NEW/REPLACEMENT NARRATIVE

The spread of HIV/AIDS in Namibia has not only affected high-risk groups, but has become a generalized

epidemic that threatens the health of the entire population. Growing numbers of HIV/AIDS patients requiring

access to prevention, care and treatment have put a strain on the already weak health systems in place in

Namibia. Weak health systems are a bottleneck in reaching and sustaining PEPFAR goals in HIV/AIDS

service delivery. Weak management systems are unable to track large infusions of funds that organizations

are receiving. Acute shortages of trained health workers lead to competition for a finite supply of competent

staff. In the absence of good health information systems, government lacks data needed to manage the

provision of quality health services. Ineffective health governance leads to weak synergies with donors, civil

society and the private sector, among other actors.

The goals expressed in the Government of the Republic of Namibia's (GRN) Namibia Vision 2020 are that

in the year 2020 "Namibia is free of the diseases of poverty and inequality; and the majority of Namibians

are living healthy lifestyles, provided with safe drinking water and comprehensive preventive and curative

health services, to which all have equal access." Recognizing the need to achieve this goal, the Ministry of

Health and Social Services (MoHSS) implemented a complete health sector evaluation which reviewed five

components, namely health financing, infrastructure, human resources, governance and service provision.

The USG is committed to supporting the MoHSS and its partners to realize this vision through the

implementation of sustainable programs that improve the delivery and financing of HIV/AIDS and general

health services.

In FY 2009 COP the USG will support the GRN through the Health Systems 20/20 (HS 20/20) project to

improve the government's capacity to maintain and finance quality HIV/AIDS prevention, care and treatment

services over the long-term in collaboration with implementing partners. Following the strategic direction of

the GRN and the recommendations of the 2008 health systems assessment (conducted via non-PEPFAR

leveraged resources from USAID/W), HS 20/20 will support health sector reform efforts in the following key

areas:

1) Infrastructure

HS 20/20 support will include the drafting of:

• One to two key policies for the maintenance of health facilities, including a report on the current state of

the facilities unit and the steps required to manage and operationalize the transition to merged facilities

maintenance and planning unit.

• Procedures for streamlining the construction of and maintenance of HIV/AIDS clinics and hospitals where

treatment is given;

• A decentralized approach for infrastructure maintenance in key areas; and

• A protocol for capital improvements in coordination with other key ministries (including Department of

Works).

The technical assistance needed to complete the objectives listed above would require HS 20/20 to:

• Provide a senior infrastructure specialist;

• Provide a local hire part-time advisor (architect or urban planner);and

• Review the results of the MOHSS Service Provision Assessment conducted in FY 2008 COP, and if

needed, provide additional support to understand what infrastructure is needed to improve service delivery.

In order to conduct the work in a collaborative and coordinated manner, HS 20/20 proposes a partnership

with the MoHSS. The MoHSS would need to provide:

• Office space with furniture and internet connectivity for HS 20/20 staff; and

• Logistical support.

2) Health Financing

Sufficient and informed financing is essential to a well-functioning health system. The GRN recognizes that

the current system of resource allocation, which relies heavily on historical budgeting, inappropriately

addresses resources needs throughout the country, particularly for HIV/AIDS. To assist the Government

and other stakeholders in making more informed resource allocation decisions, HS 20/20 will provide

technical assistance for Namibia's 2009 National Health Accounts (NHA) estimation that will include, for the

first time, focused expenditure reviews, called sub-accounts, for HIV/AIDS, TB, and possibly malaria (with

leveraged funding). These expenditure estimations will provide policymakers with a clearer understanding

of the current strengths and weaknesses of financial arrangements for priority areas.

As this is the first time the GRN will be implementing the HIV/AIDS sub-account, it is an important step in

establishing a baseline against which future PEPFAR initiatives can be measured. FY 2009 COP funding

will be used to support the GRN NHA initiative, specifically to track spending on the above mentioned areas

by donors, NGOs, employers, and insurance schemes. Intended to be done on a regular basis, this first

estimation of HIV/AIDS institutional spending will provide baseline data to monitor the status of critical

policy questions such as:

• How much of HIV/AIDS funds are being financed by external sources? Is this sustainable? Is external

funding displacing government contributions?

• How much of disbursed funds are actually spent?

• What is the role of the private sector in delivering HIV/AIDS care? Are companies also contributing

financially to the HIV/AIDS response?

• Is spending for HIV/AIDS in line with the fiscal goals for Namibia's HIV/AIDS strategic plan?

The activities suggested below refer to the USG's support of the MoHSS in leading the estimation process

and are for the general and HIV/AIDS sub-accounts component of the NHA estimation. Note that the

HIV/AIDS-focused activities will take place in tandem and in a combined manner with the non-HIV

Activity Narrative: components of the NHA exercise.

• Ensure that HIV/AIDS financiers, managers, and providers are included in overall sampling plans for

ongoing NHA surveys.

• Design survey instruments for donors, NGOs, employers and insurance companies.

• Pre-test survey instruments and consequent finalizing of questionnaires.

• Conduct primary data collection, including institutional surveys for donors, NGOs, employers and

insurance companies.

• Design data entry screens, and the entering and cleaning of data.

• Conduct analysis (and extrapolation) of primary and secondary data.

• Produce general NHA tables (that examine spending on overall health) showing the flow of funds from 1)

Financing Sources (FS) to Financing Agents (HF), 2) from HF to providers (HP), 3) from HP to functions

(HC), and 4) from HF to HC.

• Produce HIV/AIDS expenditure tables using information collected from institutional surveys relating to

HIV/AIDS spending (this will not include targeted household PLWHIV information).

•Support building local capacity to estimate NHA by training the local NHA team on data collection methods,

data processing and analysis, construction of national health accounts tables, and the interpretation of the

findings in the context of Namibia policy relevance.

These activities have been prioritized by the Ministry of Health and Social Services. The Permanent

Secretary of the Ministry has called for nothing short of health sector reform, which the government is fully

committed to carrying out. PEPFAR resources for the above two areas are urgently needed as we embark

on the second phase of PEPFAR. In this phase we must consider Namibia's categorization as a transitional

compact country and how the country can move forward with absorbing the recurrent costs associated with

the HIV/AIDS epidemic.

New/Continuing Activity: Continuing Activity

Continuing Activity: 18991

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18991 18991.08 U.S. Agency for Abt Associates 8319 8319.08 Health Systems $90,000

International 20/20

Development

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $107,200

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.18: