The U.S. President’s Emergency Plan
for AIDS Relief
Health Systems Strengthening Under PEPFAR
Positive Synergies
Meeting
June 22, 2009
The U.S. Government Response
• In 2003, the U.S. Government launched the U.S.
President's Emergency Plan for AIDS Relief (PEPFAR) –
a five-year commitment to combat global AIDS.
• Recognizing the successes of the program, in 2008 the
U.S. Government signed the Tom Lantos and Henry J.
Hyde United States Global Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Reauthorization Act of 2008
into law, reauthorizing PEPFAR for an additional five
years.
• To date, the U.S. Government, through PEPFAR, has
contributed $25 billion to the fight against HIV/AIDS.
Goals for PEPFAR II
Working in partnership with host nations around the
world, PEPFAR will support:
– Treatment for at least 3 million people
– Prevention of 12 million new infections
– Care for 12 million people, including 5 million
orphans and vulnerable children
• To meet these goals, PEPFAR will support training of
at least 140,000 new health care workers in
HIV/AIDS prevention, treatment and care.
PEPFAR Reauthorization
“ Establish a roadmap to link investments
in specific disease programs to the
broader goals of strengthening health
systems and infrastructure”
“ Integrate and coordinate HIV/AIDS, TB, or
malaria with other health or development
programs as appropriate”
PL 110-293
What is the Health System?
PEPFAR recognizes that health system
includes:
• National level ministries such as Ministries of
Health, Finance, Labor, Education and others
• The community , including civil society
organizations
• The private sector
Positive Synergies?
Investments in Health Systems
Strengthening
In FY 2009 - PEPFAR has invested
approximately $1.2 billion in to strengthen
health systems in 31 PEPFAR countries in
the areas of:
•
•
•
•
Human resources for health--$380 million
Commodities and procurement including supply
chain management--$ 229 million
Laboratory systems & infrastructure-- $201 million
Information systems--$138 million
Lessons learned from the first five
years of PEPFAR
• Where health systems are strong PEPFAR is able to
reach its targets quickly and more efficiently-Namibia,
Botswana
• PEPFAR achievements in delivering care and
treatment services are related to policy
implementation , such as policy change to allow for
task shifting –Ethiopia, Mozambique
• PEPFAR implementation can enhance the
functioning of the health system where in it is in
alignment with national health plans
Examples of Building Workforce Capacity
• In Kenya, PEPFAR supports the government’s Emergency Hiring
Plan to train and deploy retired physicians, nurses and other health
care workers for the private sector; 830 were deployed last year
• In Zambia, the rural retention scheme provides incentives such as
hardship allowance, housing, transportation and educational stipends
for children of physicians serving in rural areas
• In Botswana, Namibia and Mozambique, through contracting
mechanisms supported by PEPFAR, newly qualified health care
workers are hired on a short-term basis to work for the Ministry of
Health until the government can bring them into the public system
• In Tanzania, PEPFAR is piloting a “retired but not yet tired’ program
to bring retired health care workers back into the health workforce.
Strengthening Laboratory Systems
• Support for Avian Influenza: during the poultry
outbreaks in 2005, over 60 laboratory experts
from African countries received diagnostic
training for avian influenza and now HINI.
Similarly, laboratories in Nigeria supported
the investigation for the avian influenza
outbreak that occurred in 2005.
• WHO-AFRO – PEPFAR Partnership is a TA
program targeting MoH to: a) harmonize lab
tests and equipment across a tiered lab
system; (b) develop national lab strategies; (c)
develop tools for quality management; and (d)
integrate HIV, TB and malaria lab capacity
building.
Strengthening Supply Chains
As Ministry of Health supply
chains in most countries are
integrated across diseases
and commodities, PEPFAR
supported supply chain
technical assistance
contributes to strengthening
the entire supply chain for all
health commodities - not only
HIV/AIDS - and is therefore
key to overall health system
strengthening.
Strengthening Systems
In a study of 33 PEPFAR-supported sites providing antiretroviral treatment and
associated care in 4 countries, PEPFAR supported 92% of the systems
strengthening investments at a typical facility.
*Source: PEPFAR Fifth Annual Report to Congress, 2009
Impact of PEPFAR Support to Medical transmission
– Blood Safety and Waste management
Year
2004
2005
2006
2007
2008
Blood collections
9,513
10,823
13,622
17,094
19,646
5%
15%
27%
52%
66%
95%
85%
73%
48%
34%
Voluntary,
Non-Remunerated
Replacement/Family
PEPFAR’s Renewed Approach to
Strengthening Health Systems
• Supported by PEPFAR’s reauthorizing
legislation
• Builds upon the lessons learned from the first
five years of PEPFAR
• Promotes sustainable country capacity
• Developed in consultation with:
Host Countries
Other donors
PEPFAR headquarters and country teams
Civil society
PEPFAR partners
Applying PEPFAR HSS Approach to
PEPFAR Goals
Service
Delivery
3-12-12
Focused:
Positive
Synergies/
Intentional
Spillover:
Impacts on HSS
at no or minimal
cost to USG
Leveraging:
Collaborate with
other partners to
generate
HIV/AIDS and
other benefits
Human
Resources
Health
Financing
Medical
Products,
Vaccines and
Technologies
Information
Systems
Leadership/
Governance
Applying PEPFAR HSS Approach to
3M Under Treatment Goal
Service Delivery
3-12-12
Focused:
HIV-focused
treatment,
care, and
prevention
activities
Information Systems
• Strengthen ARV referral
• Strengthen systems to
systems and care networks,
plan, monitor and improve
service integration
ARV delivery using
• Basic laboratory services for
DHS/AIS, SPA, ARV M&E,
monitoring ART side effects,
drug resistance
community linkages
surveillance
• Outreach to special
• Implementation of
populations (MARPs)
HIVQUAL (continuous
• Decentralization of ARV
quality improvement for
services and planning to
HIV)
districts
• PHEs focusing on treatment
questions
Human Resources
• Develop sufficient ARV
service providers via
task- shifting, improved
HR efficiencies, in
service trainings,
capacity building of HIV
training institutions
Health Finance
Commodities/
Procurement
• Sustainable ARV financing
• Supply chain and
including ARV price
procurement systems for
negotiations, ARV cost
ARVs, CD4 and other lab
modeling, mainstreaming
reagents to monitor ARV Tx
ARVs into national health
employed
plans and insurance
• MOH staff trained on ARV
schemes
procurement and
• Optimizing costs per person
forecasting
treated (performance-based • Assessments on how best to
budgeting of Tx partners)
integrate ARVs into general
drug supply chain systems
Leadership/
Governance
• Recognition of HIV as national
problem, reducing stigma and increases
testing rates
• Anti-stigma policies enacted
• Multi-sector strategic planning for ARV
scale-up
• HIV accreditation for both public and
private sector
• National ARV treatment guidelines
• HIV focused management training for
NACs, DACs, and others
• Journalism training on HIV/ART
Spillover:
• Improved referral systems
impacts on
for other diseases
HSS at no or • Basic lab services for all
minimal cost
patients
to USG
• HIV Tx model adapted for
other chronic diseases (e.g.
depression, hypertension)
• Decentralization strategies
used for other health issues
• Quality improvement drives
models for other diseases
• DHS/AIS/MIS informs other
disease programs (TB,
malaria, MCH)
• PHE efforts stimulate
operational research in
other areas
• Improve HR efficiencies
across clinic/hospital
• Broader institutional
capacity-building
• Task-shifting in non-HIV
services & departments
• Doctors/nurses able to
address PHC needs
• Governments perform cost
modeling for other health
issues
• Governments better
negotiate better non-HIV
drug pricing
• Financial accountability
increases beyond HIV in
gov’t and NGO sectors
• Newly acquired forecasting
and delivery skills used for
other drugs and vaccines
• ARV procurement systems
adopted for other drugs
• More open policies for other health
and social issues
• Multi-sector and civil society
engagement approaches adopted for
other health issues
• National guidelines created for other
diseases
• Journalists use HIV training to report on
other health issues
Leveraging:
collaborate
with other
partners to
generate
HIV/AIDS
and other
benefits
• Quality MOH HMIS
improved and ARV M&E
integrated into this system
• HRIS created/ improved
• Data for decision- making
courses developed for key
health decision- makers
• DfID, IHP+ joint
• National health accounts
partnership in expanding
and costed national health
pre-service training
plans
• Expansion of community • Health insurance. Schemes
health worker schemes
cover HIV and non-HIV
and trainings in
services & drugs
partnership with MCH
• Support to MOF improves
programs
other ministries  better
• HRH strategic planning
health finance
policies/procedures
• Multi-donor efforts to
assess and strengthen
national procurement/
logistics systems for
essential drugs (eventually
allowing ARVs, other drugs
used in HIV care, lab
reagents to be
mainstreamed into general
supply chain and
procurement systems)
• Health Systems assessments pinpoint
key system weaknesses to be
addressed if further ARV scale-up and
other disease control efforts are to
succeed
• General management training for
hospital administrators and district
officials leading to better services and
planning
• General accreditation and performance
assessment schemes strengthened
• Clinic renovations =
increased use of HIV and
non-HIV services
• MCH assessments and
strategic planning lead to
improved MCH services and
ART coverage of HIV+
pregnant women,
integration of reproductive
health services
Applying PEPFAR HSS Approach to
3M Under Treatment Goal
Service Delivery
Information Systems
Human Resources
3-12-12
Focused:
HIV-focused
treatment,
care, and
prevention
activities
• Develop sufficient ARV
service providers via
task- shifting, improved
HR efficiencies, in
service trainings,
capacity building of HIV
training institutions
Spillover:
impacts on
HSS at no or
minimal cost
to USG
• Improve HR efficiencies
across clinic/hospital
• Broader institutional
capacity-building
• Task-shifting in non-HIV
services & departments
• Doctors/nurses able to
address PHC needs
Training in universal
precautions
Post expoosure prophylaxis
available
Leveraging:
collaborate
with other
partners to
generate
HIV/AIDS
and other
benefits
• DfID, IHP+ joint
partnership in expanding
pre-service training
• Expansion of community
health worker schemes
and trainings in
partnership with MCH
programs
• HRH strategic planning
Health Finance
Commodities/
Procurement
Leadership/
Governance
PEPFAR’s HSS Strategy
Will enable PEPFAR and its partners to :
• Quantify and assess existing investments
• Set priorities
• Identify gaps and areas of opportunity to
link with host governments, other USG
health initiatives and international donors
• Increase accountability for results
• Build a more sustainable response
• Maximize efficiencies
Areas for future HSS investments
• Supporting host government leadership and
management skills and capacity
• Continuing transition to indigenous
implementing partners
• Supporting a formal health systems
assessment process where needed
• Expanding the emphasis on monitoring health
services
Moving Forward
• New opportunities for an expanded
emphasis on strengthening health care
systems include:
• The development of next generation of PEPFAR
indicators
• The Congressionally mandated target of
supporting training and retention of 140,000 new
health care workers
• An emphasis on partnerships with host
governments through Partnership Frameworks
• The President’s creation of the new Global Health
Initiative
Achieving the 140,000 target
• The goal of this target is to increase the
number of health care workers in the
workforce by 140,000 by 2013
• Training is defined as “pre-service “ education
of new health care workers who graduated
from a pre-service educational institution with
full or partial PEPFAR support
• All training must occur prior to the individual
entering the health workforce in his or her
new position
Achieving the 140,000 target
• Categories of health workers to be
considered:
* Health professionals:
- clinical professionals
- other health care professionals
* Paraprofessionals, auxiliary
workers or associate
professionals
The Future of PEPFAR: Partnership
Frameworks
• The Lantos-Hyde Reauthorization Act of 2008 authorized
the U.S. Government, through PEPFAR, to establish
Partnership Frameworks with host countries to promote
a more sustainable approach to combating HIV/AIDS,
characterized by strengthened country capacity,
ownership, and leadership.
What are Partnership Frameworks?
• provide a 5-year joint strategic framework for cooperation
between the U.S. Government, the partner government,
and other partners to combat HIV/AIDS in host countries
through service delivery, policy reform, and coordinated
financial commitments.
•
support and strengthen national HIV/AIDS strategies
and focus on building strategic partnerships with host
nations to secure long-term sustainability of HIV/AIDS
programs.
• will be established with transparency, accountability, and
the active participation of other key partners from civil
society, the private sector, other bilateral and multilateral
partners, and international organizations.
Partnership Framework Countries
• To date, the following countries have been invited to
develop a Partnership Framework:
– Botswana, Caribbean Region, Central America
Region, Central Asia Region, Côte d’Ivoire, Democratic
Republic of the Congo, Dominican Republic, Ghana,
Guyana, Haiti, India, Indonesia, Kenya, Lesotho,
Malawi, Mozambique, Namibia, Nigeria, Rwanda,
South Africa, Swaziland, Tanzania, Thailand, Uganda,
Ukraine, Vietnam, and Zambia.
• To date, the following countries have completed and
signed a Partnership Framework:
– Malawi, Swaziland
The US Global Health Initiative
• In May 2009, the President committed to spending
$63 billion over the next six years to bring better
health to people around the globe.
• This funding, the majority of which is pledged to
PEPFAR, reflects an integrated approach to fight
diseases, improve basic health, and strengthen
health infrastructure.
• In addition to funding for global HIV/AIDS, there will
be an increased focus on child and maternal health,
malaria, and neglected tropical diseases.
HSS is a long-wave event…
• A
• Requires both:
– Immediate, “GHI-specific”
technological and human
resource responses
AND
– Long-term commitment to
addressing policy,
governance, and
environmental factors
“Make haste slowly”
- Milarepa
(12th Century Tibetan yogi)
• The challenge:
Can we combine a sense
of urgency with long-term
vision?
Thank you
For further information, please visit:
www.PEPFAR.gov