, curative and rehabilitative health interventions,” at an
affordable cost for all members of a population (WHO Secretariat, 2005; World Health
Assembly, 2005).
In the last decade, international donors (particularly high-income countries and
multilateral institutions) provided more than $185 billion in development assistance for health
to low- and middle-income countries (IHME, 2011). Much of this funding has been directed to
programs and interventions for specific diseases (e.g., HIV/AIDS, tuberculosis, and malaria)
and health focus areas (e.g., maternal and child health). Large global health initiatives such as
PEPFAR, the Global Fund, and the Global Alliance for Vaccines and Immunization (GAVI)
have facilitated the tremendous increase in development assistance for health, but there is
concern about the effects, intended and unintended, of these initiatives on partner country health
systems (Bärnighausen et al., 2012; Biesma et al., 2009; Grépin, 2012a; Levine and Oomman,
2009; Samb et al., 2009). There is widespread consensus within the global health community on
the need to strengthen health systems in order to improve health outcomes and meet global
targets such as universal health coverage and the health-related Millennium Development
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9-1
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9-2 EVALUATION OF PEPFAR
Goals 1 (Shakarishvili, 2009; Task Force on Global Action for Health System Strengthening,
2008; WHO, 2009). Many of the largest donors and multilateral organizations involved in
global health have faced challenges scaling up services due to health systems weaknesses and
have responded by supporting interventions specifically designed to strengthen components of
the health system (Palen et al., 2012; Shakarishvili, 2009).
In 2007, WHO developed a framework for health systems strengthening (HSS) that
identifies the following six building blocks which correspond with the essential functions of
health systems to ultimately result in effective health services:
Leadership and governance,
Financing,
Information,
Medical Products, Vaccines, and Technologies (shortened to Medical Products
and Technologies by the committee),
Health workforce, and
Service delivery (WHO, 2007a).
These building blocks are interdependent and the relationships between the building
blocks deserve as much attention as the individual components (WHO, 2007a, 2009). Effective
service delivery also critically depends on standards, guidance, and accountability mechanisms
to ensure access to quality services characterized by the essential dimensions of —safety,
effectiveness, integration, continuity, and people-centeredness (WHO, 2010b). The building-
block framework, identified in Figure 9-1, has been adopted by the Office of the U.S. Global
AIDS Coordinator (OGAC) and others stakeholders that are emphasizing prioritization,
organization, and execution of activities in the essential area of strengthening health systems
(Friedman et al., 2011; OGAC, 2009f).
1
In 2000, world leaders committed to the United Nations (UN) Millennium Declaration and adopted eight
Millennium Development Goals (MDGs) to reduce the most important determinants and consequences of poverty.
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STRENGTHENING HEALTH SYSTEMS 9-3
FIGURE 9-1 Representation of WHO’s six building blocks for effective health systems.
SOURCE: Adapted from (IOM and NRC, 2010; WHO, 2007a).
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9-4 EVALUATION OF PEPFAR
Large donor-funded global health initiatives interact with each building block within
partner country health systems. Despite sharing the same goal — to improve health outcomes
— initiatives such as PEPFAR can have both positive and negative effects on partner country
health systems. Several studies have examined the effects of HIV/AIDS and broader global
health initiatives on health systems. Positive effects have included strengthened infrastructure
and laboratories, scale-up of HIV/AIDS service delivery, improved primary health care
services, a slowing of HIV/AIDS-related deaths among the health workforce through provision
of antiretroviral treatment, greater participation of stakeholder groups, and increased funding to
nongovernmental organizations (NGOs) and faith-based bodies (Biesma et al., 2009; Samb et
al., 2009; Yu et al., 2008). Negative effects on health systems include reallocation of or
reduction in funding for other health or non-health priorities; attrition in the public health or
primary care workforce as a result of increased incentives to work for donor-funded programs;
and “distortion of recipient countries’ national policies, notably through distracting
governments from coordinated efforts to strengthen health systems and re-verticalization of
planning, management and monitoring and evaluation systems” (Biesma et al., 2009, p. 239;
Samb et al., 2009; Yu et al., 2008). In general, the evidence is mixed and limited for
determining whether strengthening effects are positive or negative (Biesma et al., 2009; Samb et
al., 2009; Yu et al., 2008). In recent years, there has been more research dedicated to the
interaction between global health initiatives and health systems which has produced
recommendations for ensuring that health systems are strengthened, not weakened by global
health initiatives.
The ability of societies generally, as well as public health and clinical care entities
specifically, to address the HIV epidemic is contingent upon functioning health systems. The
term “health system” that is used in this report is intentionally broad, referring to all of the
societal resources mobilized to achieve and preserve health and thus, a health systems approach
to constraints offers a different lens from that of a disease-specific response (see Table 9-1)
(Mills, 2007). Many scholars have argued that investments in response to scaling up disease-
specific services could be more appropriately targeted to interventions that broadly strengthen
health care systems (Mills, 2007; Travis et al., 2004; Yu et al., 2008). In 2009, the WHO
Maximizing Positive Synergies Collaborative Group issued five recommendations to improve
the joint effectiveness of large global health programs and partner country health systems: (1)
prioritize health system strengthening, (2) agree on and track health system strengthening
indicators, (3) align planning and resource allocation between global health initiatives and
country health systems, (4) generate more reliable data for the costs and benefits of
strengthening health systems, and (5) commit to increased national and global health financing
that is more predictable to support sustainable and equitable growth of health systems (Samb et
al., 2009). The challenge for global health donors is that health system interventions require
long-term investments; the longer time lags between intervention and outcomes make such
interventions more difficult to measure and evaluate (Bärnighausen et al., 2012).
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STRENGTHENING HEALTH SYSTEMS 9-5
TABLE 9-1 Health System Constraints with Potential Disease-Specific and Health System Responses
Constraint Disease-Specific Response Health-System Response
Financing
Financial inaccessibility: Permit exemptions or reduce Develop risk pooling strategies
inability to pay, informal fees prices for focal diseases
Service Delivery
Physical inaccessibility: distance Provide outreach for focal Reconsider plans for long term
to facility diseases capital investment and planning
for facilities
Poor quality of care among Provide trainings for private Develop systems for
providers in the private sector sector providers accreditation and regulation
Workforce
Inappropriately skilled staff Implement continuous education Review basic medical and
and training workshops aimed at nursing training curricula to
developing skills in focal ensure basic training includes
diseases necessary and appropriate skills
Poorly motivated staff Offer financial incentives to Institute appropriate performance
reward delivery of priority review systems, create greater
services clarity around performance roles
and expectations, review salary
structures and promotion
procedures
Leadership and Governance
Weak planning and management Provide continuous education Restructure ministries of health,
and training workshops aimed at recruit and develop a cadre of
developing planning and dedicated managers
management skills
Lack of intersectoral action and Create special disease-focused Build systems of local
partnership cross-sectoral committees and government that incorporate
task forces at the national level representatives from health,
education, and agriculture as
well as promote accountability of
local governance structures to
the people
SOURCE: Adapted from (Mills, 2007; Travis et al., 2004).
OVERVIEW OF PEPFAR’S HEALTH SYSTEMS STRENGTHENING ACTIVITIES
As part of the current IOM Evaluation of PEPFAR, Congress mandated an assessment
of PEPFAR’s effects on health systems, “including on the financing and management of health
systems and the quality of service delivery and staffing.” 2 This section provides a brief history
of PEPFAR’s approach to HSS; this is followed by a more in-depth discussion of PEPFAR
activities related to each building block of the health system.
2
Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria
Reauthorization Act of 2008, Public Law 110-293, 110th Cong., 2nd sess. (July 30, 2008), §101(c), 22 U.S.C.
7611(c)(2)(B)(ii).
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9-6 EVALUATION OF PEPFAR
History of PEPFAR’s Approach To and Increasing Focus on HSS
In PEPFAR’s first Five-Year Strategy, OGAC articulated the importance of supporting
national strategies, laboratory systems, workforce training, and information systems because
these components of health systems were essential for scaling up quality services (OGAC,
2005b). Recognizing that partner country health systems were not prepared to support needed
services, OGAC committed to providing “targeted technical assistance, training, and funding to
improve and expand the infrastructure necessary to ensure optimal delivery of HIV/AIDS
treatment services” (OGAC, 2004, p. 39). “Evidence demonstrates that scale-up of HIV services
has produced stronger health systems and, conversely, that stronger health systems were critical
to the success of the HIV scale-up” (Palen et al., 2012, p. S113). However, some have argued
that the disease-specific nature of the PEPFAR program may have undermined a coordinated
approach to health planning and delivery (Bärnighausen et al., 2012; Hanefeld, 2010; OGAC,
2009f).
OGAC has recognized the largely ad-hoc nature of HSS interventions during the first
phase of the PEPFAR program (2004-2009) and the lack of a strategic focus on strengthening
each building block of the health system (OGAC, 2009f). PEPFAR-supported HSS
interventions were largely disease-specific or somewhere on the continuum between disease-
specific and a broader health system response (see Table 9-1). The reauthorization legislation
provided the opportunity and goals for PEPFAR to formally identify and support strategies to
“strengthen overall health systems in high-prevalence countries, including support for
workforce training, retention, and effective deployment, capacity building, laboratory
development, equipment maintenance and repair, and public health and related public financial
management systems and operations,” 3 as well as for PEPFAR and partner country government
to commit to a “deeper integration” of HIV services into existing national programs and
systems. 4 The reauthorization legislation stated goals for PEPFAR to strengthen health policies
and systems for not only HIV/AIDS, but also tuberculosis and malaria, in support of increasing
partner country ability for delivery of efficient, effective, and evidence-based services. 5 This
enabled PEPFAR’s engagement and promotion of other stakeholders, such as civil society, to
participate in a country’s HIV/AIDS response.
In its second phase (2009-2013), PEPFAR “emphasizes the incorporation of health
systems strengthening goals into its prevention, care and treatment portfolios” with the goal of
training and retaining “health care workers, managers, administrators, health economists, and
other civil service employees critical to all functions of a health system” (OGAC, 2009d, p. 8).
In response to the reauthorizing legislation’s goals and objectives for health systems, PEPFAR’s
second Five-Year Strategy articulated not only its commitment to health systems in terms of
activities and resources, but that it would also be cognizant and more considerate of health
systems activities’ effects when planning prevention, care, and treatment services within partner
countries (OGAC, 2009f). The second Five-Year Strategy also articulated that PEPFAR could
be a platform for improving other health conditions, especially due to its work in HSS to ensure
quality and expanded care and treatment services, including antiretroviral therapy (ART)
(OGAC, 2009d, p. 5). In 2009, PEPFAR developed a strategic framework to help PEPFAR
3
Ibid., §301(c)(5)(D), 22 U.S.C. 2151b-2(d)(6)(G)(ii).
4
Ibid., §301(c)(6), 22 U.S.C. 2151b-2(d)(8).
5
Ibid., §204(a), 22 U.S.C. 7623(a)(1)(A).
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STRENGTHENING HEALTH SYSTEMS 9-7
mission teams plan HSS activities by identifying focused investments needed to achieve service
delivery objectives, spillover effects, and targeted leveraging of other programs and donors
(OGAC, 2009f). Specific OGAC guidance and PEPFAR activities related to each building
block are described in the sections that follow.
PEPFAR Funding for HSS
Broadly, funding for PEPFAR HSS activities is captured in three budget codes: Health
Systems Strengthening, Strategic Information, and Laboratory Infrastructure (see Box 9-1)
(OGAC, 2011c). Although funding for Strategic Information and Laboratory Strengthening can
be traced to HSS efforts in the Health Information and Medical Products and Technologies
building blocks, funding cannot be disaggregated for efforts in the other building blocks. Over
the years, PEPFAR’s budget code definitions were revised, but HSS activities generally
included broad policy reform efforts, system-wide approaches (e.g., supply chain, procurement,
information), and capacity building for financial and program management (OGAC, 2008a,
2010a). Other activities that contribute to HSS, such as those associated with service delivery,
especially human resources for health training (HRH), may not be reported in the HSS budget
codes (Palen et al., 2012), so the amounts presented in Figure 9-2 may under-represent
PEPFAR’s investments in HSS.
BOX 9-1
PEPFAR Budget Code Definitions for HSS
Health Systems Strengthening – “include activities that contribute to national,
regional or district level systems by supporting finance, leadership and governance
(including broad policy reform efforts including stigma, gender etc.), institutional
capacity building, supply chain or procurement systems, [strengthening of local
coordinating mechanisms for implementation of] Global Fund programs [or other
external grants,] and donor coordination.” (OGAC, 2011c, p. 184)
Laboratory Infrastructure – development and strengthening of laboratory systems
and facilities to support HIV/AIDS-related activities including: strengthening of
laboratory leadership and management; purchase of equipment and commodities;
strengthening of laboratory supply and equipment management systems; promotion
of quality management systems, laboratory monitoring and evaluation, and laboratory
information systems; and provision of staff training and other technical assistance.”
(OGAC, 2011c, p. 156)
Strategic Information – “Aims to build capacity in country for HIV/AIDS behavioral
and biological surveillance, facility surveys, monitoring program results, reporting
results, supporting health information systems, supporting countries to establish
and/or strengthen such systems, supporting training and retention of local cadres of
personnel needed to direct all SI activities, and related analyses and data
dissemination activities fall under strategic information.” (OGAC, 2011c, p. 165)
SOURCE (OGAC, 2011c).
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PART IV
Future of US Government Involvement
in the Global Response to HIV/AIDS
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