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 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). Although “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), 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 maintenance and repair, and public health and related public financial management 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, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008), img101(c), 22 U.S.C. 7611(c)(2)(B)(ii).

3Ibid., img301(c)(5)(D), 22 U.S.C. 2151b-2(d)(6)(G)(ii).

4Ibid., img301(c)(6), 22 U.S.C. 2151b-2(d)(8).

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