The recent unprecedented investment in combating the HIV pandemic by United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have led to the debate on whether HIV programs have strengthened or undermined national health systems in developing countries. The debate was continued by health system strengthening (HSS) and HIV specialists at the XVIII International AIDS Conference.
A quasi-experimental study in Rwanda and Zambia revealed evidence that strengthening health systems leads to positive health outcomes–including outcomes to non-HIV services, such as reproductive health and vaccination for infants. Furthermore, as a result of HSS, new services–such as treatment centers for STI and maternities for PMTCT–have been put in place. Medical procurement and supply chain management capacity has also improved in some settings. It was also highlighted that HSS has institutionalized post market surveys and quality assurance. Capacity and skills building of health staff has greatly improved.
On the other hand, community system strengthening (CSS) has also contributed to scaling up treatment, care, and support programs as seen with the case of the network support agents in Uganda, PLWH who interface between health facilities, PLWH, and communities. Over 1,303 network support agents are currently deployed in 460 health facilities in Uganda. The discussion on health system strengthening emphasized that community health systems should not be considered in isolation. As funding for health systems strengthening increases, opportunities should be created to channel funding to the full continuum of services, including community structures. Hence, more funding should go to the District AIDS Committees and such coordinating bodies.
However, HSS has also led to some negative outcomes, such as brain drain from one system to another and absence of staff due to training. Overall, one of the most striking admissions I heard was that most effects of HIV programs on the health system were a spin-off rather than results of planned action to strengthen the broader health system. In order to decipher this undesired dichotomy, HIV and HSS should be looked at as complementary and synergistic due to the mostly positive health outcomes they provide.
In Uganda, the 20 year armed conflict resulted in a weak health system in Northern Uganda that has struggled to provide basic health care, let alone coordinate HIV services within the districts. Closing the gap between health systems and communities while integrating malaria, TB, and HIV interventions are primary objectives for the Northern Uganda Malaria AIDS & Tuberculosis Program (NUMAT). NUMAT’s health systems strengthening component has come a long way in improving the health system through strengthening the following components of the World Health Organization’s HSS.
1) Leadership and governance: NUMAT has been working in partnership with PLWH groups, the district local governments, and local NGOs to ensure strategic policy frameworks exist and are responsive to the HIV epidemic.
2) Health service delivery: Through the scale up the deliver integrated quality HIV, TB and malaria prevention treatment and care services are available in over 120 health facilities in Northern Uganda.
3) Human Resources for Health: NUMAT has worked with district authorities to identify qualified staff and fill vacant positions. The project has also designed innovative approaches to ensure that staff are available at peripheral levels through partnerships with institutions, such as Makerere and Gulu Universities, to deploy students to areas with vacancies.
4) Pharmaceutical management: NUMAT has provided support in ART logistics training, procurement of essential drugs-including ARVs, provision of laboratory equipment, and refurbishment of laboratories.
5) Health care financing: NUMAT is working with sex workers in the communities to link them to microfinance institutions. These are orientated in village savings and livelihoods skills, trained in business management skills and then eventually linked to loans schemes.
6) Health information: NUMAT has strengthened the national health management information system (HMIS) around data collection, analysis, interpretation, and utilization. NUMAT has also provided planning and management tools within the districts.