Annex V - Health system strengthening priority-setting

Efforts to strengthen health systems in the context of PEPFAR Partnership Frameworks and, more broadly through the Global Health Initiative recognize that partner government-led, well-functioning health systems can effectively prevent, care for and treat HIV/AIDS, that effective interventions exist to strengthen health systems, and that strong health systems can sustain the response to HIV/AIDS over time.

Specific health system weaknesses pose critical barriers to achieving national and USG, including PEPFAR, objectives and to ensuring country capacity to sustain the response to HIV/AIDS over time. These weaknesses vary by country and they impact prevention, care and treatment differently. Partnership Framework Implementation Plans are based on a strategy that is founded on an assessment of issues related to service delivery, workforce, information, medical products and technologies, financing, and leadership and governance. Please note that in countries where there are broader USG investments in health, the expectation is that support to health systems strengthening would be based on a strategic plan across the USG and funded through multiple accounts. Additionally, given the importance of health systems strengthening to support sustainability, leveraging with other partners is critical for supporting health systems results.

Partnership Framework Implementation Plans should prioritize health system strengthening issues that can be addressed effectively during the 5-year timeframe and that build towards long-term sustainability and country ownership.

Priority setting: The questions below are purely illustrative and intended to will help you set priorities based on strengths and weaknesses in your country. While these are quite specific to HIV/AIDS they will, in many cases, also relate to other public health services within the context of an integrated program.

  • Service delivery issues: What are the roles of public, private and NGO sectors in supporting service delivery? How well do care networks function? Are referral systems in place? Are HIV/AIDS services effectively integrated into health care? What community linkages function? What arrangements ensure outreach to special populations (e.g. MARPs)? How does decentralization influence service delivery? Do district officers and clinic and hospital management staff have supervisory and planning skills? What is status of efforts to improve supply/safety of blood? To scale up PMTCT through MCH integration and strengthening? To adopt and scale up evidence-based prevention services such as male circumcision, alcohol treatment, Prevention with Positives, STIs, ARVs?
  • Health workforce issues: Is there a national HRH strategic plan? How is task-shifting being used to develop sufficient ARV service providers? How are HR systems being made efficient? What are arrangements for in-service training, pre-service training, and capacity building of training institutions? What is being done to strengthen the capacity of institutions for medical and nursing education to meet the health care demands of the future and to improve the quality of clinical education and clinical care? What is status of strategic planning, policy changes, interventions to increase country prevention expertise, circumcision skills, substance abuse experts/counselors, counselors for prevention with positives, STI service providers, etc.?
  • Health information issues: What plans are in place to strengthen systems to plan, monitor, and improve ARV delivery services, including DHS/AIS, SPA, ARV M&E, drug resistance surveillance, death registries, HIVQUAL (continuous quality improvement), and data for decision making courses? What is status of systems to plan, monitor, and improve HIV prevention services via HIV surveillance systems, DHS/AIS, SPA, MARP assessments and mapping, new prevention PHEs, data for decision-making courses, etc.?
  • Medical product and technology issues: What is the status of the general supply chain, procurement, and forecasting systems in general and more specifically for STI drugs, HIV test kits, PMTCT drugs? What is status of development of supply chain systems for ARVs, CD4 and other lab tests to monitor ARV treatment? Are ARVs integrated into general supply chain, procurement, and forecasting systems? What is status of supply chain and procurement systems for free and socially-marketed condoms?
  • Health financing issues: What has been done to create sustainable ARV financing? Discuss status of ARV cost negotiations, ARV cost modeling, efforts to assist government funding of ARVs, promoting affordable private sector ARV treatment, optimizing costs per person treated (e.g., via performance-based budgeting of treatment partners)? What support does the government need to promote cost efficiencies and sustainability by funding HIV prevention efforts, promote affordable private sector HIV prevention services (PMTCT, male circumcision, STI treatment), introduce performance-based budgeting of HIV prevention partners, etc.?
  • Health leadership & governance issues: What is status of multi-sector strategic planning for HIV/AIDS in general, and for ARV scale-up, patient rights/anti-stigma policy development, national ARV guidelines, private/public sector regulation (HIV accreditation), communication/integration of partners/donors (3 Ones)? How effective are multi-sector strategic planning and implementation for HIV prevention? How strong is civil society's role in HIV prevention efforts? In national leadership related to faithfulness, condom use, and alcohol abuse? How strong are HIV prevention guidelines in context of decentralization?

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