The capacity to deliver quality services in Swaziland is constrained by a number of interlinked factors, including the need for strengthened management, planning, monitoring and evaluation capacity, greater accountability and improved coordination. Additionally, although efforts are underway to decentralize the health system, the roles and functions of the different levels of the system are not yet clearly defined while necessary reorientation and capacity building are not yet being implemented. To be effective therefore, the health system at the national, regional, inkundla (district), community and facility levels will require increased and improved technical and managerial capacity in order to cope with the new and additional responsibilities that will come with the health sector reforms and decentralization.

Under the Partnership Framework and in line with the PEPFAR long-term strategic objective of building capacity of the public sector to coordinate, manage and fund its own HIV/AIDS response, this mechanism establishes a direct funding relationship between PEPFAR and the GKOS. It is anticipated that being an implementing partner for this mechanism will benefit the MOH not just though program outputs but also by strengthening its capacity around coordination, oversight and cooperative agreement management.

Efforts of the MOH under this cooperative agreement will be directed at building capacity for the following strategic priority areas: laboratory capacity and infrastructure, strategic information, and system strengthening, planning and policy development. While activities under this service delivery area are intended to specifically improve the management and delivery of HIV/AIDS and TB services, capacity of targeted health systems will have broad-based effects on improving service delivery throughout the health sector.

Swaziland's MOH has a new Strategic Information (SI) Department, comprised of HMIS, M&E, and Epidemiology sections and having statutory responsibility for managing all health and health service data for the country. However, due to capacity constraints, the SI department is often unable to meet the informational needs of the MOH in terms of high quality information products. Poor coordination has led to redundancy in data systems and overburdening of peripheral staff who are charged with collection and processing of information. The consequence of these twin "storms" (low capacity and inefficient/redundant systems) is that reports are often incomplete, late, and of generally low quality.

A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on the determinants of health, health system performance and health status. Actions to strengthen the health information system will include:

Strengthening personnel skills and procedures

Acquiring appropriate equipment to facilitate or improve the generation of data;

Strengthening capacity of regional level in compiling, analyzing or synthesizing health data into strategic information.

Strengthening analytical skills and in-depth data utilization for program improvement, with special focus on:

o ART cohorts

o Sexual Behavioral (HIV prevention)

o Male circumcision

Improving the quality and completeness of data

Strengthening of the overall management of SI activities, including SI planning and budgeting.

The Cooperative agreement specifically targets MOH institutional capacity and thereby supports the Partnership Framework pillar concerned with human and institutional capacity building. At the same time, the other four service delivery pillars are given support though improved health systems and higher quality, more timely information for decision making.

The MOH in collaboration with PEPFAR/CDC will build a project management and M&E functionality within the Project Management Unit (PMU) of the MOH which will track key objectives and outputs under the MOH-PEPFAR Cooperative Agreement including:

Increase strategic training outputs

Enhancing the SI budgeting and planning process

Improved timeliness and completeness of national HMIS data,

Enhancing availability of SI products for decision-making

The main functions of the MOH at the national level include policy formulation, standards and quality assurance; programming and planning; resource mobilization and allocation; capacity development and technical support to the lower levels of the system; provision of public health services, such as epidemic control, co-ordination of health services; monitoring and evaluation of the overall sector performance. Appropriate capacity building measures will be undertaken to strengthen corporate governance and management procedures, practices and systems in order to engender institutional growth, efficiency, cost-effectiveness, responsiveness and sustainability.

The purpose of the MOH decentralization program is to facilitate equitable, timely, efficient and cost-effective management of the health system and delivery of health services. Specifically, it is the aim of decentralization program to devolve authority and responsibility in the implementation, management, coordination, monitoring and evaluation of health services.

A key strategy to support and accelerate effective decentralized service delivery is to develop essential planning skills at regional planning units. For this to happen, the MOH's planning unit will itself need to be strengthened in a sustainable way.

Functionally, while the central MOH will seek to empower the regional and the other decentralized structures to function autonomously, the MOH will effectively relate to the regions in executing their roles by:

Developing service standards and guidelines for service delivery and management

Ensuring that the annual planning and budgeting cycle is strictly implemented by providing Health Policy and Planning Department's technical support to the regions as requested

Conducting pre-planned quarterly support supervision

Coordinating and providing support in matters of epidemic and disaster prevention, preparedness and management;

All laboratory testing, including rapid/simple testing for HIV consists of a series of processes and procedures that must be carried out correctly in order to obtain accurate results. An approach that monitors all parts of the testing system is needed to ensure the quality of the overall process, to detect and reduce errors, to improve consistency between testing sites, and to help contain costs. This approach to laboratory quality, called a quality system, is defined as the organizational structure, resources, processes, and procedures needed to implement quality management of the laboratory or testing site. This component of the MOH Cooperative Agreement will focus on strengthening the quality system for laboratory services. During FY10, the MOH through the national laboratory will establish a national quality system for HIV testing. This will include a national office for laboratory quality management, identification of a national quality officer or manager.

In FY11 in order to extend the quality system to all aspects of testing practices and to avoid vertical decisions and assessments the national laboratory will develop an overall, country-wide plan for the management of HIV rapid testing, including the introduction of proficiency testing and on site supervision and mentoring. Monitoring processes will be established to identify problems and solutions to the problems to ensure that the system is working efficiently. Scheduling of training programs to coincide with national program implementation, budgeting for supplies, kits, printing of training materials, etc will also form part of the plan. Protocols for Preparing HIV Positive Quality Control Materials and instructions for making a supply of HIV positive samples at a desired reactivity level to be used as a daily control, or as part of a proficiency testing panel will also be developed.

On the job mentoring will constitute a central part of facilitative supervision and QA approach to in the laboratories. The MOH will establish an organizational structure to assure that on-site monitoring occurs in all locations. This will require a sufficient number of staff who has been trained to conduct the monitoring. Visits will be conducted at least twice yearly to established sites with experienced personnel. New sites or sites with new staff will be visited at least quarterly. In sites with demonstrated problems, the number of visits will be increased in order to provide training and technical assistance. The findings from each site visit will be recorded according to the national policy, and the findings should be reviewed and corrective action taken when required. A report and the completed checklist will be submitted to the relevant authorities for review and corrective action if needed.

In COP 10 PEPFAR will fund activities to ensure accessibility of laboratory services throughout the country especially amongst the rural population. It will address specifically the areas of TB diagnostics, HIV testing and CD4 enumeration. Emphasis will be placed on developing a system that will ensure timely delivery of comprehensive quality laboratory services that are effective, efficient, accessible and affordable to all.