Strengthening Health Systems to Support HIV and AIDS Prevention, Care and Treatment

Photo of a man holding a box of antiretroviral drugs
Pharmacist Kennedy Aduol receives a delivery of US-funded antiretroviral (ARV) drugs at the Sena Health Center on Mfangano Island in Lake Victoria.
Riccardo Gangale/USAID


Progress toward an AIDS-free generation is dependent upon the ability of at-risk individuals and people living with HIV and AIDS to find and access quality health services, providers and products. A well-functioning health system meets these needs, effectively supporting prevention, care and treatment for HIV and AIDS. Building strong health systems is a crucial step on the path toward universal access to comprehensive HIV programs and a country-led, sustainable response to the epidemic. Unfortunately, many health systems are weak, overburdened and unable to meet the needs of the people they serve.

Six interconnected building blocks outline the functions of the health system:

  1. Service Delivery: delivery of effective, safe, high-quality health interventions to those who need them, when and where needed, with minimum waste of resources
  2. Leadership and Governance: ensuring strategic policy frameworks exist and are combined with effective oversight, coalition building, appropriate regulations and incentives, attention to system design and accountability
  3. Financing: mobilization of adequate resources from reliable sources, pooling of resources to foster efficiency and spread costs and allocation of resources to promote efficiency, equity and health impact
  4. Medical Products, Vaccines and Technologies: equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use
  5. Information: production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status
  6. Human Resources for Health: ensuring a sufficient number and mix of staff and volunteers that are fairly distributed, efficient, responsive and competent to achieve the best health outcomes possible given available resources and circumstances


Under the 2008 reauthorization of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), special emphasis was placed on strengthening health systems and workforce capacity and deeper integration of HIV and AIDS programs into health systems. This shift toward greater emphasis on sustainability and country ownership of the HIV and AIDS response has yielded significant gains against this global epidemic. As a key implementing agency of PEPFAR, the U.S. Agency for International Development’s (USAID’s) health systems strengthening (HSS) efforts enable PEPFAR to reach its ambitious targets for prevention, care and treatment.

USAID’s Office of HIV/AIDS engages in HSS in three ways:

  1. Focused interventions in HSS to address health system gaps specific to the achievement of PEPFAR and host country goals for HIV and AIDS prevention, care and treatment (for example, developing information systems to improve antiretroviral drug [ARV] delivery).
  2. Intentional spillovers, which are achieved when PEPFAR designs and implements HIV-focused activities in anticipation that these activities can and will benefit non-HIV and AIDS elements of the health system at no or very low additional cost (for example, capacity building for ARV procurement systems can also be used to purchase maternal and child health commodities).
  3. Targeted leveraging of funds, which is achieved by partnering with other development or entities to jointly sponsor broad-based health system improvement efforts that have an HIV and AIDS link (for example, joining other donors in developing a comprehensive national health insurance program that includes coverage for HIV and AIDS services).

The Office of HIV/AIDS collaborates closely with the Bureau for Global Health Office of Health Systems to help support HIV and AIDS and PEPFAR HSS efforts.


Photo of a man getting his blood pressure taken.
Community health workers trained by USAID provide basic health services.

Monitoring HIV Policy

The USAID-funded Health Policy Project, in collaboration with the Centers for Disease Control and Prevention and the University of Washington, works to strengthen country ownership of and accountability for HIV programs through support to country stakeholders in the planning, implementing and monitoring of progress of policy intervention commitments in PEPFAR Partnership Framework Implementation Plans. Central to these efforts is the Road Map for Implementing and Monitoring Policy Interventions, a tool that strengthens the capacity of U.S. Government teams, partner governments and civil society organizations to monitor progress of policy interventions.

PEPFAR Expenditure Analysis

The PEPFAR Blueprint: Creating an AIDS-free Generation and the PEPFAR Stewardship and Oversight Act of 2013 highlight the importance of improved collection and use of economic and financial data for increasing the efficiency, effectiveness and sustainability of HIV and AIDS programs. After extensive piloting during 2009-2012, PEPFAR institutionalized the Expenditure Analysis Initiative in fiscal years 2012 and 2013 across nineteen countries to routinely track expenditures of PEPFAR programs to:

  • Provide a better understanding of the expenses the U.S. Government incurs to provide a range of HIV services;
  • Improve accountability and oversight of PEPFAR efforts by tracking spending and accomplishments over time;
  • Improve transparency, collaboration, and strategic planning with other stakeholders;
  • Highlight areas for improved efficiency and improve alignment of future investments to program needs; and
  • Estimate the resources needed to support future programs.

In its final phase of institutionalization, In FY 2014 PEPFAR will roll-out the Expenditure Analysis Initiative across its global portfolio to all operating units, which include thirty two countries and four regional programs. Expenditures are reported annually at the end of the USG fiscal year.

Improving HIV Service Quality and Outcomes

Women being counseled on health choices
Beatrice, holding Gabriel, and Grace, with baby Mary, listen as CHW Jane Akoth (right) counsels them on their health choices.

Building on USAID's history and leadership in application of modern improvement approaches in LMICs, the USAID-funded Applying Science to Strengthen and Improve Systems (ASSIST) Project supports the use of modern quality improvement (QI) methodologies by health care workers, producing evidence-based improvements in the implementation of AIDS-related services. Currently working in over 20 PEPFAR countries, these improvements directly relate to PEPFAR goals and objectives including increased compliance with clinical guidelines, increased efficiency and effectiveness, expanded coverage and scale-up of services, and patient-centered HIV care. An integral focus of ASSIST is institutionalizing ongoing improvement as an integral part of service delivery, a priority of the PEPFAR Quality Strategy. This work involves strengthening capacity for QI application at all levels of a country health system, which is essential for continued utilization of QI methods in HIV programs and sustained improvement of HIV service quality. ASSIST supports research and evaluation to further adapt modern QI to the needs of LMIC health systems and furthering south-to-south exchange amongst countries to ensure that knowledge gained from improvement activities is made available to others that might benefit.

Gender and Health Systems Strengthening

Gender-Based Violence Cost Calculator

USAID and the USAID-funded Health Policy Project (HPP) recently developed the GBV Program Cost Calculator, a tool designed to assist program managers, policy makers, donors and other stakeholders to estimate the cost of components of GBV-related clinical and community-based services. The tool reflects a comprehensive framework of GBV programs, with flexibility to respond to unique country priorities. HPP is currently using the calculator to conduct a study of discrete unit costs of providing GBV services in health care facilities in Tanzania.

This new electronic course developed by USAID-funded CapacityPlus offers a chance to learn about the gender issues that exist within the major health systems components, key interventions that promote gender equality and women's empowerment, and how to address gender issues in HSS activities in order to improve health systems and gender-related outcomes. Women and men have different opportunities, constraints, needs, power and access to resources affecting their health; thus, promoting gender equality in the six health system building blocks means assuring fairness and justice in the distribution of benefits, power and resources between women and men, girls and boys.



Last updated: August 26, 2014

Share This Page