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Appendix H Illustrative Questions for the Evaluation of PEPFAR’s Health Systems Strengthening Activities 193

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WHO HSS Building Block PEPFAR Inputs Activities Outputs Outcomes Impacts Finance To what extent has What specific PEPFAR What has been the balance between What has been the trend in What, if any, health PEPFAR-funded activities are aimed at reducing PEPFAR funding on prevention the cost per person treated for improvements can be linked government HIV, non- the cost, and/or improving the and treatment? specific HIV services to PEPFAR’s activities? HIV, and non-health cost-effectiveness or supported by PEPFAR in the programs? affordability of the health What percentage of PEPFAR government health system system? budgets is channeled through the government versus directly to How sustainable is funding How is PEPFAR coordinating partners and what share of total for HIV services? its financing activities with financing of government services other donors and partners? does this represent? How have PEPFAR’s inputs affected affordability of government health services? To what extent do PEPFAR’s technical assistance activities contribute to a sound public finance system for health? Has PEPFAR improved equity of access to health or AIDS services? Equity in improvements in health? (income and gender) Commodities What infrastructure has What are the training activities What amount and quality of drugs How have PEPFAR activities What, if any, health and been put in place to ensure for drug and lab procurement (and other variable inputs) has affected: improvements can be linked Procurement reliable procurement and and other supply chain PEPFAR financed for use by the -health service forecasting? to PEPFAR’s activities? supply chain systems? management and pharmacist public health system? - procurement and delivery of activities? HIV and non-HIV drugs How much of this HIV To what extent has PEPFAR services (e.g., for infrastructure (labs, Are PEPFAR supported increased: tuberculosis, malaria, pain, pharmacy, information commodity/procurement -access to HIV lab services? cancer, cardiovascular technology, etc.) is used activities mainstreamed into -availability of HIV testing disease)? for non-HIV services public health system services (ELISA, CD4, viral loads) in public -national essential drug list? (spillover)? (parallel or integrated) and labs? -health service ability to run coordinated with similar multi- HIV services based on CD4 donor efforts? What is the quality of HIV and count testing, viral load non-HIV lab services in country testing (QA certification)? -functionality of country’s supply chain system for high quality, reliable HIV and non-HIV services? 195

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196 Information What has PEPFAR What activities has PEPFAR What is the functionality of the What is the evidence that the What, if any, health systems introduced to improve undertaken to introduce new health information systems health information and improvements can be linked monitoring and evaluation data systems or to strengthen supporting HIV and non-HIV surveillance systems to PEPFAR’s activities? of HIV care systems, HR existing health information programs, and what the number of supported by PEPFAR are and health management systems that support HIV and information officers trained? being used and are systems, and decision non-HIV programs? functioning better as a result making? What new publicly available data of PEPFAR activities? and/or research has PEPFAR- funded that could be used by To what extent has capacity governments to improve the been built and retained to effectiveness of AIDS or health carry on these tasks in the programs? absence of PEPFAR support? To what extent has PEPFAR contributed to a high functioning, single data system for quality-driven health system performance? Service What resources has For HIV and non-HIV care, To what extent have PEPFAR’s Are PEPFARs activities What, if any, health delivery PEPFAR added to improve what activities have PEPFAR HIV services been decentralized linked to effective, efficient, improvements can be linked service delivery for HIV undertaken to: and scaled up in a geographic area? safe, equitable and, patient- to PEPFAR’s activities? and non-HIV services -strengthen referral systems centered HIV and non-HIV (personnel, buildings, and care networks? To what extent are leaders of the care? technical assistance, etc.) -use continuous quality health system and health care and to what extent has this improvement methods? workers using CQI to manage and Can PEPFAR HIV and non- support been appropriate -design scalable (rate, cost) execute HIV and non-HIV HIV programs show for resource-constrained and equitable services? programs? improvement in performance environments? -integrate HIV and non-HIV and quality of processes and care? outcomes over time? What is the evidence that PEPFAR’s investments in the public health system have improved access to HIV and non-HIV preventive or curative health care? Is there a spillover of improvement to non-health sectors?

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Leadership What countries have What activities has PEPFAR What PEPFAR supported What is the evidence that What, if any, health and developed and signed supported to specifically improvements in leadership or PEPFAR’s investments have improvements can be linked Governance partnership frameworks improve leadership and governance of the public health improved: to PEPFAR’s activities? and to what extent have governance of: sector can be identified, such as: -health system management leadership and governance -effective and efficient health -anti-stigma policies enacted and leadership or governance activities been specifically protocols? -public and private sector programs capable of planning and funded? -HIV and non-HIV protocols, accredited for HIV care implementing effective, policy development and -updates of national HIV plans and integrated health system programming? guidelines and concordance with interventions for HIV and -partnership agreements? WHO recommendations non-HIV programs? -interactions with other -integration of HIV into maternal -more open policies for other bilateral and multilaterals to and child health, primary care, health and social issues? expand training, financing? hospital or portfolios -multi-sector and civil society engagement approaches adopted for other health issues? -capacity to plan and sustain health systems? Human What human resources What activities contributed to What are the outputs of PEPFAR To what extent are PEPFAR- What, if any, health Resources have been introduced by building capacity of workforce financed capacity building (number financed capacity building improvements can be linked PEPFAR? (pre-service, in-service)? of people trained, by type of worker activities supporting national to PEPFAR’s activities? or training, in relation to the HR plans for a sufficiently What training programs exist number of public workers, pre- skilled HIV and non-HIV for managers directed at - service versus in-service): care workforce? better service and planning: -percentage of HIV HCW paid vs. -performance assessment volunteer What are the outcomes of -CQI -percentage of PEPFAR trained PEFAR investments in HR, workers transferred to/integrated such as: with public sector -retention of PEPFAR trained workers in public sectors What are the outputs of PEFAR versus non-governmental investments in HR, such as: organizations, and in-country -absolute number of new HCW -urban-rural distribution added to the pool. HCW -net number of new HCW added to pool (incoming versus lost workers) NOTE: CD4 = cluster of differentiation 4, CQI = continuous quality improvement, ELISA = enzyme-linked immunoabsorbent assay, HCW = health care worker, HHS = health systems strengthening, HR = human resources, QA = quality assessment, WHO = World Health Organization. 197