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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 defined as 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 objectives of a health system are 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 for ensuring the well-being 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, p. 1; World Health Assembly, 2005).

Over the past decade (2001–2010), 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 for other health focus areas (e.g., maternal and child



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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 re- sources that are devoted to producing health actions. A health action is defined as 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 objectives of a health system are to improve health by achieving the best attainable average level of popula- tion health and minimizing the differences between individuals and groups. National governments are ultimately responsible for the performance of health systems and for ensuring the well-being 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 pro- viding universal health coverage, defined as “access to key promotive, pre- ventive, curative and rehabilitative health interventions,” at an affordable cost for all members of a population (WHO Secretariat, 2005, p. 1; World Health Assembly, 2005). Over the past decade (2001–2010), 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, tu- berculosis) and for other health focus areas (e.g., maternal and child 435

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436 EVALUATION OF PEPFAR health). Large global health initiatives such as PEPFAR, the Global Fund, and the Global Alliance for Vaccines and Immunization 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 Goals1 (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 in scaling up services because of health systems weaknesses and have responded by supporting interventions spe- cifically designed to strengthen components of the health system (Palen et al., 2012; Shakarishvili, 2009). In 2007, WHO developed a framework for health systems strengthen- ing (HSS) that identifies six building blocks corresponding with the essential functions of health systems: 1. Leadership and governance, 2. Financing, 3. Information, 4. Medical products, vaccines, and technologies (shortened to “medi- cal products and technologies” by the committee), 5. Health workforce, and 6. 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). The building block framework, illustrated in Figure 9-1, has been adopted by the Office of the U.S. Global AIDS Coordinator (OGAC) and others stakeholders that are emphasizing the prioritization, organization, and execution of activities in the essential area of strengthen- ing health systems (Friedman et al., 2011; OGAC, 2009f). Large donor-funded global health initiatives interact with each building block within partner country health systems. Despite sharing the same goal as partner country health systems—to improve health outcomes—initiatives such as PEPFAR can have negative as well as positive effects on these sys- 1  In 2000, world leaders committed to the United Nations Millennium Declaration and adopted eight Millennium Development Goals to reduce the most important determinants and consequences of poverty (United National General Assembly, 2000).

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STRENGTHENING HEALTH SYSTEMS 437 Services Good health services deliver effective, safe, quality individual and population health interventions when and where needed, with Workforce Leadership & minimum waste of resources. A well-performing health Governance workforce works in ways that are responsive, fair, Ensuring strategic policy and efficient to achieve frameworks exist and are the best health combined with effective outcomes, given oversight, coalition available resources and building, regulation, circumstances (e.g., attention to system- sufficient staff that are design, and fairly distributed, accountability. competent, responsive, Health Systems and productive). ACCESS COVERAGE QUALITY Financing SAFETY Information Good health financing raises adequate funds for A well-functioning health, in ways that information system is one ensure people can use that ensures the needed services and are production, analysis, protected from financial dissemination, and use of catastrophe or reliable and timely impoverishment due to Commodities & information on health associated costs. Sound Technologies determinants, health financing provides system performance, and incentives for provider A well-functioning health health status. and user efficiency. system ensures equitable access to essential medical products, vaccines, and technologies of assured quality, safety, efficacy, and cost-effectiveness, as well as their scientifically sound and cost-effective use. FIGURE 9-1 Representation of WHO’s six building blocks for effective health systems. SOURCE: Adapted from IOM and NRC, 2010 and WHO, 2007a. tems. Several studies have examined the effects of global HIV/AIDS initia- tives 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 slow- ing of HIV/AIDS-related deaths among the health workforce through the provision of antiretroviral treatment, greater participation of stakeholder

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438 EVALUATION OF PEPFAR 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 the 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 incen- tives to work for donor-funded programs; and the “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 evi- dence is mixed and limited for determining whether 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 devoted to the interaction between global health initiatives and health systems, and this research 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 clini- cal care entities in particular, to address the HIV epidemic is contingent upon functioning health systems. The term “health system” 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 (Travis et al., 2004; Yu et al., 2008). In 2009 the WHO Maximizing Positive Synergies Collaborative Group issued five recommendations (paraphrased here) for improving the joint effectiveness of large global health programs and part- ner country health systems: (1) prioritize health system strengthening, (2) agree on and track health system strengthening indicators, (3) align plan- ning 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 in order to support sustain- able and equitable growth of health systems (Samb et al., 2009). The chal- lenge for global health donors is that health system interventions require long-term investments and the longer time lags between interventions and outcomes make such interventions more difficult to measure and evaluate (Bärnighausen et al., 2012).

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STRENGTHENING HEALTH SYSTEMS 439 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 Develop risk pooling strategies inability to pay, informal reduce prices for focal fees diseases Service Delivery Physical inaccessibility: Provide outreach for focal Reconsider plans for long- distance to facility diseases term capital investment and planning for facilities Poor quality of care among Provide trainings for Develop systems for providers in the private private-sector providers accreditation and regulation sector Workforce Inappropriately skilled staff Implement continuous Review basic medical and education and training nursing training curricula to workshops aimed at ensure basic training includes developing skills in focal necessary and appropriate diseases skills Poorly motivated staff Offer financial incentives to Institute appropriate reward delivery of priority performance review systems, services create greater clarity around performance roles and expectations, review salary structures and promotion procedures Leadership and Governance Weak planning and Provide continuous Restructure ministries of management education and training health, recruit and develop a workshops aimed at cadre of dedicated managers developing planning and management skills Lack of intersectoral action Create special disease- Build systems of local and partnership focused cross-sectoral government that incorporate committees and task representatives from health, forces at the national level education, and agriculture and that promote accountability of local governance structures to the people SOURCE: Adapted from Travis et al., 2004. OVERVIEW OF PEPFAR’S HEALTH SYSTEMS STRENGTHENING ACTIVITIES As part of the current Institute of Medicine (IOM) evaluation of PEPFAR, Congress mandated an assessment of PEPFAR’s effects on health systems, “including on the financing and management of health systems

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440 EVALUATION OF PEPFAR 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. 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 train- ing, 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). Although “evidence demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health sys- tems were critical to the success of the HIV scale-up” (Palen et al., 2012, p. S113), 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., 2011; 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 also 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 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 main- tenance and repair, and public health and related public financial manage- ment systems and operations”3 as well as for PEPFAR and partner country governments to commit to a “deeper integration” of HIV services into existing national programs and systems.4 The reauthorization legislation laid out goals for PEPFAR to strengthen health policies and systems for not only HIV/AIDS, but also tuberculosis and malaria, in support of increasing 2  Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tu- berculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008), §101(c), 22 U.S.C. 7611(c)(2)(B)(ii). 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).

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STRENGTHENING HEALTH SYSTEMS 441 partner country ability to deliver efficient, effective, and evidence-based services.5 This further 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 incorpora- tion of health systems strengthening goals into its prevention, care and treatment portfolios,” including the training and retaining “health care workers, managers, administrators, health economists, and other civil ser- vice 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 not only articulated its commitment to health systems in terms of activities and resources, but also specified that it would 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 specified that PEPFAR could be a platform for improving other health conditions, especially because of its work in HSS to ensure quality and ex- panded care and treatment services, including antiretroviral therapy (ART) (OGAC, 2009d). In 2009 PEPFAR developed a strategic framework to help PEPFAR mission teams plan HSS activities by identifying the focused invest- ments 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 speaking, 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 defini- tions were revised, but HSS activities have generally included broad policy reform efforts, system-wide approaches (e.g., supply chain, procurement, and information), and capacity building for financial and program manage- ment (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 5  Ibid., §204(a), 22 U.S.C. 7623(a)(1)(A).

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442 EVALUATION OF PEPFAR BOX 9-1 PEPFAR Budget Code Definitions for HSS Health Systems Strengthening: “include[s] activities that contribute to national, regional or district level systems by supporting finance, leader- ship and governance (including broad policy reform efforts including stigma, gender etc.), institutional capacity building, supply chain or pro- curement 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: includes “development and strengthening of laboratory systems and facilities to support HIV/AIDS-related activi- ties including: strengthening of laboratory leadership and management; purchase of equipment and commodities; strengthening of laboratory supply and equipment management systems; promotion of quality man- agement systems, laboratory monitoring and evaluation, and laboratory information systems; and provision of staff training and other technical assistance” (OGAC, 2011c, p. 156). Strategic Information: “[a]ims to build capacity in country for HIV/AIDS behavioral and biological surveillance, facility surveys, monitoring pro- gram results, reporting results, supporting health information systems, supporting countries to establish and/or strengthen such systems, sup- porting training and retention of local cadres of personnel needed to direct all SI activities, and related analyses and data dissemination activi- ties” (OGAC, 2011c, p. 165). SOURCE: OGAC, 2011c. et al., 2012), so the amounts presented in Figure 9-2 may underrepresent PEPFAR’s investments in HSS. Over time, as shown in Figure 9-2, funding for the three budget codes most directly related to HSS, as a proportion of all PEPFAR funding has in- creased from nearly 12 percent in fiscal year (FY) 2006 to nearly 18 percent in FY 2011 (data for two of the three budget codes were not reported in FY 2005) (OGAC, 2005a, 2006b, 2007c, 2008b, 2010b, 2011d,e). Funding for these three budget codes increased from $175 million in FY 2006 to $769 million in FY 2011. Initially, Strategic Information and Laboratory Strengthening activities received a greater share of funding, but over time more funding has been directed to the Health Systems Strengthening budget code. From FY 2006 to FY 2011, 38 percent of PEPFAR funding for HSS was directed to the Health Systems Strengthening budget code, 33 percent to Laboratory Strengthening, and 29 percent to Strategic Information.

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STRENGTHENING HEALTH SYSTEMS 443 $900 20% $800 18% Constant 2010 USD Millions $700 16% 14% $600 Health System 12% Strengthening $500 10% Strategic Information $400 8% Laboratory Strengthening $300 Funding for HSS as % of 6% $200 Total PEPFAR Funding 4% $100 2% $0 0% FY05 FY06 FY07 FY08 FY09 FY10 FY11 FIGURE 9-2 PEPFAR funding for HSS (country activities) (constant 2010 USD millions). NOTES: These data represent funding for country activities planned through the Health Systems Strengthen- ing, Strategic Information, and Laboratory Strengthening budget codes. For FY 2005, data were not reported for the Health Systems Strengthening and Strategic Information budget codes. To compare data most ac- curately over time, data are presented in constant 2010 USD. These totals do not include funding for the Medical Education Partnership Initiative (MEPI) and the Nursing/Midwifery Education Partnership Initiative (NEPI), which are supported by PEPFAR. SOURCE: OGAC, 2005a, 2006b, 2007c, 2008b, 2010b, 2011d,e. Committee’s Approach to the Assessment of PEPFAR by Health Systems Building Block The committee systematically collected and analyzed data about PEPFAR activities and effects for each health systems building block; these data included semi-structured interviews with key stakeholders, program- matic and financial data, and other published information including peer- reviewed and grey literature, PEPFAR/OGAC guidance documents, and a targeted review of 2008 and 2010 PEPFAR Country Operational Plans (COPs) for a subset of countries. Based on these analyses, the sections below describe PEPFAR’s inputs and activities within each of the WHO health systems building blocks. PEPFAR inputs include funding for HSS activities and the strategic documents (such as the authorizing and reau- thorizing legislation, 5-year strategies, and programmatic guidance) that provide direction for HSS activities. Although funding information is not disaggregated by each building block’s activities, it is presented where avail- able. Reflecting the interdependent nature of the building blocks, many of PEPFAR’s activities involve two or more building blocks. In the following sections, PEPFAR activities are discussed within the context of the most relevant building block for each activity, based on the intent of the activity as it was described in semi-structured interviews and guidance documents. Finally, the committee drew upon these data to outline PEPFAR’s historic and current achievements and made recommendations for future directions for HSS efforts.

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444 EVALUATION OF PEPFAR LEADERSHIP AND GOVERNANCE Introduction The Leadership and Governance building block represents the most critical function of the health system: stewardship (WHO, 2000, 2007a). Broadly speaking, stewardship has been defined as the “careful and re- sponsible management of the well-being of the population” (WHO, 2000, p. viii). The stewardship function in health systems is quite complex and has been difficult to operationalize since its proposal by WHO in 2000. In 2001, WHO organized a technical consultation through which experts recommended several considerations for a refined definition of stewardship and for conceptualizing “more tangible elements for better assessment of stewardship in a particular country” (WHO, 2001, p. 2). In this redefined definition, stewardship incorporates much of what is described as gover- nance with an emphasis on the role of government; it differs from gover- nance in its style or approach to particular tasks more than in its scope. Stewardship should be ethical, inclusive, and proactive. By reflecting the cultural, political, and societal norms in each country’s context, steward- ship can facilitate addressing interactions between the health system and other aspects of society as well as influence other stakeholders in the private and other sectors. Stewardship includes the mobilization of multisectoral stakeholders to produce positive changes that address today’s challenges while maintaining a long-term perspective in order “to develop lasting solutions, to build the capacity to solve the problems of the future, and to foster continuous improvement” (WHO, 2001, p. 4). For health systems, stewardship includes priority setting, strategy and policy development, multisectoral collaboration and coalition building, oversight and guidance for the whole health system (public and private), and regulation of all actors involved in the health system (WHO, 2007a). Although national governments are ultimately responsible for the per- formance of their health systems, other entities and institutions from the private sector and civil society may be involved in or carry out some of the functions of stewardship (IOM and NRC, 2009; WHO, 2000, 2007a). Leadership and Management In 2007, WHO organized another international consultation on im- proving leadership and management for health. Reports from that con- sultation stated that leadership and management are complex concepts relevant to many different parts of the health system and acknowledged the different, yet complementary, roles of leaders and managers. Leaders were identified as essential for setting a strategic vision and planning and

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STRENGTHENING HEALTH SYSTEMS 445 mobilizing efforts toward the realization of that vision, while skilled and motivated managers work throughout a health system to “ensure effective organization and utilization of resources to achieve results” and meet the objectives set forth in the strategic vision (WHO, 2007b, p. 1). Good lead- ership and management were described as key to effectively using resources devoted to health to achieve measurable results, particularly by “providing direction to, and gaining commitment from, partners and staff, facilitating change, and achieving better health services through efficient, creative and responsible deployment of people and other resources” (WHO, 2007b, p. 1). Additionally, the report stated that countries needed to develop and implement overall plans for leadership and management and that external donor assistance should coherently support these plans. Governance In the broadest sense, “[g]overnance refers to the structures, rules, and processes that societies use to organize and exercise political power to identify and achieve objectives [. . .] Governance includes, but is not syn- onymous with, government [. . .] National governance refers to the way in which a country organizes political power within its territory and controls interactions among local, sub-national, and central governmental authori- ties” (IOM and NRC, 2009, p. 206). Governance for the health system has been defined by WHO as “the wide range of functions carried out by governments as they seek to achieve national health policy objectives” and includes identifying the health needs of a population, setting priorities, strategic planning, policy development and implementation, and regulation of different types of actors within the health system (WHO, 2012c, p. 1). To achieve good governance, governments must have the capacity to “plan, manage, and regulate policy, financial resources, and service delivery” with efficiency, effectiveness, openness, transparency, and accountability (Brinkerhoff and Bossert, 2008; Fox et al., 2010, p. 12). Effective governance of the HIV/AIDS response requires a multisectoral approach that is responsive to and inclusive of other government sectors as well as the private sector and civil society (Brinkerhoff and Bossert, 2008). HIV/AIDS impacts all the social and economic sectors within a country, so to be truly effective, national responses to HIV/AIDS must be multisectoral (Piot and Coll Seck, 2001). The health sector may be the focus of a coun- try’s HIV/AIDS response (and donor support), but comprehensive responses involve other sectors, such as finance, education, labor, transportation, military, policy, women, and young people (UNAIDS, 2009). Frameworks and principles for good governance seem to be rooted in historical devel- opment from postwar conflicts and other activities that have threatened the principles of democracy, security, and the rights of people around the

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