Health Systems Strengthening (HSS)


In South Africa, an innovative PEPFAR-supported public-private partnership with Toga Integrated HIV Solutions is improving the standard of care and treatment provided to people living with HIV/AIDS in resource-poor settings - by taking lab services to the people. 'Togatainers' are self-contained laboratories containing state-of-the-art equipment in refurbished shipping containers. Each Togatainer is staffed by trained lab technicians who provide instant results to clinics in the vicinity, and who ensure that data is fed back through a comprehensive monitoring system to the headquarters in Johannesburg. The central laboratory in Johannesburg flags any inconsistencies in data, ensuring a comprehensive monitoring solution in a compact, cost-effective container. Photo by South Africa PEPFAR Team

Health Systems Strengthening (HSS)

Key Points:

  • PEPFAR is implementing new tools to help country teams strategically plan, support and document contributions to strengthening country health systems.
  • As part of the GHI and increased multilateral engagement, PEPFAR will integrate and link health systems activities to leverage global action on this issue.
  • In order to develop skills necessary to engage in strategic HSS planning and implementation, PEPFAR must support additional training for both partner government personnel and PEPFAR employees.
  • In its next phase, PEPFAR is emphasizing the strategic planning and implementation of its prevention, care, and treatment activities with consideration for their country-level health systems impacts.
  • PEPFAR is working with partner countries to expand understanding of each health system at the national, provincial, district, and community level.
  • PEPFAR, through the GHI and increased multilateral engagement, will work to develop universally accepted and harmonized indicators for HSS. In addition, PEPFAR is supporting countries in expanding their own mechanisms for data collection to measure the most important health services and health outcomes in a country.


WHO has identified six core health systems functions: service delivery; human resources for health; medical products, vaccines and technologies; information; governance; and finance. PEPFAR is assisting countries to improve health systems in these six core areas while achieving significant HIV/AIDS prevention, care, and treatment outcomes.

A health system encompasses the individuals, organizations and processes - from the national government to the private sector to community based organizations - focusing primarily on ensuring health outcomes. Examples of how PEPFAR has contributed to these six building blocks include the following. These represent a small sample of PEPFAR's larger health systems impacts:

WHO has identified six core health systems functions: service delivery; human resources for health; medical products, vaccines and technologies; information; governance; and finance. PEPFAR is assisting countries to improve health systems in these six core areas while achieving significant HIV/AIDS prevention, care, and treatment outcomes.

As part of broad global investments in HIV/AIDS, PEPFAR has contributed to improvements of larger health systems, with impacts on maternal and child health.10 However, PEPFAR has not had a strategic vision or plan to incorporate a health systems lens into its programming. In the first phase of PEPFAR, health systems activities were largely ad hoc, varied across countries, and did not always factor in an intervention's impact on the country's broader health system.

In 2009 PEPFAR developed a strategic framework tool for HSS. This tool is designed to help country teams plan HSS activities. Such planning can maximize the positive impacts of prevention, care, and treatment activities and identify opportunities to leverage and partner with other health and development programs. Through this framework, PEPFAR programs can identify:

  • Focused investments needed to achieve prevention, care, and treatment objectives;
  • Intentional spillovers or collateral benefits - primarily HIV-related work that benefits other parts of the health system at low additional cost; and
  • Targeted leveraging with other donors or USG programs, allowing PEPFAR and other health and development partners to jointly support programs that broadly benefit the health system.

In its next phase, PEPFAR is emphasizing the strategic planning and implementation of its prevention, care, and treatment activities with consideration for their countrylevel health systems impacts. To enable country health systems to respond to both HIV/AIDS and broader health needs, PEPFAR is engaging in the following activities:

Supporting strong government leadership of health systems, which is integral to sustainability

Health systems are strongest where governments have leadership and technical skills to address health system weaknesses. While a network of public and private partners deliver services, governments play the lead role in overseeing health systems among multiple actors at national, district, and community levels. In collaboration with other USG programs and international donors, PEPFAR supports governments to identify opportunities for HSS within their HIV and broader health sector plans. By working with governments, PEPFAR can create technical capacity necessary to engage, coordinate and oversee the multisectoral activities falling within the six building blocks. PEPFAR will provide mentoring and technical assistance to government employees and promote the involvement of a multisectoral country response in addressing a country's health needs.

Expanding efforts to partner with multilateral organizations on this issue

Organizations such as the Global Fund, the Global AIDS Vaccine Initiative (GAVI), the World Bank, WHO, and the International Health Partnership Plus (IHP+) are expanding HSS activities. Heightened donor interest provides PEPFAR with an opportunity to work in partnership and strengthen health systems at the country and regional level. As part of larger efforts, PEPFAR can work with countries to leverage additional donor resources and coordinate activities to realize a broader impact on an overall health system. As part of the GHI, PEPFAR will explore opportunities for joint programming and increased coordination around implementation and evaluation of health systems activities.

Including considerations of health systems dynamics in work to define, map, and implement plans to address country-level need

With its focus on rapid scale-up during the first five years of PEPFAR, the program sometimes established parallel health systems within a country, rather than strengthening the complex health systems that exist in each country. The process of assessing a health system itself can be a skill- and relationship-building tool with ministries, civil society, the private sector, and donor community counterparts. PEPFAR is working with partner governments to expand understanding of each health system at the national, provincial, district, and community level.

Through this engagement, PEPFAR is supporting creation of new, or review of existing, health systems assessments that contribute to overall country HIV/AIDS plans.

Developing good indicators to track progress with health systems strengthening

The challenge in health systems lies in identifying impact. It is difficult to determine exactly which health systems parameters are most closely associated with positive health outcomes, which interventions are most effective at improving health system performance, and which measures most effectively track progress. Setting appropriate targets, developing sound indicators, and monitoring change can be particularly challenging. PEPFAR, in collaboration with the GHI and other donors, will work to develop universally accepted and harmonized indicators for HSS. In addition, PEPFAR is supporting countries in expanding their own mechanisms for data collection to measure the most important health services and health outcomes in a country.


Moving Forward with Health Systems Strengthening

Years 1-2 -

  • Work with countries to identify how HIV/AIDS activities can contribute to broader HSS efforts.
  • Support both headquarters and country teams to obtain the skills necessary to carry out programming with a HSS perspective, and provide the technical assistance necessary to increase these skills in partner countries.
  • Increase multilateral engagement around accomplishing HSS HIV/AIDS activities.
  • Continue efforts to identify internationally accepted indicators for HSS.
  • Support policy change needed to attain HSS goals defined in Partnership Frameworks.

Years 3-5 -

  • Implement harmonized HSS indicators within PEPFAR programming.
  • Expand and coordinate, as appropriate, multilateral efforts to support HSS.
  • Strengthen country governance and financing of the health system to advance the goals of country ownership and sustainability.

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