N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $2,667,027

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Swaziland's HIV and AIDS response suffers from severe deficits in infrastructure and human resources. The scale of the

epidemic has placed undue stress on an already overburdened health care system. Challenges include a lack of sufficient

number of personnel with skills in planning and management; crumbling facilities; inadequate equipment; a vertical HIV service

delivery approach that limits access; and, insufficient systems and capacity for data-driven decision making. These constraints

result in slow implementation, lack of coordination and unspent HIV and health sector allocations.

The Government of Swaziland, with significant support from the Global Fund, United Nations agencies and PEPFAR among other

donors, is making efforts to address these deficiencies. The country has in place a National Multisectoral Policy and Action Plan

on HIV and AIDS 2206-2008 and is currently developing the follow-on National Strategic Framework for 2009-2013. The

managerial structures of the national coordinating body, NERCHA, have been strengthened. Regions and sectors are now

involved in planning, managing coordinating, monitoring and evaluating the response. A national monitoring and evaluation

system has been established; however, quality, timeliness and coordination remain significant challenges. Although efforts have

been made towards workforce planning and absorption of new posts, the lack of qualified human resources in all cadres and at all

levels remains an overarching constraint.

Since 2006, PEPFAR has been working to develop local organizational and human capacity through work with government,

NGOs, the military, Peace Corps volunteers and the private sector. The quality assurance program has empowered public sector

health staff to provide integrated HIV and AIDS care. At a national level, PEPFAR provided leadership development and support

to the core Performance Improvement (PI) champion teams and trained managers to use it at national and facility level. The

program continued to expand and focus on community-based workforce development through in-service training, supportive

supervision and mentoring programs. PEPFAR has supported the implementation of a drug procurement and management

system to help meet Global Fund requirements. The USG has also provided on-going TA to the CCM and NERCHA to strengthen

the support systems for planning, delivery, monitoring and evaluation around Global Funds. Significant TA was provided to

strengthen laboratory services. PEPFAR partners also supported the development and costing of policies and information

systems to help drive decisions around HR, drug supply, male circumcision and provider-initiated counseling and testing.

Swaziland has been designated as a FY 08 Partnership Compact Country. HSS is one of the five key areas under development

with the government. The PEPFAR HSS approach prioritizes human capacity development as well as the decentralization of HIV

and AIDS services. Policy priorities include task shifting to increase access to services and translating several key national

policies and bills that are currently awaiting government approval into accelerated action. PEPFAR's efforts to strengthen the

health care system are in line with the National Strategic Framework currently under development and cut across all program

areas.

In FY 09, PEPFAR will significantly expand its efforts in HSS, especially in terms of human capacity development. HSS activities

in the various program areas will also focus on improving service quality, leadership and management, training, logistics and

knowledge management for evidence-based decision making.

1) Strengthening the capacity of host country government institutions to plan, manage, and implement HIV programs (including

national procurement and logistics systems)

PEPFAR will directly increase its support to strengthen the leadership, capacity and coordination activities of the MOHSW in the

areas of human capacity development, prevention, care and treatment service delivery including referral mechanisms, laboratory

services, blood safety, fiscal budgeting, health sector planning, pharmaceutical management, information management and

epidemiology. One element of the strategy is to establish a cooperative agreement with MOHSW to empower and foster internal

management capacity. As part of its systems strengthening efforts, PEPFAR and its partners will continue to serve on the various

national Technical Working Groups. Of the many public sector HSS areas supported by PEPFAR, human capacity development

and national procurement and logistics systems are described in further detail below.

In terms of human capacity development, PEPFAR will continue to emphasize workforce planning, development and support

including assistance to the MOHSW in recruitment and deployment, using HR data for decision-making, implementing the human

resources development plan and improving HR Management policies, especially with respect accreditation and task shifting

required for national scale up. PEPFAR and its partners will engage in a consultative process with Government and other

stakeholders to standardize scopes of work, training and compensation for different cadres of community health workers.

PEPFAR will also focus on strengthening pre-service and in-service training and curricula across the program areas. PEPFAR

will continue to work with government towards decentralizing the human resources information system. (HRH/HCD)

Since 2005, USG Swaziland has been carrying out activities to improve pharmaceutical management. In FY09, PEPFAR through

MSH will continue to assist the Pharmacy Services to implement the Swaziland Medicines Regulatory Authority to standardize the

importation, procurement, storage and distribution of medicines for the public and private sector. This activity also implies

interactions/negotiations with all stakeholders and establishing link with other regulatory authorities within and outside the SADC

region (HTXD).

2) Strengthening local partner organizations, particularly in management, leadership and policy development

In FY09, Pact will continue its primary focus on the development of human and organizational capacity of local NGO sub-grantees

to promote the participation of viable and sustainable civil society organizations in the HIV and AIDS response. Pact's capacity

building activities will continue to be: assessment of sub-recipient organizational and technical capacity, development of

institutional strengthening plans, delivering capacity building services, reassessment and refinement of institutional strengthening

plans. Pact has recognized that management skills among the leadership of many of the NGOs need to be further developed.

With FY 08 and 09 funding, Pact will identify short term management courses in Swaziland or South Africa that will enhance

leadership and management skills. Attendance to leadership courses will be made available to priority sub-grantees, such as

FLAS, which are experiencing difficulty in transitioning to increased funding levels or have new management staff and structures.

Pact will also provide technical assistance and mentoring to the Coordinating Assembly of Non-Governmental Organizations

(CANGO), a local umbrella group, to ensure effective absorption of Global Funds.

The DOL/ILO project will continue to support the enforcement of the multisectoral HIV/AIDS National Policy, which has now been

approved by parliament. This will include the development of HIV/AIDS workplace guidelines to support Ministry of Enterprise &

Employment - Department of Labour, the Federation of Swaziland Employers & Chamber of Commerce, the Swaziland

Federation of Trade Unions, the Swaziland Federation of Labour as well as all other Project Advisory Board (PAB) members in

the implementation of the national policy. For this purpose, capacity building will be pursued through training of labor inspectors.

Other partners will also be engaged in capacity development of local organizations. SAHCD will provide the Institution for

Development Management (IDM) with TA to establish partnerships with Ministries and other stakeholders to obtain buy in for their

training and tools. Capacity building for IDM will also focus on their capacity to document and disseminate best practices.

Working with local sub-grantees to promote HCT and prevention, PSI will build their capacity in planning, management and

implementation.

3) Strengthen leadership and the policy environment to reduce stigma and discrimination, including addressing key gender issues

DOL/ILO will link to the PACT grantee Swaziland Network of People Living with HIV/AIDS to participate in the Project Advisory

Board and build their capacity on how to use the ILO Code of Practice on HIV/AIDS in the workplace to reduce stigma and

discrimination. PSI will train outreach communication agents to provide leadership in the community on reducing stigma and

discrimination against people living with HIV.

During FY09, PEPFAR will pursue several activities to address gender issues that are deeply entrenched in Swazi society and

present significant challenges for the HIV and AIDS response. The USG along with other key donors will advocate for the

approval of the National Gender Policy and the National Domestic Violence and Sexual Offences Bill. PACT and PSI will begin to

gender mainstream in their programs during FY 09. DOL/ILO will provide training and TA on gender equity as one of 10 key HIV

policy principles in the workplace. Partners will be supported with TA to improve gender disaggregated data collection, analysis

and use to improve programming. (Gender)

4) Strengthening leadership and policy environment to expand access to HIV care and treatment services for children.

PEPFAR's priority focus on decentralization of HIV care and treatment services through task shifting, improving guidelines,

strengthening regional offices, integration and quality of services and expanding the number of sites that provide HIV services will

be the foundation for expanding access for children. PEPFAR will continue to work closely with the MOHSW and a consortium of

stakeholders, to develop policies, technical guidelines and training curricula in support of comprehensive HIV care and treatment

for children. PEPFAR will also continue to support capacity development for roll-out of Early Infant Diagnosis and increased

access to Early Infant Treatment. Improvements in pharmaceutical management and patient monitoring will allow better analysis

of pediatric treatment. Efforts to strengthen capacity for community-based and home-based extension of service delivery will

provide an important gateway for children to access testing and services. The evolving OVC portfolio will also provide opportunity

to improve policies and referrals for access to HIV services (PDCS, HKID).

5) Strengthening the GFATM management structure and improving donor coordination

With FY 09 funding, PEPFAR will continue to provide TA and support to strengthen the GFATM management structure and

organizational capabilities of the MOHSW and Global Fund sub-recipients to effectively perform their functions. In particular,

PEPFAR will support:

•Improvements in sub-granting by the principal recipient NERCHA, CCM oversight/M&E and the management structure for

NERCHA and SNAP,

•The establishment of a functional Global Fund Secretariat, and

•Increased quality and timeliness of national reporting, including information to the CCM and GF Geneva (Global Fund

Supplemental).

PEPFAR will continue to work in partnership with UN agencies to coordinate program planning and technical assistance

interventions.

6) Support for construction and renovation

Infrastructure and renovation work will be supported to expand access to care and treatment into the rural areas (HBHC) and to

improve the quality of OVC services and support provided through Neighborhood Care Points (HKID).

Products/Outputs

* National Policies (HVCT, HVTB, HKID, HLAB, HMBL, Gender, HRH/HCD)

* National Guidelines (HBHC, PDCS, HVCT, HVTB, HLAB, HTXD, HRH/HCD)

* Training Curricula (HBHC, HVCT, HVTB, PDCS, HRH/HCD)

* Referral Directories (HVCT, PDCS, HBHC, HVSI )

* Quality Management System/Plan/Tools (HBHC, PDCS, HMBL, HLAB, HRH/HCD)

* HRIS networked to the regional level (HRH/HCD)

* Operational TMIS (HRH/HCD)

* 24 workplace enterprises with a written HIV workplace policy in effect and an active committee addressing HIV and AIDS issues

(HVAB).

* Functional Global Fund Secretariat (Global Fund Supplemental)

Much of the expanded activity in human capacity development was designed on the basis of increased funding levels under a

Compact. Specifically, expansion of the HRIS to regional levels, recruitment and training of additional staff for MC scale up and

decentralization of care and treatment, streamlining of pre and in-service training and task shifting would be scaled way back.

Efforts to standardize scopes of practice and compensation for community-based workers are entirely dependent on Compact

funding. The cooperative agreement with the Ministry of Health for capacity building in epidemiology, laboratory services and

health systems strengthening would be considerably scaled back in scope.

Table 3.3.18: