N/A

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.17:

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $1,449,575

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

OVERVIEW

Lesotho's health systems are underdeveloped, creating challenges for health care providers working to carry out HIV/AIDS

services. Significant resources need to be invested within the country to strengthen MOHSW planning and management of the

health system, including the procurement and supply chain system. While Lesotho participated in developing the Accra Agenda

for Action, currently donor coordination by GOL is quite loose, and this has resulted in duplication of efforts in the health field.

Development partners are starting to work together more closely to align their efforts and further assist GOL in its two main

challenges: the HIV/AIDS epidemic and the human resource crisis related to providing appropriate and consistent prevention, care

and treatment services.

GOL is moving forward with its decentralization program, which envisions stronger health service delivery at the local level

through devolution of responsibilities and funding to District Health Management Teams. District level teams are receiving training

and support from GTZ and some international organizations, but still remain weak in both management capacity and sufficient

human resources. Lesotho has few local non-governmental organizations that are capable of receiving direct USG funding, and

many indigenous CBOs and NGOs need management and financial systems capacity-building in order to be able to support

HIV/AIDS related programs in their communities.

CURRENT USG PROGRAM

PEPFAR/Lesotho's program has prioritized health strengthening systems and human resources for health at the national level,

providing significant investments in these areas. Current USG programs strengthen systems in four key areas, as described

below. Investments in human resources, a key component of the current PEPFAR program and proposed compact, can be found

in the HRH narrative.

I. Improve Supply Chain

Since 2006, GOL has been procuring antiretroviral drugs, with assistance from Global Fund. Drugs are available in all 10 districts

throughout the country. Systems supporting the procurement and supply logistics of ARV drugs and other commodities are weak.

PEPFAR, World Bank, Clinton Foundation (CHAI), and Global Fund have all provided assistance over the last few years to

improve access to ARVs and essential pharmaceutical products. PEPFAR, through MSH's Strengthening Pharmaceutical

Services (SPS) project, is strengthening the National Drug Supply Organization (NDSO) to improve pharmaceutical services at

national, district and facility levels. MSH has upgraded NDSO information operations systems, and has improved quantification

practices. In FY 2008, MSH conducted several training courses for pharmacists, procurement officers and program managers at

national and district levels on forecasting commodity requirements using consumption and morbidity based methods. MSH also

trained pharmacy technicians, facility managers and data clerks in the use of the computerized drug supply management systems

to support activities related to procurement, storage, distribution, dispensing and down referrals, ensuring availability of ARVs at

all times.

Despite these attempts to improve the drug supply system, shortages of essential HIV/AIDS related commodities, such as lab

reagents, disposable supplies, rapid test kits, and condoms are still being reported from clinical facilities. The current supply chain

system is a hybrid of push and pull, and the push system to health clinics, in particular, is not working well. Various stakeholders,

including PEPFAR implementing partners, have supplied these commodities on an emergency basis, which helps in the short

term. However, a reform of the system, along with training for staff at health clinic level and pharmacists working in hospitals

needs to move the system beyond reacting to stock-outs and toward a more systemic change. Many PEPFAR implementing

partners continue to request a small supply of needed commodities for stock-outs which is a good indication that the National

Supply Chain Management System is still not 100% operational.

II. Support for Decentralization of Services

As the GOL slowly moves forward with its decentralization program, USG has been supporting MOHSW in developing an HR

strategy. Decentralization to the districts means that MOHSW will continue setting policy and providing guidance and strategy, but

the Ministry of Local Government and Chieftainship (MOLGC) will assume responsibility for funding health care providers and

overseeing health clinics and hospitals. In order to assure patients have access to continued HIV services of improved quality,

MOHSW and the PEFPAR-funded SA-HCD TA have laid out required staff at all levels of the health system and training and HR

requirements for these positions. SA-HCD, with PEPFAR support, will continue advocating for rational decentralization of staff and

HR, while USG works with other donors to identify challenges to decentralization and advocate for solutions.

III. Strengthening Capacity of Indigenous Partners

As part of its mandate, PEPFAR/Lesotho is assisting indigenous organizations to develop financial and management systems so

that they can expand their reach and ability to provide prevention, care, and treatment services to the Basotho people. Pact, Inc.

has 6 local NGOs, to whom it provides organizational capacity building and support, as well as technical skills. PEPFAR also

provides Vast grants to CBOs linked to Peace Corps Volunteers, and provides support to small CBOs through the Ambassador's

Small Grants program.

IV. Improve Donor Coordination

PEPFAR/Lesotho sits on several donor coordination bodies, including the Development Partners Consultative Forum, the Health

Development Partners Forum, the Global Fund CCM, and the informal Health Decentralization Working Group. Despite weak

coordination efforts by GOL and MOHSW, PEPFAR takes its coordination role seriously and is working closely with the EU, Irish

Aid, GTZ, and the UN to further improve coordination between donors working in the health and HIV/AIDS sector.

FY2009 USG SUPPORT

I. Improve the Supply Chain

The PEPFAR team has decided to have a TBD partner for this program in COP 2009. Depending on the achievements of MSH

over the next 6-8 months, and its responsiveness to MOHSW's priorities, PEPFAR/Lesotho may decide to fund its current partner

or acquire a new partner under a competitive bidding process in FY 2009.

PEFPAR/Lesotho, through either MSH or a new partner, will prioritize national pharmaceutical policies; procurement;

quantification and quality assurance; warehousing; distribution and logistics; and facility supply management. PEPFAR will work

closely with NDSO and MOHSW's procurement unit to reform the supply chain system so it provides drugs and commodities in an

efficient and timely manner. PEPFAR will also provide training and mentoring for pharmacists and pharmacy technicians, with the

goal of strengthening the procurement and supply chain system.

II. Support for Decentralization of Services

PEPFAR/Lesotho plans to continue working through SA-HCD to identify and advocate for appropriate staffing patterns at district

level. The main focus of the SA-HCD program will be on approval of positions under the PEPFAR-supported revised functional

structure of the MOHSW, decentralization of public health functions (including integrated HIV services) to MOLG and

implementation of recruitment; deployment and retention policies. As decentralization moves forward and districts take greater

responsibility for health services, PEPFAR plans to work through its technical partners to strengthen capacity of the technical

leads who sit on the District Health Management Teams (DHMTs). Based on work with DHMTs, PEPFAR plans to continue its

advocacy role at the national level, collaborating with MCC and other donor partners to raise district-level decentralization

concerns to the MOHSW.

III. Strengthen Capacity of Indigenous Partners

PEPFAR's agreement with current umbrella organization, Pact Inc., is ending in FY 2009. PEFPAR will be soliciting for a new

partner to act as umbrella to indigenous organizations and build capacity of small community-based organizations to increase

grantees' effectiveness. Through this new partner, PEPFAR plans to strengthen indigenous partners' financial management,

strategic program planning, and monitoring and reporting systems and achieve expanded, high quality services. The new umbrella

partner will leverage technical assistance from current and new PEPFAR partners: AED/C-Change for prevention, SA-HCD for

human capacity and human resource support, PSI and other service delivery partners in counseling, testing, treatment and new

partners for TB, community-based care and OVC.

At this time, there is no large local organization that can take on grant-making to smaller organizations. However, NAC and

GFATM are reviving the currently dormant Lesotho Network of HIVAIDS Service Organizations (LENHASO), and Peace Corps,

with PEPFAR support, will be placing a PCV at the organization. It is envisioned that after several years of support, LENHASO

may be able to take on grant-making functions. PEPFAR will also continue working with Peace Corps, who provide Vast grants to

CBOs linked with PCVs. The Ambassador's Small Grants program will expand slightly, and will partner with the new umbrella

organization, which will provide training for small grants partners on financial management, monitoring, and evaluation.

IV. Improve Donor Coordination

PEPFAR/Lesotho will continue to participate in the CCM and coordinate with NAC. PEFPAR will replace Irish Aid as co-chair for

the MOHSW Health Development Partners Forum; this new role will leverage overall USG oversight in our investments in the

health sector but also allow us to lead health program negotiations with MOHSW. As Health Partners Forum co-chair, PEPFAR

will provide support to MOHSW in their quarterly and annual joint review meetings. PEPFAR is a signatory to the MOHSW

Partners Code of Conduct, and will continue aligning its implementing partners with the MOHSW Policy and Planning directorate's

joint program planning efforts. Irish AID and the USG will become the bilateral partner leads on HR support plans, with funding

from MCC, the EU and World Bank in FY09.

LEVERAGING AND WRAPAROUNDS

PEPFAR's systems strengthening program leverages the MCC Compact Agreement's condition precedent that all health centers

MCC builds be fully staffed. This has been a key starting point for PEPFAR to work to rationalize staffing patterns and strengthen

HIV/AIDS service provision. The key USG strategies for success will blend and transition the PEPFAR investments in HSS and

HCD over to the MCC program. Specifically, PEPFAR will work closely with MCC as they begin a program focused on Health

System Strengthening which will support on-going reforms in decentralization, health management information systems, human

resources and health waste management and infection control. Some of the PEPFAR portfolio in this area may transition to the

MCC project funding in FY09. PEPFAR and MCC share offices, allowing us to collaborate closely on issues of HSS. PEPFAR

also collaborates with Irish Aid, EU, WHO, and the UN family to strengthen donor coordination. PEPFAR is a member of the

Global Fund CCM, and provides input and feedback to strengthen the implementation of Global Fund grants.

PROPOSED COMPACT EXPANSION

As PEPFAR/Lesotho moves forward to negotiate a Partnership Compact with GOL, we anticipate that funding for health systems

strengthening will increase significantly in order to scale up work in decentralization and supply chain management. We anticipate

providing more funding to our supply chain partner to more rapidly strengthen supply chain management at all levels of the health

system. We also anticipate negotiating with MOHSW, MOLGC, the Ministry of Public Service, and the Ministry of Finance for

revised and strengthened recruitment, deployment, and retention policies. As Compact negotiations are only at the early stages,

we understand that we may need to revise expectations, and will be in touch with our core team and DP "friend" as we move

forward.

OTHER QUALITATIVE ACCOMPLISHMENTS

• Transfer of QI functions from COHSASA to the National QA Team completed by July 30th 2010

• Essential Medicines stock monitoring systems functional at all levels by June 2010

• Medicines regulatory authority in place by December 2009

• Standard operating procedures (LESOPS) in place and used in all the facilities by January 2010

• Pharmaceutical Therapeutics Committees established and functioning by the end of 2009

• The EDL and Standard Treatment Guidelines revised by November 2009

• Medicines Information and Pharmacovigilance Centre in place by end 2010

Table 3.3.18: