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.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,inkundl (district),community and facility levels will require 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 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, quality assurance, and 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.

The MOH CDC Cooperative Agreement (Coag) works on systems strengthening that focuses on supporting care and treatment for people with HIV. Portions of this budget code therefore will fund coordination of these system strengthening efforts, including related laboratory services and systems to provide blood transfusions as a result of AZT-induced anemia. Another key area in which the Coag is giving increased support is strategic planning, capacity building and implementation of quality improvement and quality assurance activities. Consistent use of QI and QA methodology is the key to tracking, 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 the government owned health facilities in Swaziland are inadequate for current needs. Some are in outright disrepair. Others are not designed in a manner that meets the chronic care needs of the current population: 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 management facilities are often completely lacking. As a result, patient flow is inefficient and, with the high rates of TB and poor infection control, often dangerous to both patients and staff. Some of the funds in this budget code will be used to renovate facilities to bring them up to standard and provide the basic furniture needed to run the facility to support quality chronic care services (eg, filing cabinets). The renovation funds will be leveraged with resources from the MOH and other donors like the World Bank, Clinton Foundation and MSF.

In FY13 in partnership with URC assist aims to: scale up and strengthen provision of integrated TB/HIV including MDR-TB care and treatment services to PHC clinics and communities; institutionalize Quality Improvement/Quality Assurance for TB/HIV services at national and health facility levels; strengthen the capacity of MOH Tuberculosis Control and AIDS programs to lead and manage roll out of TB/HIV care and treatment services; contribute to health systems strengthening; conduct operational research to inform current practices; strengthen the programmatic and clinical MDR-TB management; and improve TB/HIV knowledge management, monitoring and evaluation.

The PEPFAR Swaziland Pediatric HIIV care and support covers a target population of 0-15yrs. PEPFAR Swaziland supports the government of swaziland's family-centered approach to HIV care and treatment which includes family testing strategies at health care facilities (DBS for infants 0-18months and rapid test thereafter) as well as during home-based HTC. Children are tested as part of the family during home-based testing and are referred for care and support services similar to standard protocols for adult care and support. At health facilities, a family tree approach is used to identify all children in the family who need to be tested, using the parent as an index case at pre-ART and ART care points. There is an efficient system in place at health facilities to identify exposed infants for DBS. More than 95% of exposed infants currently receive DBS. The far majority (79%) of exposed infants are initiated on co-trimoxazole and over 95% are initiated on extended Nevirapine. The main challenge is tracking exposed infants to know what happens to them. PEPFAR Swaziland is currently working with the national strategic information department to set up a surveillance system to follow up exposed infants. PEPFAR supports adolescent clubs to provide peer support for adolescents living with HIV. These clubs meet regularly to discuss adherence issues, and how to live positively. Efforts are in place to strengthen adolescent care and support through special clinics where adolescents will receive more attention to issues specific to adolescents and to ensure smooth transition into the adult care and support programme to minimize lose to follow up. An adolescent TWG has recently been formed at the national level. This TWG which is a sub-committee of the Pediatric TWG will focus of adolescent specific issues to ensure that their issues are not lost between the adult and pediatric TWG discussions. PEPFAR Swaziland partners will participate in these meetings to provide technical support for both pediatric and adolescent issues. PEPFAR will support job aides and IEC materials that are kid friendly to support psychosocial and adherence counseling. PEPFAR Swaziland is supporting efforts to improve early enrollment of infants testing positive from DNA-PCR into care and treatment. Nurses are being trained both in didactic trainings and clinical attachments through a sub-award to Baylor Center of Excellence to acquire more knowledge and skills in diagnosis and management of pediatric opportunistic infection, pediatric phlebotomy as well as psychosocial and adherence needs of pediatrics. Starting from FY 13 through FY 14, the pediatric guidelines will be revised in line with current evidence to improve pediatric HIV care and support. World Food Programme has a food for prescription programme for children from 5yrs and above. PEPFAR partners support the implementation of this program by training healthcare workers on how to identify malnourished children using MUAC and/or BMI.

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. 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 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.

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.

Swazilands MOH has a 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

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. Given the wide scope of the SI activities, some of the 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 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 MOHs 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 in line with the MOH Essential Package of Health Services

Ensuring that the annual planning and budgeting cycle is strictly implemented by providing Health Policy and Planning Departments 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 the foundation provided by the male circumcision program Support to the Global Fund/PEPFAR collaboration

In FY12, PEPFAR will continue to support the Swaziland National Blood Transfusion (SNBTS) in line with its Strategic Plan, which will have cross-cutting benefits for several PEPFAR programs. A fully capacitated SNBTS will provide at least 18,000 units of safe blood per annum to the health service. The establishment of a nationally-coordinated blood transfusion service, collection of blood from voluntary non-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, are all critical elements of a successful program. PEPFAR will continue working with the SNBTS to develop a set of quantitative indicators modeled after WHO standards. A safe blood supply is increasingly acknowledged as a critical treatment adjunct to manage HIV related anemia with up to 70% of all patients with HIV developing anemia.

The MOH CDC Cooperative Agreement (Coag) works on systems strengthening that focuses on supporting care and treatment for people with HIV. Portions of this budget code therefore will fund coordination of these system strengthening efforts, including related laboratory services and systems to provide blood transfusions as a result of AZT-induced anemia. Another key area in which the Coag is giving increased support is strategic planning, capacity building and implementation of quality improvement and quality assurance activities. Consistent use of QI and QA methodology is the key to tracking, 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 the government owned health facilities in Swaziland are inadequate for current needs. Some are in outright disrepair. Others are not designed in a manner that meets the chronic care needs of the current population: 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 management facilities are often completely lacking. As a result, patient flow is inefficient and, with the high rates of TB and poor infection control, often dangerous to both patients and staff. Some of the funds in this budget code will be used to renovate facilities to bring them up to standard and provide the basic furniture needed to run the facility to support quality chronic care services (eg, filing cabinets). The renovation funds will be leveraged with resources from the MOH and other donors like the World Bank, Clinton Foundation and MSF.

he PEPFAR Swaziland Pediatric HIIV treatment covers a target population of 0-15yrs. PEPFAR Swaziland supports the government of swaziland's family-centered approach to HIV care and treatment which includes family testing strategies at health care facilities (DBS for infants 0-18months and rapid test thereafter) as well as during home-based HTC. Children are tested as part of the family during home-based testing and are referred for care and support services similar to standard protocols for adult care and support. At health facilities, a family tree approach is used to identify all children in the family who need to be tested, using the parent as an index case at pre-ART and ART care points. There is an efficient system in place at health facilities to identify exposed infants for DBS. More than 95% of exposed infants currently receive DBS. The far majority (79%) of exposed infants are initiated on co-trimoxazole and over 95% are initiated on extended Nevirapine. The main challenge is tracking exposed infants to know what happens to them. PEPFAR Swaziland is currently working with the national strategic information department to set up a surveillance system to follow up exposed infants. PEPFAR supports adolescent clubs to provide peer support for adolescents living with HIV. Efforts are in place to strengthen adolescent treatment, care and support through special clinics where adolescents will receive more attention to issues specific to adolescents and to ensure smooth transition into the adult care and support programme to minimize lose to follow up. An adolescent TWG has recently been formed at the national level. This TWG which is a sub-committee of the Pediatric TWG will focus of adolescent specific issues to ensure that their issues are not lost between the adult and pediatric TWG discussions. PEPFAR Swaziland partners will participate in these meetings to provide technical support for both pediatric and adolescent issues. PEPFAR will support job aides and IEC materials that are kid friendly to support psychosocial and adherence counseling. PEPFAR Swaziland is supporting efforts to improve early enrollment of infants testing positive from DNA-PCR into care and treatment. Nurses are being trained both in didactic trainings and clinical attachments through a sub-award to Baylor Center of Excellence to acquire more knowledge and skills in diagnosis and management of pediatric opportunistic infection, pediatric phlebotomy as well as psychosocial and adherence needs of pediatrics. Starting from FY 13 through FY 14, the pediatric guidelines will be revised in line with current evidence to improve pediatric HIV treatment World Food Programme has a food for prescription programme for children from 5yrs and above. PEPFAR partners support the implementation of this program by training healthcare workers on how to identify malnourished children using MUAC and/or BMI.