Health Systems 20/20 is a continuing Implementing Mechanism.

The Health Systems 20/20 project (HS 20/20) is a Leader with Associates Cooperative Agreement awarded by USAID's Global Health Bureau to Abt Associates and its partners. The goal of HS 20/20 is to increase the use of priority population, health, and nutrition (PHN) services, especially by the disadvantaged. Towards this goal, it implements activities to improve health system performance in four key areas (1) health financing, (2) governance, (3) operations, and (4) local capacity. The project team brings together an exceptional pool of professionals with depth and experience in capacity building, governance, finance and operations.

Health system strengthening related to HIV/AIDS is a key element of the Partnership Framework. HS20/20 is committed to country ownership and the development of local capacity to ensure sustainability of activities initiated under the agreement. Furthermore, HS20/20 will continue its ongoing efforts in Namibia to strengthen human resources for health (HRH) planning, governance, and financial management of HIV/AIDS related activities, three important components of the Partnership Framework.

HS 20/20 will work at the national level with government officials and civil society stakeholders. The key ministry partners will include the Ministry of Health and Social Services, the Ministry of Finance and the proposed new National HIV/AIDS Council. By supporting the GRN in its development of a national costed HRH plan, HS20/20 will also target the cross-cutting issue of HRH strengthening.

The HS 20/20 vision for both strengthening health systems and making them more efficient over time relies on the project's success in its core intervention areas, which include strengthening of financial systems, operations, and governance and building capacity. The project's results framework calls for improvements in these areas.

HS 20/20's work aligns with PEPFAR's cost-efficiency principles by strengthening GRN leadership. Through this approach, HS 20/20 is able to save resources needed to lead, implement, and champion each activity. Instead, the GRN will lead each activity and this allows for HS 20/20 funds to be maximized across a number of activities through the provision of strategic technical assistance provided at key phases—initiation and design, data analysis and interpretation, and in some cases report writing.

At its onset, HS 20/20 drafted a set of program indicators to benchmark its performance. HS 20/20 will apply them to each of the activities proposed for Namibia in order to both monitor and evaluate performance and create opportunities for learning. In addition, HS 20/20 will partner with the MOHSS to collect information on the COP10 core indicator activities and report on targets that have been met. The

data quality for program monitoring will be ensured through data validation exercises undertaken in conjunction with implementing partners in the MOHSS and the Monitoring and Evaluation Officer at USAID. HS20/20 will also strengthen data feedback loops and dissemination mechanisms by working with our implementing partners in the MOHSS to widely share health finance information, final resource allocation criteria, and results from HRH situation assessments, planning workshops, and gap estimations. These dissemination efforts will involve district, regional and national level health system administrators and managers.

This continued activity has two components: 1) Health Financing and 2) Human Resources for Health (HRH).

1) Health Financing: Technical assistance to the GRN to strengthen its tracking and policy use of health expenditure data, develop equitable resource allocation processes, and develop a national HIV resource mobilization and sustainability plan.

Namibia completed three rounds of National Health Assessments (NHA), most recently in FY09 for 2007. It is ideally placed to institutionalize NHA, the goals of which are to strengthen and streamline routine NHA production and increase stakeholders' use of NHA data. This includes actions such as integrating

NHA data sources into routine health information systems; building routine in-country capacity for data collection, analysis, and reporting; and designing and implementing tools that simplify the NHA production process. On the demand-side, needed actions are in disseminating NHA results to a wider array of stakeholders and building their capacity to use NHA to guide policy and planning.

In addition, there is a critical need to identify and develop local (including public and private) resource mobilization strategies to sustain an effective response.

HS 20/20 is providing assistance for Namibia's 2009 NHA estimation, which for the first time, includes subaccounts for HIV/AIDS. This is the second NHA to be produced with technical assistance from HS 20/20. Specific tasks include the following: • Implement the NHA institutionalization assessment tool to assess the level of NHA institutionalization in Namibia and identify strengths and weaknesses. • Implement specific institutionalization related activities with respect to data collection, including implementation of a donor-NGO database for routine expenditure reporting, incorporation of finance indicators into the MOHSS's health information system, and establishing a protocol for the incorporation of expenditure questions in upcoming household questionnaires. • Partner with UNAIDS and other donors to strengthen civil society use of finance and HIV expenditure data through training and outreach workshops for civil society organizations. • Support MOHSS to undertake additional analysis of the NHA data for the purposes of drafting policy briefs, informing resource allocation and mobilization, and developing linkages with other policy planning tools. • Provide technical support to the MOHSS, Policy, Planning and Human Resources Directorate to develop criteria for an equitable and efficient resource allocation process. • Support GRN development of a national resource mobilization and sustainability plan for the HIV/AIDS response.

2) HRH: Provision of technical assistance to the MOHSS to develop a comprehensive costed national HRH plan

Namibia's critical shortage of health care workforce is a serious concern for the GRN and to the sustainability of the national HIV/AIDS response. Existing policy, National HR Development Policy (2008- 2012), is not focused on health and the HR strategic framework was developed prior to the HIV/AIDS epidemic in 1997. Thus, there is a need to develop a new HR plan for health care to encompass all cadres of workers. In addition, private sector partnerships need to be cultivated to reach national HR goals. A new HRH plan would analyze existing gaps, forecast HR needs, and address issues of recruitment, retention, and capacity building.

HS 20/20 worked with the GRN on HR issues before, serving in the HRH working group of the National Health Systems Review team. In this capacity, HS 20/20 helped collect, analyze, and interpret HRH data and coordinated the drafting of the HRH chapter. Assisting the development of a HRH plan is an extension of HS 20/20's previous work.

HS 20/20 will support the MOHSS: • Design and conduct HRH situation assessment based on interviews with HR staff regarding job satisfaction, workload, motivation, willingness to stay in public sector, etc. • Estimate current HRH gaps and needs • Convene stakeholder HRH planning workshops (inclusive of both the public, private, and donor sectors) • Draft a national HRH plan • Cost the HRH plan's activities

HS 20/20 will collaborate with HRH stakeholders in Namibia, including HRH partners such as the Namibia HIV Prevention, Care and Support project.

The outcomes and impact of each activity will be defined jointly at the onset by GRN and HS 20/20. Progress towards these targets will be monitored closely and jointly. Also, HS 20/20 will provide extensive technical review to ensure that the designed national plans and approaches respond to the minimum basic package of services, comparable to other country plans (e.g. HRH) and in accordance with international standards and norms (e.g. for resource tracking institutionalization).

HS20/20 will also strengthen data feedback loops and dissemination mechanisms by working with our implementing partners in the MOHSS to widely share health finance information, resource allocation criteria, and results from HRH situation assessments, planning workshops, and gap estimations.

All the above activities promote sustainability, as they entail direct technical support to the MOHSS to develop better informed and more comprehensive health policies, plans, and processes. The outcomes will contribute to equitable resource allocation practices, stronger accountability of resource use, and a concerted way forward to address the HRH workforce crises.