• 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, the Office of the Global AIDS Coordinator (OGAC) adopted the six-building-block framework articulated by the World Health Organization (WHO), around which the following main messages have been organized:
Leadership and Governance
• Many stakeholders reported that there is strong leadership in partner countries for the HIV/AIDS response, both within 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 national stakeholders, and external donors is a critical activity that is needed for the current and future responses to HIV/AIDS. For the U.S. Government (USG) support for PEPFAR countries, this type of planning is the primary tool for ensuring leadership and governance as well as a vehicle for joint planning efforts that support the principles of ownership and mutual transparency, responsibility, and accountability.
• PEPFAR has increasingly provided stronger support for partner country planning and the development of national frameworks, policies, and strategic plans. There is variable alignment or harmonization with partner country planning processes, which are primarily driven by national government priorities. It is reasonable that the USG, like all donors, has 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 for the committee to 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, and 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.
• 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 the costing of services and the 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 mobilization plans, conduct costing activities and resource projections, or identify funding needs.
• Despite initial PEPFAR-specific systems for program monitoring data, PEPFAR has worked with partner country governments to integrate and strengthen health information systems, including work that has strengthened partner country Laboratory Information Management 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 use in 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 and warehouse, distribute, and track commodities, but challenges to assuring 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 for avoiding disruptions to the 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.
• PEPFAR’s contribution to health workforces in partner countries has over time been 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 fulfilling that need by leveraging and maximizing its investments in collaborative efforts to build the capacity of health professional training schools, which would improve the ability of countries to address not only HIV but also 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 Practice on the International Recruitment of Health Personnel and followthrough on commitments to the Abuja Declaration could support both sustainability of their own health workforces and country ownership.
• 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 national health systems. In some countries, an early emphasis in PEPFAR implementation on increasing the volume of services to meet targets for service delivery resulted in disease-specific 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 or need for greater integration of HIV services into the general health system. The best practices for integrating services—such as those for HIV and tuberculosis, reproductive health, and primary care—need to be identified, evaluated, and scaled up.
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. The Medical Education and Nursing/Midwifery Education Partnership Initiatives 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 the 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 the Supply Chain Management System, 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 the 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.)