The capacity to deliver quality services in Swaziland is constrained by a number of interlinkedfactors,including the need for strengthened management,planning,monitoring and evaluationcapacity,greater accountability and improved coordination.Although efforts are underway to decentralize

the health system,the roles and functions of the different levels of the system are not yet clearly definedwhile necessary reorientation and capacity building are not yet being implemented.To be effectivetherefore,the health system at the national regional,inkundl (district),community and facility levels willrequire improved technical and managerial capacity in order to cope with the new and additionalresponsibilities that will come with the health sector reforms and decentralization.Under the PartnershipFramework strategic objective of building capacity of the public sector to coordinate,manage and fund itsown HIV/AIDS response,this mechanism establishes a direct funding relationship between PEPFAR andthe GKOS.It is anticipated that being an implementing partner for this mechanism will benefit the MOH notjust though program outputs but also by strengthening its capacity around coordination,oversight andcooperative agreement management.Efforts of the MOH under this cooperative agreement will bedirected at building capacity for the following strategic priority areas:laboratory capacity andinfrastructure,strategic information, quality assurance, and planning and policy development.Whileactivities under this service delivery area are intended to specifically improve the management anddelivery of HIV/AIDS and TB services, capacity of targeted health systems will have broad-based effectson improving service delivery throughout the health sector.

All laboratory testing, including rapid/simple testing for HIV consists of a series of processes andprocedures that must be carried out correctly in order to obtain accurate results. An approach thatmonitors all parts of the testing system is needed to ensure the quality of the overall process, to detectand reduce errors, to improve consistency between testing sites, and to help contain costs. Thisapproach 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 ortesting site. This component of the MOH Cooperative Agreement will focus on strengthening the qualitysystem for laboratory services. The MOH through the national laboratory will establish a national qualitysystem for HIV testing. This will include a national office for laboratory quality management, identificationof a national quality officer or manager.In order to extend the quality system to all aspects of testing practices and to avoid vertical decisions andassessments the national laboratory will develop an overall, country-wide plan for the management ofHIV 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 thatthe system is working efficiently. Scheduling of training programs to coincide with national programimplementation, budgeting for supplies, kits, printing of training materials, etc will also form part of theplan. Protocols for Preparing HIV Positive Quality Control Materials and instructions for making a supplyof HIV positive samples at a desired reactivity level to be used as a daily control, or as part of aproficiency testing panel will also be developed.On the job mentoring will constitute a central part of facilitative supervision and QA approach to in thelaboratories. The MOH will establish an organizational structure to assure that on-site monitoring occursin all locations. This will require a sufficient number of staff who has been trained to conduct themonitoring. Visits will be conducted at least twice yearly to established sites with experiencedpersonnel. New sites or sites with new staff will be visited at least quarterly. In sites with demonstratedproblems, the number of visits will be increased in order to provide training and technical assistance. Thefindings 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 besubmitted to the relevant authorities for review and corrective action if needed.PEPFAR will fund activities to ensure accessibility of laboratory services throughout the countryespecially amongst the rural population. It will address specifically the areas of TB diagnostics, HIVtesting and CD4 enumeration. Emphasis will be placed on developing a system that will ensure timelydelivery of comprehensive quality laboratory services that are effective, efficient, accessible andaffordable to all.

Strategic Area Budget Code Planned Amount

Swaziland's MOH has a Strategic Information (SI) Department, comprised of HMIS, M&E, andEpidemiology sections and having statutory responsibility for managing all health and health service datafor the country. However, due to capacity constraints, the SI department is often unable to meet theinformational needs of the MOH in terms of high quality information products. Poor coordination hasled to redundancy in data systems and overburdening of peripheral staff who are charged with collectionand processing of information. The consequence of these twin "storms" (low capacity andinefficient/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, disseminationand use of reliable and timely information on the determinants of health, health system performance andhealth 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 strategicinformation.• Strengthening analytical skills and in-depth data utilization for program improvementThe Cooperative agreement specifically targets MOH institutional capacity and thereby supports thePartnership Framework pillar concerned with human and institutional capacity building. At the sametime, the other four service delivery pillars are given support though improved health systems and higherquality, more timely information for decision making. Given the wide scope of the SI activities, some ofthe costs of the Cooperative agreement coordination unit are borne by the SI budget code.The MOH in collaboration with PEPFAR/CDC will build a project management and M&E functionalitywithin 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

Strategic Area Budget Code Planned Amount

The main functions of the MOH at the national level include policy formulation, standards and qualityassurance; programming and planning; resource mobilization and allocation; capacity development andtechnical support to the lower levels of the system; provision of public health services, such as epidemiccontrol, co-ordination of health services; monitoring and evaluation of the overall sector performance.Appropriate capacity building measures will be undertaken to strengthen corporate governance andmanagement 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 andcost-effective management of the health system and delivery of health services. Specifically, it is the aimof 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 essentialplanning skills at regional planning units. For this to happen, the MOH's planning unit will itself need tobe strengthened in a sustainable way.

Functionally, while the central MOH will seek to empower the regional and the other decentralizedstructures to function autonomously, the MOH will effectively relate to the regions in executing their rolesby:

• Developing service standards and guidelines for service delivery and management in line with the MOHEssential Package of Health Services• Ensuring that the annual planning and budgeting cycle is strictly implemented by providing Health Policyand Planning Department's technical support to the regions as requested• Establishing systems for monitoring the state of infrastructure and equipment, prioritizing needs and

coordinating the use of MOH, PEPFAR and other donor resources to respond to them.• Support to the QA/QI program, institutionalizing QA/QI practices into daily practice-- building from thefoundation provided by the male circumcision program• Support to the Global Fund/PEPFAR collaboration

Strategic Area Budget Code Planned Amount

In FY12, PEPFAR will continue to support the Swaziland National Blood Transfusion (SNBTS) in line withits Strategic Plan, which will have cross-cutting benefits for several PEPFAR programs. A fullycapacitated SNBTS will provide at least 18,000 units of safe blood per annum to the health service. Theestablishment of a nationally-coordinated blood transfusion service, collection of blood from voluntarynon-remunerated blood donors from low-risk populations, as well as testing of all donated blood for HIV,including screening for transfusion-transmissible infections, blood grouping and compatibility testing, areall critical elements of a successful program. PEPFAR will continue working with the SNBTS to develop aset of quantitative indicators modeled after WHO standards. A safe blood supply is increasinglyacknowledged as a critical treatment adjunct to manage HIV related anemia with up to 70% of all patientswith HIV developing anemia.

Strategic Area Budget Code Planned Amount

The MOH CDC Cooperative Agreement (Coag) works on systems strengthening that focuses onsupporting care and treatment for people with HIV. Portions of this budget code therefore will fundcoordination of these system strengthening efforts, including related laboratory services and systems toprovide blood transfusions as a result of AZT-induced anemia. Another key area in which the Coag isgiving increased support is strategic planning, capacity building and implementation of qualityimprovement and quality assurance activities. Consistent use of QI and QA methodology is the key totracking, evaluating and improving clinical outcomes and other performance data, both nationally,regionally and at the site level. In addition, the Coag has funds reserved for renovations as many of thegovernment owned health facilities in Swaziland are inadequate for current needs. Some are in outrightdisrepair. Others are not designed in a manner that meets the chronic care needs of the currentpopulation: waiting areas are too small; infection control needs (windows, ventilation) are unmet;

adequate space for consulting rooms, record keeping, point of care laboratories, and waste managementfacilities are often completely lacking. As a result, patient flow is inefficient and, with the high rates of TBand poor infection control, often dangerous to both patients and staff. Some of the funds in this budgetcode will be used to renovate facilities to bring them up to standard and provide the basic furnitureneeded to run the facility to support quality chronic care services (eg, filing cabinets). The renovationfunds will be leveraged with resources from the MOH and other donors like the World Bank, ClintonFoundation and MSF.